Assessment of subendocardial contractile function in aortic stenosis: a study using speckle tracking echocardiography

Interdependence between myocardial deformation and perfusion in patients with T2DM and HFpEF: a feature-tracking and stress perfusion CMR study

BACKGROUND

Patients with diabetes have an increased risk of developing heart failure with preserved ejection fraction (HFpEF). This study aimed to compare indices of myocardial deformation and perfusion between patients with type 2 diabetes mellitus (T2DM) with and without HFpEF and to investigate the relationship between myocardial strain and perfusion reserve.

METHODS

This study included 156 patients with T2DM without obstructive coronary artery disease (CAD) and 50 healthy volunteers who underwent cardiac magnetic resonance (CMR) examination at our center. Patients with T2DM were subdivided into the T2DM-HFpEF (n = 74) and the T2DM-non-HFpEF (n = 82) groups. The parameters of left ventricular (LV) and left atrial (LA) strain as well as stress myocardial perfusion were compared. The correlation between myocardial deformation and perfusion parameters was also assessed. Mediation analyses were used to evaluate the direct and indirect effects of T2DM on LA strain.

RESULTS

Patients with T2DM and HFpEF had reduced LV radial peak systolic strain rate (PSSR), LV circumferential peak diastolic strain rate (PDSR), LA reservoir strain, global myocardial perfusion reserve index (MPRI), and increased LA booster strain compared to patients with T2DM without HFpEF (all P < 0.05). Furthermore, LV longitudinal PSSR, LA reservoir, and LA conduit strain were notably impaired in patients with T2DM without HFpEF compared to controls (all P < 0.05), but LV torsion, LV radial PSSR, and LA booster strain compensated for these alterations (all P < 0.05). Multivariate linear regression analysis demonstrated that LA reservoir and LA booster strain were independently associated with global MPRI (β = 0.259, P < 0.001; β =  - 0.326, P < 0.001, respectively). Further, the difference in LA reservoir and LA booster strain between patients with T2DM with and without HFpEF was totally mediated by global MPRI. Global stress PI, LA booster, global rest PI, and global MPRI showed high accuracy in diagnosing HFpEF among patients with T2DM (areas under the curve [AUC]: 0.803, 0.790, 0.740, 0.740, respectively).

CONCLUSIONS

Patients with T2DM and HFpEF exhibited significant LV systolic and diastolic deformation, decreased LA reservoir strain, severe impairment of myocardial perfusion, and elevated LA booster strain that is a compensatory response in HFpEF. Global MPRI was identified as an independent influencing factor on LA reservoir and LA booster strain. The difference in LA reservoir and LA booster strain between patients with T2DM with and without HFpEF was totally mediated by global MPRI, suggesting a possible mechanistic link between microcirculation impairment and cardiac dysfunction in diabetes. Myocardial perfusion and LA strain may prove valuable for diagnosing and managing HFpEF in the future.

Fragmented QRS complex may predict long-term mortality after isolated surgical aortic valve replacement in patients with severe aortic stenosis

OBJECTIVES

Fragmented QRS (fQRS), related to myocardial fibrosis, is an important prognostic marker of cardiovascular events and mortality. Aortic stenosis (AS), the most frequent valvular heart disease in developed countries, causes myocardial fibrosis due to ventricular pressure overload. The current study aimed to investigate whether fQRS is associated with long-term mortality after isolated surgical aortic valve replacement (SAVR) in patients with severe AS.

METHODS

A total of 289 patients who underwent SAVR for severe AS between May 2009 and January 2020 with interpretable electrocardiogram were included. Patients were divided into 2 groups according to the presence of fQRS. Kaplan-Meier survival analyses were used to detect cumulative survival rates. Univariable and multivariable Cox proportional hazards models were used to determine the predictors of all-cause mortality.

RESULTS

fQRS occurred in 126 (43.5%) patients. A total of 59 (20.4%) patients died over a follow-up period of 54 ± 32 months. All-cause mortality was higher in the fQRS group (23 [14.1%] vs 36 [28.6], log-rank test P = 0.002) in the long term. The presence of fQRS [hazard ratio (HR): 1.802, confidence interval (CI): 1.035-3.135, P = 0.037], electrocardiographic left ventricular strain (HR: 1.836, CI: 1.036-3.254, P = 0.038) and history of stroke or transient ischaemic attack (HR: 3.130, CI: 1.528-6.412, P = 0.002) were independent predictors of all-cause mortality in the multivariable Cox regression model.

CONCLUSIONS

fQRS is associated with a 1.8-fold increase in long-term mortality in patients undergoing isolated SAVR for severe AS. Detecting fQRS in electrocardiograms may provide prognostic information about the long-term outcomes.

Advanced cardiovascular multimodal imaging and aortic stenosis

Aortic valve stenosis has become the most common valvular heart disease on account of aging population and increasing life expectancy. Echocardiography is the primary diagnosis tool for this, but it still has many flaws. Therefore, advanced cardiovascular multimodal imaging techniques are continuously being developed in order to overcome these limitations. Cardiac magnetic resonance imaging (CMR) allows a comprehensive morphological and functional evaluation of the aortic valve and provides important data for the diagnosis and risk stratification in patients with aortic stenosis. CMR can functionally assess the aortic flow using two-dimensional and time-resolved three-dimensional velocity-encoded phase-contrast techniques. Furthermore, by late gadolinium enhancement and T1-mapping, CMR can reveal the presence of both irreversible replacement and diffuse interstitial myocardial fibrosis. Moreover, its role in guiding aortic valve replacement procedures is beginning to take shape. Recent studies have rendered the importance of active and passive biomechanics in risk stratification and prognosis prediction in patients with aortic stenosis, but more work is required is just in its infancy, but data are promising. In addition, cardiac computed tomography is particularly useful for the diagnosis of aortic valve stenosis, and in preprocedural evaluation of the aorta, while positron emission tomography can be also used to assess valvular inflammation and active calcification. The purpose of this review is to provide a comprehensive overview of current available data regarding advanced cardiovascular multimodal imaging in aortic stenosis.

Urgent neonatal balloon atrial septostomy in simple transposition of the great arteries: predictive value of fetal cardiac parameters

OBJECTIVES

To investigate the impact of abnormal perinatal loading conditions on cardiac geometry and function in term fetuses and neonates with transposition of the great arteries with intact interventricular septum (simple TGA), and to explore the predictive value of fetal cardiac parameters for an urgent balloon atrial septostomy (BAS) after birth.

METHODS

This was a prospective longitudinal follow-up study of women delivering at term, including both uncomplicated pregnancies with normal outcome and pregnancies affected by fetal simple TGA. Conventional, spectral-tissue Doppler and speckle-tracking echocardiographic parameters were obtained within 1 week before delivery and within the first few hours after delivery. Neonates with simple TGA that required urgent BAS were assessed after the procedure and before corrective arterial switch surgery. Cardiac parameters were normalized by cardiac cycle length, ventricular end-diastolic length or end-diastolic dimension, as appropriate. Fetal and neonatal cardiac parameters were compared between simple-TGA cases and controls, and perinatal changes in the simple-TGA group were assessed. Receiver-operating-characteristics (ROC)-curve analysis was used to assess the predictive value of fetal cardiac parameters for urgent BAS after birth in the simple-TGA group.

RESULTS

A total of 67 pregnant women delivering at term were included in the study (54 normal pregnancies and 13 with a diagnosis of fetal simple TGA). Compared with normal term fetuses, term fetuses with simple TGA exhibited more globular hypertrophied ventricles, increased biventricular systolic function and diastolic dysfunction (right ventricular (RV) sphericity index (SI), 0.58 vs 0.54; left ventricular (LV)-SI, 0.55 vs 0.49; combined cardiac output (CCO), 483 vs 406 mL/min/kg; LV torsion, 4.3 vs 3.0 deg/cm; RV isovolumetric relaxation time (IVRT'), 127 vs 102 ms; P < 0.01 for all). Compared with normal neonates, neonates with simple TGA demonstrated biventricular hypertrophy, a more spherical right ventricle and altered systolic and diastolic functional parameters (RV-SI, 0.61 vs 0.43; RV myocardial performance index, 0.47 vs 0.34; CCO, 697 vs 486 mL/min/kg; LV-IVRT', 100 vs 79 ms; RV-IVRT', 106 vs 71 ms; P < 0.001 for all). Paired comparison of neonatal and fetal cardiac indices in the simple-TGA group showed persistence of the fetal phenotype, increased biventricular systolic myocardial contractility and CCO, and diastolic dysfunction (RV systolic myocardial velocity (S'), 0.31 vs 0.24 cm/s; LV-S', 0.23 vs 0.18 cm/s; CCO, 697 vs 483 mL/min/kg; LV torsion, 1.1 vs 4.3 deg/cm; P < 0.001 for all). Several fetal cardiac parameters in term fetuses with simple TGA demonstrated high predictive value for an urgent BAS procedure after birth. Our proposed novel fetal cardiac index, LV rotation-to-shortening ratio, as a potential marker of subendocardial dysfunction, for a cut-off value of ≥ 0.23, had an area under the ROC curve (AUC) of 0.94, sensitivity of 100% and specificity of 83%. For RV/LV end-diastolic area ratio ≥ 1.33, pulmonary-valve-to-aortic-valve-dimension ratio ≤ 0.89, RV/LV cardiac output ratio ≥ 1.38 and foramen-ovale-dimension-to-total-interatrial-septal-length ratio ≤ 0.27, AUC was 0.93-0.98, sensitivity was 86% and specificity was 83-100% for all.

CONCLUSIONS

Simple-TGA fetuses exhibited cardiac remodeling at term with more profound alterations in these cardiac parameters after birth, suggestive of adaptation to abnormal loading conditions and possible adaptive responses to hypoxemia. Perinatal adaptation in simple TGA might reflect persistence of the abnormal parallel arrangement of cardiovascular circulation and the presence of widely patent fetal shunts imposing volume load on the neonatal heart. The fetal cardiac parameters that showed high predictive value for urgent BAS after birth might reflect the impact of late-gestation pathophysiology and progressive hypoxemia on fetal cardiac geometry and function in simple TGA. If these findings are validated in larger prospective studies, detailed cardiac assessment of fetuses with simple TGA near term could facilitate improvements in perinatal management and refinement of the timing of postnatal intervention strategies to prevent adverse pregnancy outcomes. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Subclinical cardiac dysfunction in obesity patients is linked to autonomic dysfunction: findings from the CARDIOBESE study

Aims

Obesity doubles the lifetime risk of developing heart failure. Current knowledge on the role of obesity in causing cardiac dysfunction is insufficient for optimal risk stratification. The aim of this study was first to estimate the prevalence of subclinical cardiac dysfunction in obesity patients and second to investigate the underlying pathophysiology.

Methods and results

The CARDIOBESE study is a cross‐sectional multicentre study of 100 obesity patients [body mass index (BMI) ≥ 35 kg/m²] without known cardiovascular disease and 50 age‐matched and gender‐matched non‐obese controls (BMI ≤ 30 kg/m²). Echocardiography was performed, blood samples were collected, and a Holter monitor was affixed. Fifty‐nine obesity patients [48 (42–50) years, 70% female] showed subclinical cardiac dysfunction: 57 patients had decreased global longitudinal strain (GLS), and two patients with normal GLS had either diastolic dysfunction or increased brain natriuretic peptide (BNP). Only one non‐obese control had diastolic dysfunction, and none had another sign of cardiac dysfunction. Multivariable logistic analysis identified male gender and standard deviation of all NN intervals (SDNN) index, which is a measure of autonomic dysfunction, as independent significant risk factors for subclinical cardiac dysfunction in obesity patients.

Conclusions

There was a high prevalence (61%) of subclinical cardiac dysfunction in obesity patients without known cardiovascular disease, which appeared to be best identified by GLS. Subclinical cardiac dysfunction in obesity was linked to autonomic dysfunction and male gender, and not to the presence of traditional cardiac risk factors, increased C‐reactive protein, increased BNP, increased high‐sensitivity troponin I, or increased left ventricular mass.

Early Changes of Myocardial Function After Transcatheter Aortic Valve Implantation Using Multilayer Strain Speckle Tracking Echocardiography

Transcatheter aortic valve implantation (TAVI) is an effective therapeutic option for severe symptomatic aortic valve stenosis (AS) with intermediate or high surgical risk. The purpose of this study was to examine the effects of TAVI on left ventricular (LV) mechanics using multilayer global longitudinal strain (GLS) by 2D speckle-tracking echocardiography. A total of 119 patients (mean age 83 ± 7.0 years, male 54%) with severe symptomatic AS and normal LV ejection fraction (LVEF) underwent echocardiography at baseline and 1 month after TAVI. Global longitudinal strain was measured from the endocardial layer (GLSendo), mid-ventricular layer (GLSmyo), epicardial layer (GLSepi) and full thickness of myocardium (GLSwhole). There was significant improvement in all 3 layers of GLS after TAVI compared with baseline, but there was no significant change in LVEF. The relative % increment in GLS in each layer strain were 11.2 ± 23.4% (GLSendo), 13.4 ± 33.0% (GLSmyo) and 18.0 ± 46.6% (GLSepi) with significant difference between GLSendo and GLSepi (p < 0.05). In conclusion, multilayer GLS is more sensitive than conventional LVEF to detect early improvement in LV systolic function after TAVI in patients with severe AS. There is a disproportional improvement in different layers with least improvement in the endocardium. Multilayer strain analysis may provide new insights into understanding mechanics of AS.

Prognostic Implication of Electrocardiographic Left Ventricular Strain in Patients Who Underwent Transcatheter Aortic Valve Implantation

Electrocardiographic (ECG) strain has been linked to excess cardiovascular morbidity and mortality in asymptomatic patients with aortic stenosis. We aim to determine the differential impact of baseline ECG-strain on long-term mortality after transcatheter aortic valve implantation (TAVI). Patients who underwent TAVI from January 2012 to March 2016 at Mayo Clinic were included. Left ventricular (LV) strain was defined as the presence of ≥1mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on baseline ECG. Primary end point was all-cause long-term mortality. Of the 520 patients screened, 130 were excluded due to left bundle branch block or paced rhythm. Median follow-up was 1.5 years, IQR (0.9 to 2.7). In the 390 included patients, 47 (12%) had strain pattern on pre-TAVI ECG. Patients in the strain group had higher prevalence of peripheral vascular disease (83% vs 68%, p = 0.04), and atrial fibrillation/flutter (51% vs 37%, p = 0.06). They also had lower mean LV-ejection fraction (51 ± 16% vs 58±12%, p = 0.003, larger LV-internal diameter in systole (3.71 ± 1.04cm vs 3.26 ± 0.75 cm), higher LV-mass-index (136 ± 44 vs 121 ± 29 g/m²; p = 0.044), and higher estimated pulmonary artery systolic pressure (50 ± 13 vs 43 ± 15mm Hg; p = 0.02). Kaplan-Meier survival analysis showed a cumulative probability of survival at 3 years of 35.4% ± 8% in patients with LV-strain compared with 67% ± 3.4% in patients without LV-strain (log-rank p <0.001). In a multivariate logistic regression analysis, ECG-strain was an independent predictor of long-term mortality (Hazard ratio 2.67, 95% CI [1.72 to 4.05]; p <0.001). In conclusion, ECG strain is an independent predictor of long-term mortality post TAVI. Systematic strain measurements might aid in risk-stratifying patients who underwent TAVI.

Newer echocardiographic techniques for aortic-valve imaging: Clinical aids today, clinical practice tomorrow

Increasing life expectancy is expected to lead to a corresponding increase in the prevalence of aortic valve disease (AVD). Further, the number of indications for transcatheter aortic valve replacement (TAVR) as a treatment option for AVD is expanding, with a growing role for echocardiography in its management. In this review we summarize the current literature on some newer echocardiographic modalities and the parameters they generate, with a particular focus on their prognostic and clinical value beyond conventional methods in the management of aortic stenosis, TAVR, and aortic regurgitation. Speckle tracking and 3D echocardiography are now increasingly being used in the management of AVD. For instance, global longitudinal strain, the best-studied speckle tracking echocardiographic parameter, can detect subtle subclinical cardiac dysfunction in patients with AVD that is not apparent using traditional echocardiographic techniques. The emerging technique of 3D full volume color Doppler echocardiography provides more accurate measurement of the severity of aortic regurgitation than 2D-proximal isovelocity surface area. These novel techniques are promising for evaluating and risk stratifying patients to optimize surgical interventions, predict recovery, and improve clinical outcomes.

Usefulness of Electrocardiographic Strain to Predict Survival After Surgical Aortic Valve Replacement for Aortic Stenosis

Electrocardiographic (ECG) strain has been reported as a specific marker of midwall left ventricular (LV) myocardial fibrosis, predictive of adverse clinical outcomes in aortic stenosis (AS), but its prognostic impact after aortic valve replacement (AVR) is unknown. We aimed to assess the impact of ECG strain on long-term mortality after surgical AVR for AS. From January 2005 to January 2014, patients with interpretable preoperative ECG who underwent isolated AVR for AS were included. ECG strain was defined as ≥1-mm concave downslopping ST-segment depression with asymmetrical T-wave inversion in lateral leads. Mortality was assessed over a follow-up period of 4.8 ± 2.7 years. Among the 390 patients included, 110 had ECG strain (28%). They had significantly lower body mass index, higher mean transaortic pressure gradient and Cornell-product ECG LV hypertrophy than in those without ECG strain. There was also a trend for lower LV ejection fraction in patients with ECG strain as compared with those without. Patients with ECG strain had significantly lower 8-year survival than those without. ECG strain remained associated with reduced survival both in patients with and without LV hypertrophy (p <0.0001 for both). After adjustment, ECG strain remained a strong and independent determinant of long-term survival (hazard ratio 4.4, p <0.0001). Similar results were found in patients with LV hypertrophy or without LV hypertrophy. In the multivariate model, the addition of ECG strain provided incremental prognostic value (p <0.0001). In conclusion, in patients with AS, ECG strain is associated with 4-fold increased risk of long-term mortality after isolated AVR, regardless of preoperative LV hypertrophy.

Prognostic Value of Exercise-Stress Echocardiography in Asymptomatic Patients With Aortic Valve Stenosis

OBJECTIVES

This study sought to evaluate the prognostic value of mean pressure gradient (MPG) increase and peak systolic pulmonary artery pressure (SPAP) measured during exercise stress echocardiography in asymptomatic patients with aortic stenosis (AS).

BACKGROUND

Exercise testing is recommended in asymptomatic AS patients, but the additional value of exercise-stress echocardiography, especially the prognostic value of MPG increase and peak SPAP, is still debated.

METHODS

We enrolled all consecutive patients with pure, isolated, asymptomatic AS and preserved ejection fraction ≥50% and normal SPAP (<50 mm Hg) who underwent symptom-limited exercise echocardiography at our institution. Occurrence of AS-related events (symptoms or congestive heart failure) or occurrence of aortic valve replacement was recorded.

RESULTS

We enrolled 148 patients (66 ± 15 years of age; 74% males; MPG: 47 ± 13 mm Hg; SPAP: 34 ± 6 mm Hg). No complications were observed. Thirty-six patients (24%) had an abnormal exercise test result (occurrence of symptoms, fall in blood pressure, and/or ST-segment depression) and were referred for surgery. Among the 112 patients with a normal exercise test result, 38 patients (34%) had abnormal exercise echocardiography scores (MPG increase >20 mm Hg and/or SPAP at peak exercise >60 mm Hg). These 112 patients were managed conservatively. During a mean follow-up of 14 ± 8 months, an AS-related event occurred in 30 patients, and 25 patients underwent surgery. Neither MPG increase >20 mm Hg nor peak SPAP >60 mm Hg was predictive of occurrence of AS-related events or aortic valve replacement (all p > 0.20). In contrast, baseline AS severity was an important prognostic factor (all p < 0.01).

CONCLUSIONS

In this observational study including 148 patients with asymptomatic AS, we confirmed and extended the importance of exercise testing for unveiling functional limitation. More importantly, neither the increase in MPG nor in SPAP at peak exercise was predictive of outcome. Our results do not support the use of these parameters in risk-stratification and clinical management of asymptomatic AS patients.

Incremental Value of Two Dimensional Speckle Tracking Echocardiography in the Functional Assessment and Characterization of Subclinical Left Ventricular Dysfunction

Subclinical left ventricular (LV) dysfunction refers to subtle abnormalities in LV function which typically precede a reduction in the left ventricular ejection fraction (LVEF). The assessment of myocardial function using LVEF, a radial metric of systolic function, is subject to load dependence, intra-observer and inter-observer variability. Reductions in LVEF typically manifest late in the disease process thus compromising the ability to intervene before irreversible impairment of systolic performance sets in. 2-Dimensional speckle tracking echocardiography (2D-STE), a novel strain imaging modality has shown promise as a sensitive indicator of myocardial contractility. It arms the clinician with a powerful and practical tool to rapidly quantify cardiac mechanics, circumventing several inherent limitations of conventional echocardiography. This article highlights the incremental utility of 2D-STE in the detection of subclinical LV dysfunction.

Increased apical rotation in severe aortic stenosis is associated with reduced survival: a speckle-tracking study

BACKGROUND

Patients with severe aortic stenosis (AS) are known to have increased left ventricular apical rotation (ApRot) during systole, but its clinical relevance is unknown. The aim of this study was to assess the association of ApRot with patient symptoms and total mortality.

METHODS

A retrospective analysis was performed on 82 patients (mean age, 77 ± 14 years; 40% men) with newly diagnosed severe AS with indexed aortic valve areas ≤ 0.6 cm(2)/m(2) and left ventricular ejection fractions ≥ 50%. Sixty-three percent of patients were symptomatic. ApRot was calculated using speckle-tracking echocardiography. Patients were divided into two groups on the basis of ApRot: high ApRot (>4.0°, n = 41) and low ApRot (≤4.0°, n = 41).

RESULTS

There were 33 deaths and 30 aortic valve replacement procedures after 33 ± 17 months of follow-up. Patients in the high-ApRot group had smaller indexed aortic valve areas (P = .021) and increased valvuloarterial impedance (P = .014). There was no difference in overall symptoms, but the low-ApRot group experienced more syncope (P = .020). Patients in the high-ApRot group had reduced survival with medical therapy (log-rank P = .018) after aortic valve replacement (log-rank P = .039) and overall (log-rank P = .009). Asymptomatic patients with low ApRot had the best survival, while asymptomatic patients with high ApRot had similar survival to that of symptomatic patients (log-rank P = .008). On adjusted Cox regression, ApRot ≥ 6.0° was independently associated with death (hazard ratio, 3.06; P = .003). On receiver operating characteristic curve analysis, ApRot added incremental prognostic value to indexed aortic valve area, symptom status, and aortic valve replacement status.

CONCLUSION

Increased ApRot is independently associated with poor survival and may represent a compensatory mechanism to preserve cardiac output against severe obstruction to flow and high systolic load.

Role of left ventricular twist mechanics in cardiomyopathies, dance of the helices

Left ventricular twist is an essential part of left ventricular function. Nevertheless, knowledge is limited in “the cardiology community” as it comes to twist mechanics. Fortunately the development of speckle tracking echocardiography, allowing accurate, reproducible and rapid bedside assessment of left ventricular twist, has boosted the interest in this important mechanical aspect of left ventricular deformation. Although the fundamental physiological role of left ventricular twist is undisputable, the clinical relevance of assessment of left ventricular twist in cardiomyopathies still needs to be established. The fact remains; analysis of left ventricular twist mechanics has already provided substantial pathophysiological understanding on a comprehensive variety of cardiomyopathies. It has become clear that increased left ventricular twist in for example hypertrophic cardiomyopathy may be an early sign of subendocardial (microvascular) dysfunction. Furthermore, decreased left ventricular twist may be caused by left ventricular dilatation or an extensive myocardial scar. Finally, the detection of left ventricular rigid body rotation in noncompaction cardiomyopathy may provide an indispensible method to objectively confirm this difficult diagnosis. All this endorses the value of left ventricular twist in the field of cardiomyopathies and may further encourage the implementation of left ventricular twist parameters in the “diagnostic toolbox” for cardiomyopathies.

Left ventricular twisting modifications in patients with left ventricular concentric hypertrophy at increasing after-load conditions

AIMS

Left ventricular hypertrophy (LVH) develops as a result of several clinical conditions, such as intensive training, hypertension, aortic valve stenosis. Aim of this study was to analyze the left ventricular twist (LVT) modifications in LVH patients with increasing after-load conditions.

METHODS

A total of 131 patients were enrolled: 17 healthy sedentary people (Hg), without concentric LVH; 45 water polo players (ATg); 22 patients with hypertensive cardiopathy (HPg); 47 patients with different degrees of aortic stenosis (ASg); all patients had concentric LVH, ejection fraction (EF) >54%, and were age-matched. The left ventricular end-systolic wall stress (LV-ESWS) was used as index of after-load.

RESULTS

Left ventricular twist value showed a progressive increase from ATg to ASg, according to increasing after-load. Longitudinal left ventricular function by tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) was reduced in HPg and ASg. There was a negative correlation between LVT and longitudinal systolic function at TDI and STE (r = -0.4; P < 0.001; -0.23; P < 0.05). E/A ratio was lower in HPg and ASg than ATg and Hg. LVT was linearly related to LV-ESWS (r = 0.36; P < 0.01), E/A ratio (r = -0.59; P < 0.001), E/E' ratio (r = 0.43; P < 0.001), age (r = 0.5; P < 0.001), relative wall thickness (RWT) (r = 0.38; P < 0.01), heart rate (HR) (r = 0.3; P < 0.05), maximum (G. max), and mean transvalvular gradient (G. mean) in ASg (r = 0.37; P < 0.01, r = 0.4; P < 0.01). RWT, E/A ratio, and HR were independent predictor of LVT (β = 0.23; P = 0.007; -0.44; P = 0.001; 0.17; P = 0.049). Only in ASg, G. mean was independent predictor of LVT (β = 0.44; P = 0.01).

CONCLUSION

Left ventricular twist showed a linear trend at increasing after-load values to compensate the reduction in systolic longitudinal function in pathological LVH patients.