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Li GA, Huang J, Fan L. Evaluation of left ventricular systolic function in type 2 diabetes mellitus patients with and without peripheral vascular disease. World J Diabetes 2024; 15:1280-1290. [DOI: 10.4239/wjd.v15.i6.1280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/29/2024] [Accepted: 04/26/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Peripheral vascular disease (PVD) is a common complication of type 2 diabetes mellitus (T2DM). Patients with T2DM have twice the risk of PVD as nondiabetic patients.
AIM To evaluate left ventricular (LV) systolic function by layer-specific global longitudinal strain (GLS) and peak strain dispersion (PSD) in T2DM patients with and without PVD.
METHODS Sixty-five T2DM patients without PVD, 57 T2DM patients with PVD and 63 normal controls were enrolled in the study. Layer-specific GLS [GLS of the epimyocardium (GLSepi), GLS of the middle myocardium (GLSmid) and GLS of the endocardium (GLSendo)] and PSD were calculated. Receiver operating characteristic (ROC) analysis was performed to calculate the sensitivity and specificity of LV systolic dysfunction in T2DM patients with PVD. We calculated Pearson’s correlation coefficients between biochemical data, echocardiographic characteristics, and layer-specific GLS and PSD.
RESULTS There were significant differences in GLSepi, GLSmid and GLSendo between normal controls, T2DM patients without PVD and T2DM patients with PVD (P < 0.001). Trend tests revealed a ranking of normal controls > T2DM patients without PVD > T2DM patients with PVD in the absolute value of GLS (P < 0.001). PSD differed significantly between the three groups, and the trend ranking was as follows: normal controls < T2DM patients without PVD < T2DM patients with PVD (P < 0.001). ROC analysis revealed that the combination of layer-specific GLS and PSD had high diagnostic efficiency for detecting LV systolic dysfunction in T2DM patients with PVD. Low-density lipoprotein cholesterol was positively correlated with GLSepi, GLSmid and PSD (P < 0.05), while LV ejection fraction was negatively correlated with GLSepi, GLSmid and GLSendo in T2DM patients with PVD (P < 0.01).
CONCLUSION PVD may aggravate the deterioration of LV systolic dysfunction in T2DM patients. Layer-specific GLS and PSD can be used to detect LV systolic dysfunction accurately and conveniently in T2DM patients with or without PVD.
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Affiliation(s)
- Guang-An Li
- Department of Echocardiography, The Affiliated Changzhou Second People’s Hospital with Nanjing Medical University, Changzhou 213000, Jiangsu Province, China
| | - Jun Huang
- Department of Echocardiography, The Affiliated Changzhou Second People’s Hospital with Nanjing Medical University, Changzhou 213000, Jiangsu Province, China
| | - Li Fan
- Department of Echocardiography, The Affiliated Changzhou Second People’s Hospital with Nanjing Medical University, Changzhou 213000, Jiangsu Province, China
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2
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Steudel T, Barzen G, Frumkin D, Romero-Dorta E, Spethmann S, Hindricks G, Stangl K, Knebel F, Heidecker B, Canaan-Kühl S, Pernice HF, Hahn K, Mattig I, Brand A. Diagnostic value of left ventricular layer strain and specific regional strain patterns in cardiac amyloidosis and Fabry disease. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae041. [PMID: 38863522 PMCID: PMC11165315 DOI: 10.1093/ehjopen/oeae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/30/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
Aims Layer-specific left ventricular (LV) strain alterations have been suggested as a specific finding in Fabry disease (FD). Our study aimed to assess the diagnostic value of layer-specific radial strain (RS) indices compared to the established LV regional strain pattern in cardiac amyloidosis (CA) and FD, i.e. apical sparing and posterolateral strain deficiency (PLSD). Methods and results We retrospectively analysed the global, subendocardial, subepicardial LV radial strain, the corresponding strain gradient, as well as the regional and global longitudinal strain. The diagnostic accuracy of the diverse LV strain analyses was comparatively assessed using receiver operating characteristic curve and multivariable regression analyses. In 40 FD and 76 CA patients, CA featured more reduced layer strain values [global RS -12.3 (-15.6 to -9.6) in CA vs. -16.7 (-20.0 to -13.6) in FD; P < 0.001; subendocardial RS -22.3 (-27.4 to -15.9) vs. -28.3 (-31.8 to -23.6), P < 0.001; subepicardial RS -6.6 (-8.6 to -4.7) in CA vs. -8.9 (-11.7 to - 6.5) in FD; P < 0.001]. Global radial and longitudinal strain held an area under the curve (AUC) of 0.75 (0.66-0.84) and AUC 0.73 (0.63-0.83). While the apical sparing and PLSD strain pattern showed the highest accuracy as single parameters [AUC 0.87 (0.79-0.95) and 0.81 (0.72-0.89), P < 0.001], the combination of subendocardial RS and the apical sparing pattern featured the highest diagnostic accuracy [AUC 0.92 (0.87-0.97)]. Conclusion Combining radial strain-derived parameters to the established strain pattern apical sparing and PLSD improve the diagnostic accuracy in the echocardiographic assessment in suspected storage disease.
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Affiliation(s)
- Tilman Steudel
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
| | - Gina Barzen
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
| | - David Frumkin
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Elena Romero-Dorta
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
| | - Sebastian Spethmann
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Gerhard Hindricks
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Karl Stangl
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Fabian Knebel
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- Sana Klinikum Lichtenberg, Innere Medizin II: Schwerpunkt Kardiologie, Berlin, Germany
| | - Bettina Heidecker
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, Berlin 12203, Germany
| | - Sima Canaan-Kühl
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Fabry Zentrum, Zentrum für seltene Nierenerkrankungen (CeRKiD), Campus Charité Mitte, Charitéplatz 1, Berlin 10117, Germany
| | - Helena Franziska Pernice
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie und Experimentelle Neurologie, Charitéplatz 1, Berlin 10117, Germany
| | - Katrin Hahn
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik für Neurologie und Experimentelle Neurologie, Charitéplatz 1, Berlin 10117, Germany
| | - Isabel Mattig
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Anna Brand
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Charité – Universitätsmedizin Berlin, Amyloidosis Center Charité Berlin (ACCB) , Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Monda E, Falco L, Palmiero G, Rubino M, Perna A, Diana G, Verrillo F, Dongiglio F, Cirillo A, Fusco A, Caiazza M, Limongelli G. Cardiovascular Involvement in Fabry's Disease: New Advances in Diagnostic Strategies, Outcome Prediction and Management. Card Fail Rev 2023; 9:e12. [PMID: 37602190 PMCID: PMC10433112 DOI: 10.15420/cfr.2023.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/22/2023] [Indexed: 08/22/2023] Open
Abstract
Cardiovascular involvement is common in Fabry's disease and is the leading cause of morbidity and mortality. The research is focused on identifying diagnostic clues suggestive of cardiovascular involvement in the preclinical stage of the disease through clinical and imaging markers. Different pathophysiologically driven therapies are currently or will soon be available for the treatment of Fabry's disease, with the most significant benefit observed in the early stages of the disease. Thus, early diagnosis and risk stratification for adverse outcomes are crucial to determine when to start an aetiological treatment. This review describes the cardiovascular involvement in Fabry's disease, focusing on the advances in diagnostic strategies, outcome prediction and disease management.
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Affiliation(s)
- Emanuele Monda
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
- Institute of Cardiovascular Science, University College LondonLondon, UK
| | - Luigi Falco
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Alessia Perna
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Gaetano Diana
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Annapaola Cirillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Adelaide Fusco
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi HospitalNaples, Italy
- Institute of Cardiovascular Science, University College LondonLondon, UK
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4
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Pucci M, Iadevaia V, Gammaldi V, Iervolino A, Capece LM, Sciascia D, Cuomo V, Iacono M, Paoletta D, Santoro C, Esposito R. Right Ventricular Myocardial Involvement in Anderson-Fabry Disease at Diagnosis: Evaluation with Three-Dimensional Strain Imaging. Life (Basel) 2023; 13:1571. [PMID: 37511946 PMCID: PMC10381814 DOI: 10.3390/life13071571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Background: Right ventricular (RV) involvement in Anderson-Fabry disease (AFD) is well known in the advanced stages of the disease RV hypertrophies, but little is known about the early involvement. The aim of our study was to assess RV function in AFD patients at diagnosis. Methods: A total of 23 AFD patients and 15 controls comparable for age and sex were recruited. A complete 2D standard echo with 3D volumetric and strain analysis of RV was performed. Results: Two patient populations, comparable for clinical baseline characteristics were considered. RV free wall thickness was significantly increased in the AFD group. No significant differences in standard RV indices (TAPSE, transverse diameter, tissue Doppler velocities of the lateral tricuspid annulus) were found. A 3D volumetric analysis showed reduced RV ejection fraction and lower values of longitudinal septal, free wall and global longitudinal strain (GLS) in AFD patients. RV free wall thickness significantly correlated with both free wall RV LS and RV GLS. In multiple linear regression analysis, RV free wall thickness was independently associated with RV GLS even after correction for age and heart rate. Conclusions: In AFD patients, 3D echocardiography allows for the identification of early subclinical functional impairment of RV. RV dysfunction is independently associated with RV hypertrophy.
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Affiliation(s)
- Martina Pucci
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Velia Iadevaia
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Vittoria Gammaldi
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Adelaide Iervolino
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Luca Maria Capece
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Domenico Sciascia
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Vittoria Cuomo
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Marina Iacono
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Daniele Paoletta
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy
| | - Roberta Esposito
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
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5
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Citro R, Prota C, Ferraioli D, Iuliano G, Bellino M, Radano I, Silverio A, Migliarino S, Polito MV, Ruggiero A, Napoletano R, Bellizzi V, Ciccarelli M, Galasso G, Vecchione C. Importance of Echocardiography and Clinical “Red Flags” in Guiding Genetic Screening for Fabry Disease. Front Cardiovasc Med 2022; 9:838200. [PMID: 35548424 PMCID: PMC9081601 DOI: 10.3389/fcvm.2022.838200] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/24/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Aim of this study was to evaluate, in a metropolitan area not already explored, the prevalence of Anderson–Fabry disease, by genetic screening, in patients with echocardiographic evidence of left ventricular hypertrophy (LVH) of unknown origin and “clinical red flags”. Methods From August 2016 to October 2017, all consecutive patients referring to our echo-lab for daily hospital practices with echocardiographic evidence of LVH of unknown origin in association with history of at least one of the classical signs and symptoms related to Fabry disease (FD) (neuropathic pain, anhidrosis/hypohidrosis, angiokeratomas, gastrointestinal problems, chronic kidney disease, or cerebrovascular complications) were considered eligible for the FD genetic screening program. Through dried blood spot testing, α-Galactosidase A (α-Gal A) activity and analysis of the GLA gene were performed. Results Among 3,360 patients who underwent transthoracic echocardiography in our echo-lab during the study period, 30 patients (0.89%; 19 men, mean age 58 ± 18.2 years) were selected. FD was diagnosed in 3 (10%) unrelated patients. Three different GLA gene mutations were detected, one of them [mutation c.388A > G (p.Lys130Glu) in exon 3] never described before. Moreover, probands' familiar genetic screening allowed the identification of 5 other subjects affected by FD. Conclusion In a metropolitan area not previously investigated, among patients with LVH of unknown origin associated with other “red flags,” undergoing genetic screening, the prevalence of FD was very high (10%). Our results highlight the importance of an echocardiographic- and clinical-oriented genetic screening for FD in patients with uncommon cause of LVH.
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Affiliation(s)
- Rodolfo Citro
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
- Vascular Physiopathology Unit, Department of Angio-Cardio-Neurology, IRCCS Neuromed, Pozzilli, Italy
- *Correspondence: Rodolfo Citro
| | - Costantina Prota
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Donatella Ferraioli
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Giuseppe Iuliano
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Michele Bellino
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Ilaria Radano
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Angelo Silverio
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Serena Migliarino
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Maria Vincenza Polito
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Artemisia Ruggiero
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Rosa Napoletano
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Vincenzo Bellizzi
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Michele Ciccarelli
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Gennaro Galasso
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Carmine Vecchione
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
- Vascular Physiopathology Unit, Department of Angio-Cardio-Neurology, IRCCS Neuromed, Pozzilli, Italy
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6
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Wang SC, Tapia D, Kimonis VE, Lombardo DM. Regional Strain Pattern and Correlation with Cardiac Magnetic Resonance Imaging in Fabry Disease. J Cardiovasc Echogr 2021; 31:131-136. [PMID: 34900547 PMCID: PMC8603780 DOI: 10.4103/jcecho.jcecho_119_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/31/2021] [Accepted: 07/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Cardiovascular disease is the most common cause of death among Fabry disease patients, who carry significantly increased risk for heart failure and sudden cardiac death. Echocardiographic strain imaging and cardiac MRI are important clinical tools for early detection of cardiomyopathy before onset of systolic or diastolic dysfunction. However, studies on these imaging modalities are limited among Fabry patients. Aim and Objective: To evaluate echocardiographic strain pattern and correlation with cardiac MRI in Fabry disease. Materials and Methods: We performed a detailed analysis of global longitudinal strain and correlation with cardiac MRI finding in 9 patients diagnosed with Fabry disease. Results: Despite normal left ventricular ejection fraction, basal and mid inferior segments are more likely to demonstrate strain abnormalities compared to other regions. Additionally, increased interventricular septal and left ventricular posterior wall thickness are correlated with greater strain abnormalities. Finally, MRI evidence of fibrosis and infiltration are detected among most patients with strain abnormalities, but in some cases, strain imaging were able to detect early evidence of cardiomyopathy even before MRI was fully able to detect the change. Basal and mid inferoseptal segment strain abnormalities are early signs of developing cardiomyopathy among patients with Fabry disease. Conclusion: Though cardiac MRIs are critical tools for detection of myocardial infiltration and scarring, these findings may not always be detectable in early phases of the disease. Multiple imaging modalities maybe considered in monitoring and evaluation of cardiomyopathy in Fabry disease.
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Affiliation(s)
- Stephani C Wang
- Department of Medicine, Division of Cardiology, University of California, Irvine, CA, USA
| | - Daisy Tapia
- Department of Pediatrics, Division of Genetic and Genomic Medicine, University of California, Irvine, CA, USA
| | - Virginia E Kimonis
- Department of Pediatrics, Division of Genetic and Genomic Medicine, University of California, Irvine, CA, USA
| | - Dawn M Lombardo
- Department of Medicine, Division of Cardiology, University of California, Irvine, CA, USA
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7
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Barssoum K, Victor V, Salem A, Kumar A, Mubasher M, Hassib M, Magdi M, Renjithlal S, Abdelazeem M, Shariff M, Idemudia O, Ibrahim M, Mohamed A, Thakkar S, Patel H, Diab M, Szeles A, Ibrahim F, Jha R, Chowdhury M, Akula N, Kalra A, Nanda NC. Echocardiography, lung ultrasound, and cardiac magnetic resonance findings in COVID-19: A systematic review. Echocardiography 2021; 38:1365-1404. [PMID: 34236091 PMCID: PMC8444724 DOI: 10.1111/echo.15152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/25/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The manifestations of COVID-19 as outlined by imaging modalities such as echocardiography, lung ultrasound (LUS), and cardiac magnetic resonance (CMR) imaging are not fully described. METHODS We conducted a systematic review of the current literature and included studies that described cardiovascular manifestations of COVID-19 using echocardiography, CMR, and pulmonary manifestations using LUS. We queried PubMed, EMBASE, and Web of Science for relevant articles. Original studies and case series were included. RESULTS This review describes the most common abnormalities encountered on echocardiography, LUS, and CMR in patients infected with COVID-19.
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Affiliation(s)
- Kirolos Barssoum
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Varun Victor
- Department of Internal MedicineCanton Medical Education FoundationCantonOhioUSA
| | - Ahmad Salem
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Ashish Kumar
- Section of Cardiovascular ResearchHeartVascular and Thoracic DepartmentCleveland Clinic Akron GeneralAkronOhioUSA
- Department of Internal MedicineCleveland Clinic Akron GeneralAkronOhioUSA
| | - Mahmood Mubasher
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | | | - Mohamed Magdi
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Sarathlal Renjithlal
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Mohamed Abdelazeem
- Department of Internal MedicineSt. Elizabeth Medical CenterBrightonMassachusettsUSA
| | | | - Osarenren Idemudia
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Mounir Ibrahim
- Department of Internal MedicineHackensack Meridian Health Palisades Medical CenterNorth BergenNew JerseyUSA
| | - Amr Mohamed
- Department of Internal MedicineRochester General HospitalRochesterNew YorkUSA
| | | | - Harsh Patel
- Department of Internal MedicineLouis A Weiss Memorial HospitalChicagoIllinoisUSA
| | - Mohamed Diab
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Andras Szeles
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Fadi Ibrahim
- American University of AntiguaAntigua and Barbuda
| | - Roshan Jha
- Department of Internal MedicineHackensack Meridian Health Palisades Medical CenterNorth BergenNew JerseyUSA
| | - Medhat Chowdhury
- Department of Internal MedicineRochester General HospitalRochesterNew YorkUSA
| | - Navya Akula
- Department of Internal MedicineRochester Regional HealthUnity HospitalRochesterNew YorkUSA
| | - Ankur Kalra
- Section of Cardiovascular ResearchHeartVascular and Thoracic DepartmentCleveland Clinic Akron GeneralAkronOhioUSA
- Department of Cardiovascular MedicineHeart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Navin C. Nanda
- Division of Cardiovascular DiseaseDepartment of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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8
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Tsugu T, Nagatomo Y, Dulgheru R, Lancellotti P. Layer-specific longitudinal strain predicts left ventricular maximum wall thickness in patients with hypertrophic cardiomyopathy. Echocardiography 2021; 38:1149-1156. [PMID: 34028870 DOI: 10.1111/echo.15125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS The aim of this study was (a) to clarify the detailed mechanisms of structural and functional abnormalities of myocardial tissue in hypertrophic cardiomyopathy (HCM) using layer-specific strain (LSS) and compare it with healthy subjects (b) to investigate the diagnostic accuracy of LSS for HCM. METHODS AND RESULTS Forty-one patients with HCM and preserved left ventricular ejection fraction (LVEF; 66% male, 52 ± 18 years, LVEF 62.9% ± 3.7%) and 41 controls matched for age and sex (66% male, 52 ± 20 years, LVEF 63.5% ± 8.2%) underwent 2D-speckle tracking echocardiography. Absolute values of LSS were globally lower and the ratio of endocardial/epicardial layer (End/Epi ratio) was higher in HCM. LSS gradually increased from the epicardial toward the endocardial layer at all chamber views and at all levels of the LV. LSS and End/Epi ratio at the apex were higher than those at the middle or basal level of the LV. End/Epi ratio was correlated with LV maximal wall thickness both controls (r = .35, P = .03) and HCM (r = .81, P < .001). End/Epi ratio was an independent factor associated with LV maximal wall thickness (β = 0.96, P < .001). A higher End/Epi ratio (≥1.31) was associated with diagnostic criteria for HCM (sensitivity 98%, specificity 95%, area under the curve 0.99, P < .001). CONCLUSION LSS has the potential for unraveling the mechanism of impaired LV wall motion in HCM and to accurately detect HCM.
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Affiliation(s)
- Toshimitsu Tsugu
- Departments of Cardiology, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, University of Liège Hospital, Liège, Belgium
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Tokorozawa, Japan
| | - Raluca Dulgheru
- Departments of Cardiology, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, University of Liège Hospital, Liège, Belgium
| | - Patrizio Lancellotti
- Departments of Cardiology, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, University of Liège Hospital, Liège, Belgium
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9
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Cardiac Imaging in Anderson-Fabry Disease: Past, Present and Future. J Clin Med 2021; 10:jcm10091994. [PMID: 34066467 PMCID: PMC8124634 DOI: 10.3390/jcm10091994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/21/2021] [Accepted: 04/26/2021] [Indexed: 01/04/2023] Open
Abstract
Anderson-Fabrydisease is an X-linked lysosomal storage disorder caused by a deficiency in the lysosomal enzyme α-galactosidase A. This results in pathological accumulation of glycosphingolipids in several tissues and multi-organ progressive dysfunction. The typical clinical phenotype of Anderson-Fabry cardiomyopathy is progressive hypertrophic cardiomyopathy associated with rhythm and conduction disturbances. Cardiac imaging plays a key role in the evaluation and management of Anderson-Fabry disease patients. The present review highlights the value and perspectives of standard and advanced cardiovascular imaging in Anderson-Fabry disease.
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10
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Cennamo G, Montorio D, Santoro C, Cocozza S, Spinelli L, Di Risi T, Riccio E, Russo C, Pontillo G, Esposito R, Imbriaco M, Pisani A. The Retinal Vessel Density as a New Vascular Biomarker in Multisystem Involvement in Fabry Disease: An Optical Coherence Tomography Angiography Study. J Clin Med 2020; 9:jcm9124087. [PMID: 33352849 PMCID: PMC7766384 DOI: 10.3390/jcm9124087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022] Open
Abstract
In this study, we evaluated the possible relationship between the changes in retinal vessel density (VD) by optical coherence tomography angiography (OCTA) and the vascular alterations involving renal, cardiovascular and central nervous systems in patients affected by Fabry disease (FD). In 50 FD patients, the retinal superficial capillary plexus (SCP) and deep capillary plexus (DCP) in macular region were evaluated by OCTA examination. The patients also underwent a brain magnetic resonance imaging scan, renal and echocardiographic examinations with quantification of systolic pulmonary arterial pressure (PAPs) and left atrial volume index (LAVi). The VD of SCP and DCP was inversely related with E/e’ ratio, LAVi, interventricular septal thickness, global longitudinal strain (GLS) and PAPs (p < 0.05). No relationship was found, with a multivariate analysis, between OCTA parameters and kidney function and neuroradiological signs of central nervous system involvement. OCTA could be a new vascular biomarker in FD, revealing a strong correlation between retinal capillary damage and myocardial impairment, possibly preceding both renal dysfunction and cerebrovascular involvement.
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Affiliation(s)
- Gilda Cennamo
- Eye Clinic, Public Health Department, University of Naples “Federico II”, 80131 Naples, Italy
- Correspondence:
| | - Daniela Montorio
- Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Letizia Spinelli
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Teodolinda Di Risi
- CEINGE—Advanced Biotechnologies, 80145 Naples, Italy;
- Department of Public Medicine, University Federico II, 80131 Naples, Italy; (E.R.); (A.P.)
| | - Eleonora Riccio
- Department of Public Medicine, University Federico II, 80131 Naples, Italy; (E.R.); (A.P.)
| | - Camilla Russo
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
- Department of Electrical Engineering and Information Technology, University of Naples “Federico II”, 80125 Naples, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Massimo Imbriaco
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Antonio Pisani
- Department of Public Medicine, University Federico II, 80131 Naples, Italy; (E.R.); (A.P.)
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11
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Stöbe S, Richter S, Seige M, Stehr S, Laufs U, Hagendorff A. Echocardiographic characteristics of patients with SARS-CoV-2 infection. Clin Res Cardiol 2020; 109:1549-1566. [PMID: 32803387 PMCID: PMC7428201 DOI: 10.1007/s00392-020-01727-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/03/2020] [Indexed: 12/25/2022]
Abstract
Background Myocardial involvement induced by SARS-CoV-2 infection might be important for long-term prognosis. The aim of this observational study was to characterize the myocardial effects during SARS-CoV-2 infections by echocardiography. Results and methods An extended echocardiographic image acquisition protocol was performed in 18 patients with SARS-CoV-2 infection assessing LV longitudinal, radial, and circumferential deformation including rotation, twist, and untwisting. Furthermore, LV deformation was analyzed in an age-matched control group of healthy individuals (n = 20). The most prevalent finding was a reduced longitudinal strain observed predominantly in more than one basal LV segment (n = 10/14 patients, 71%). This pattern reminded of a “reverse tako-tsubo” morphology that is not typical for other viral myocarditis. Additional findings included a biphasic pattern with maximum post-systolic or negative regional radial strain predominantly basal (n = 5/14 patients, 36%); the absence or dispersion of basal LV rotation (n = 6/14 patients, 43%); a reduced or positive regional circumferential strain in more than one segment (n = 7/14 patients, 50%); a net rotation showing late post-systolic twist or biphasic pattern (n = 8/14 patients, 57%); a net rotation showing polyphasic pattern and/or higher maximum net values during diastole (n = 8/14 patients, 57%). Conclusion Myocardial involvement due to SARS-CoV-2-infection was highly prevalent in the present cohort—even in patients with mild symptoms. It appears to be characterized by specific speckle tracking deformation abnormalities in the basal LV segments. These data set the stage to prospectively test whether these parameters are helpful for risk stratification and for the long-term follow-up of these patients.
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Affiliation(s)
- Stephan Stöbe
- Department of Cardiology, Leipzig University Hospital, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Sarah Richter
- Department of Internal Medicine I, Martha-Maria Hospital Halle-Dölau, Röntgenstr. 1, 06129, Halle (Saale), Germany
| | - Markus Seige
- Department of Internal Medicine I, Martha-Maria Hospital Halle-Dölau, Röntgenstr. 1, 06129, Halle (Saale), Germany
| | - Sebastian Stehr
- Department of Anesthesiology and Intensive Care, Leipzig University Hospital, Liebigstr. 20, 04103, Leipzig, Germany
| | - Ulrich Laufs
- Department of Cardiology, Leipzig University Hospital, Liebigstr. 20, 04103, Leipzig, Germany
| | - Andreas Hagendorff
- Department of Cardiology, Leipzig University Hospital, Liebigstr. 20, 04103, Leipzig, Germany
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12
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Tünnemann-Tarr A, Stöbe S, Laufs U, Hagendorff A, Tayal B. Speckle tracking echocardiography in a patient with viral myocarditis and acute myocardial infarction. J Cardiol Cases 2020; 22:184-191. [PMID: 33014202 DOI: 10.1016/j.jccase.2020.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 10/23/2022] Open
Abstract
The present case of a patient with acute myocarditis with preserved left ventricular (LV) ejection fraction at the acute stage illustrates the obvious impairment of circumferential and rotational deformation, which can be documented by speckle tracking echocardiography. Thus, qualitative patterns of LV twist, radial strain, and circumferential layer strain, might be a new approach to detect acute myocarditis. The early diagnosis of acute myocarditis by echocardiography is important because of the considerable risk of cardiovascular morbidity as documented by the occurrence of an acute myocardial infarction presumably induced by inflammatory process in this case. <Learning objective: The compound of myocardial deformations caused by left ventricular subendomyocardial and subepimyocardial fibers may be a crucial diagnostic target in cardiac diseases. The predominant involvement of viral myocarditis of the outer myocardial layers might induce impairment of circumferential and rotational deformation, which can potentially serve as a new diagnostic key by echocardiography. In contrast, left ventricular ejection fraction and longitudinal deformation are often observed within normal ranges in patients with acute myocarditis. Acute myocardial infarction as a major cardiac event in acute stage of myocarditis causes completely different deformation patterns, mainly by the predominant involvement of the inner myocardial layers inducing severe pathologies of territorial longitudinal deformation. Patients with suspected acute myocarditis and abnormal findings of circumferential and rotational deformation should undergo additional diagnostic procedures as cardiac magnetic resonance and myocardial biopsy to confirm the diagnosis.>.
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Affiliation(s)
| | - Stephan Stöbe
- Department of Cardiology, University Hospital of Leipzig, Leipzig, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital of Leipzig, Leipzig, Germany
| | - Andreas Hagendorff
- Department of Cardiology, University Hospital of Leipzig, Leipzig, Germany
| | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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13
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Assessment of left ventricular systolic function in hypertrophic cardiomyopathy patients with myocardial injury: a study based on layer-specific speckle tracking echocardiaography. Int J Cardiovasc Imaging 2020; 36:2129-2137. [PMID: 32602022 DOI: 10.1007/s10554-020-01921-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/15/2020] [Indexed: 10/24/2022]
Abstract
We conducted this study to investigate left ventricle (LV) systolic function in endocardial, mid-myocardial, and epicardial layers by two-dimensional (2D) speckle tracking echocardiography (STE) in hypertrophic cardiomyopathy (HCM) patients with myocardial injury indexed by elevated serum cardiac troponin I (cTnI). Twenty-nine HCM patients with myocardial injury, thirty-five HCM patients without myocardial injury, and ninty-one healthy controls were enrolled in this study. Serum cTnI > 0.026 ng/mL was defined as myocardial injury. LV longitudinal and circumferential strain (LS and CS) were assessed in endocardial, mid-myocardial and epicardial layers. Layer-specific LS and CS differed significantly (all P < 0.001) among all three groups in all three layers, in a descending order from healthy controls to HCM patients without myocardial injury to HCM patients with myocardial injury. Layer-specific LS and CS were decreased the most in HCM patients with myocardial injury indexed by elevated seum cTnI (all P < 0.05). In HCM patients with myocardial injury, layer-specific LS and CS were significantly lower in the segments with greater hypertrophy (segmental thickness ≥ 15 mm) (all P < 0.001) except for endocardial CS (P > 0.05). Layer-specific evaluation of LV strain may improve understanding of impaired LV systolic function in HCM patients with myocardial injury, thus preventing further damage.
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14
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Salemi VMC, Melo MDTD. Are Myocardium Deformation Indices Influenced by Cardiac Load, Age or Body Mass Index? Arq Bras Cardiol 2019; 113:685-686. [PMID: 31691750 PMCID: PMC7020874 DOI: 10.5935/abc.20190211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Vera Maria Cury Salemi
- Instituto do Coração (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
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