Automated Functional Imaging for Assessment of Left Ventricular Mechanics in the Presence of Left Ventricular Hypertrophy

Incremental prognostic utility of left ventricular and left atrial strains in coronary artery disease patients with reduced systolic function

OBJECTIVE

This study aimed to investigate the predictive value of left ventricular global longitudinal strain (GLS) and left atrial reservoir strain (LARS) on adverse events in chronic coronary artery disease (CAD) patients with reduced systolic function.

METHODS

A total of 192 consecutive patients clinically diagnosed with chronic CAD and left ventricular ejection fraction (LVEF) ≤ 50% were finally included. Multiple strain parameters were analyzed with speckle tracking echocardiography. The composite endpoint included all-cause mortality, rehospitalization due to heart failure, myocardial infarction, and stroke.

RESULTS

Patients experiencing the endpoint showed lower LVEF, lower absolute GLS and LARS than those without events. Both GLS (AUC = 0.82 [GLS] vs. 0.58 [LVEF], p < 0.001) and LARS (AUC = 0.71 [LARS] vs. 0.58 [LVEF], p = 0.033) were superior to LVEF in predicting adverse events. Multivariate cox regression analysis showed that both GLS (hazard ratio, 0.71; 95% CI, 0.63-0.79; p < 0.001) and LARS (hazard ratio, 0.96; 95% CI, 0.93-0.98; p < 0.001) were independent predictors for the endpoint. The addition of LARS (global chi-squared, 35.7 vs. 17.4; p < 0.05), GLS (global chi-squared, 58.6 vs. 17.4; p < 0.05) or both LARS and GLS (global chi-squared, 79.6 vs. 17.4; p < 0.05) to LVEF in the prediction model significantly improved its performance. The same significant improvement was also shown in the subgroups of mild (30% < LVEF ≤ 50%) and severe (LVEF ≤ 30%) reduced systolic function.

CONCLUSIONS

Regarding CAD patients with reduced LVEF, both GLS and LARS are superior to LVEF in predicting adverse events, providing significant incremental value to LVEF.

Glycogen storage cardiomyopathy (PRKAG2): diagnostic findings of standard and advanced echocardiography techniques

AIMS

Describe the findings obtained using standard echocardiography (Echo) and deformation indices (2D and 3D speckle tracking strain) in patients (Pts) with PRKAG2 cardiomyopathy. Seek to identify any peculiar characteristics and possible strain patterns that may distinguish this condition from other causes of left ventricular hypertrophy (LVH).

METHODS AND RESULTS

Thirty Pts with genetically proven PRKAG2 (R302Q and H401Q), 16 (53.3%) male, mean age 39.1± 15.4 years old, were examined using standard, speckle tracking (STE), and 3D Echo. Pacemaker (PM) had been implanted in 12 (40%) Pts with a mean age of 38.1 ± 13 years. Hypertrophy was found in varying degrees in 18 (86%) Pts. Seven Pts (24%) presented 3D ejection fraction (EF) below normal limits. Diastolic function was abnormal in 17 (63%) Pts. Global longitudinal strain (GLS) on 2D measured -16.4% ± 5.3%. GLS measured -13.2% ± 4.8%, global radial strain 40.8% ± 13.8%, global circumferential strain (GCS) -16.1% ± 4.4%, and global area strain -26.1% ± 6.7% by 3D Echo offline analyses. Pts with PM presented lower EF and GCS compared with those without PM. EF/GLS measured 3.65 ± 1.00. In the bull's eye map, a strain pattern similar to stripes in 18 (60%) Pts was identified, which might be a differentiating signal among LVH.

CONCLUSION

Echocardiography is a valuable tool in detecting diffuse and focal myocardial abnormalities in PRKAG2 cardiomyopathy. The deformation indices are especially revealing because they may help distinguish this rare infiltrative disease, thereby favouring early diagnosis, enhanced treatment, and improved outcome.

Exploring the determinants of the cardiac changes after ultra-long duration exercise: The echocardiographic Spartathlon study

Aim

The investigation of the pathophysiological determinants of cardiac changes following ultra-long duration exercise.

Methods

Twenty-seven runners who finished a 246 km running race were examined both before and after the finish of the race. Examinations included echocardiography and measurement of body weight and blood biochemical parameters.

Results

Exercise increased left ventricular end-diastolic interventricular septum thickness (LVIVSd) ( p < 0.001) and posterior wall thickness (LVPWTd) ( p = 0.001) and right ventricular end-diastolic area ( p = 0.005), while reduced tricuspid annular plane systolic excursion (TAPSE) ( p = 0.004). A minor decrease in the peak absolute values of both left ventricular (from −20.9 ± 2.3% to −18.8 ± 2.0%, p = 0.009) and right ventricular (from −22.9 ± 3.6% to −21.2 ± 3.0%, p = 0.040) global longitudinal strains occurred. There was decrease in body weight ( p < 0.001) and increase in both circulating high-sensitivity troponin I ( p = 0.028) and amino-terminal pro-B type natriuretic peptide (NT-proBNP) ( p = 0.018). The change in the sum of LVIVSd and LVPWTd correlated negatively with percentage change of body weight ( r = −0.416, p = 0.049). The only independent determinant of post-exercise NT-proBNP was pulmonary artery systolic pressure ( r = 0.797, p = 0.002). Post-exercise NT-proBNP correlated positively with percentage changes of basal (RVbas) ( r = 0.582, p = 0.037) and mid-cavity (RVmid) ( r = 0.618, p = 0.043) right ventricular diameters and negatively with percentage change of TAPSE ( r = −0.720, p = 0.008). Similar correlations with RVbas, RVmid and TAPSE were found for pulmonary artery systolic pressure. Post-exercise high-sensitivity troponin I correlated negatively with percentage change of body weight ( r = −0.601, p = 0.039), but was not associated with any cardiac parameter.

Conclusion

The main cardiac effects of ultra-long duration exercise were the decrease in left ventricular end-diastolic dimensions and increase in left ventricular wall thickness, as well as minimal dilatation and alteration in systolic function of right ventricle, possibly due to the altered exercise-related right ventricular afterload.

Heart failure readmissions: a losing battle or an opportunity for improvement?

Despite great strides in diagnosis and management of heart failure (HF), this chronic illness continues to be a worldwide epidemic with approximately 23 million people afflicted across the globe. In the US, over 6.5 million carry a HF diagnosis with almost 90% of all HF deaths occurring in patients over the age of 70. Since one in five Americans are expected to be older than 65 years by 2050, almost 1,000,000 new HF cases are expected to be diagnosed every year. The staggering nature of these numbers only pales in comparison to current dismal HF survival statistics. The unavoidable natural history of HF continues to be characterized by the occurrence of repetitive hospital admissions. Not only are hospital readmissions demarcated as one of the most important risk factors associated with mortality; but also, a well-recognized trigger for additional hospital readmissions. Even when HF treatment guidelines have been recently updated; the mere fact that four HF societies have issued individual recommendations without reaching a common unifying consensus statement adds to the complexity of HF patient management. The purpose of this Editorial not only to fuel more interest on this topic but also to spark the notion that we have a potential catastrophe in our hands and is the responsibility of all health-care professionals to attend to this vital issue.

Are Measures of Left Ventricular Longitudinal Shortening Affected by Left Atrial Enlargement?

BACKGROUND

Even though left atrial (LA) size and function are intimately related to left ventricular (LV) diastolic dysfunction, the role of LA with regard to LV systolic function is less clear. Consequently, we examined the potential association that might exist between measures of longitudinal LV systolic shortening and LA dilation using LA volume index (LAVI).

METHODS

In this retrospective analysis, data from 75 echocardiograms (mean age 53 ± 14; range 24 - 89 years; mean body surface area (BSA) 2.0 ± 0.3) were analyzed.

RESULTS

Peak global longitudinal (PGLS) correlated best with LV mass index (LVMI) followed by mitral annular systolic excursion (MAPSE), and age. Similar results were obtained when analyzing the best variables that correlated with LAVI. Finally, MAPSE correlated best with PGLS, then with MA tissue Doppler systolic velocity, BSA, and LAVI in that order. All patients had normal LV ejection fraction (LVEF) and normal sinus rhythm when studied.

CONCLUSIONS

LAVI does not directly affect LV systolic function and longitudinal measures of LV shortening are mainly dependent on LV mass. Additional studies are now required to determine how these associations vary when different degrees of LV dilatation and systolic dysfunction are included in the analysis.

Left ventricular global longitudinal strain is independently associated with mortality in septic shock patients

PURPOSE

Conventional echocardiography may not detect subtle cardiac dysfunction of septic patients. Two-dimensional left ventricular (LV) global peak systolic longitudinal strain (GLS) can detect early cardiac dysfunction. We sought to determine the prognostic value of GLS for septic shock patients admitted to intensive care units (ICUs).

METHODS

We prospectively included 111 ICU patients with septic shock. A full medical history was recorded for each patient, and LV systolic function, including GLS, was measured. Our endpoints were ICU and hospital mortality.

RESULTS

The ICU and hospital mortalities were 31.5% (n = 35) and 35.1% (n = 39), respectively. There was no significant difference in LV ejection fraction of the non-survivors and the survivors; however, upon ICU admission, the non-survivors exhibited GLSs that were less negative than those of the survivors, which indicated worse LV systolic function. GLS of -13% presented the best sensitivity and specificity in the prediction of mortality (area under the curve 0.79). The patients with GLS ≥ -13% exhibited higher ICU and hospital mortality rates (hazard ratio 4.34, p < 0.001 and hazard ratio 4.21, p < 0.001, respectively). Cox regression analyses revealed that higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores and less negative GLSs were independent predictors of ICU and hospital mortalities. GLS was found to add prognostic information to the APACHE II score.

CONCLUSIONS

These findings suggest that combining GLS and the APACHE II score has additive value in the prediction of ICU and hospital mortalities and that GLS may help in early identification of high-risk septic shock patients in ICU.