Impact of Myocardial Acceleration during Isovolumic Contraction in Evaluating Subclinical Right Ventricular Systolic Dysfunction in Type 2 Diabetes Mellitus Patients

Association of Glycemic Control With Right Ventricular Function Assessed by Two-Dimensional Speckle-Tracking and Three-Dimensional Echocardiography in Type 2 Diabetes Mellitus

BACKGROUND

Right ventricular (RV) involvement has been reported in type 2 diabetes mellitus (T2DM). The relationship between glycemic control and RV function remains unknown. We aimed to investigate the association between glycemic control and RV function assessed by two-dimensional speckle-tracking echocardiography and three-dimensional echocardiography in T2DM individuals.

METHODS

This study prospectively enrolled 207 patients with T2DM and 84 individuals with normal glucose metabolism. The T2DM patients were divided into 2 subgroups according to glycated hemoglobin (HbA1c) level: controlled (HbA1c < 7.0%, n = 91) and uncontrolled subgroup (HbA1c ≥ 7.0%, n = 116). Right venticular free wall longitudinal strain (RVFWLS) was acquired by two-dimensional speckle-tracking echocardiography, and RV volumes and RV ejection fraction (RVEF) were assessed using three-dimensional echocardiography . Right ventricular coupling to pulmonary circulation was defined as the ratio of RVFWLS/pulmonary artery systolic pressure (PASP).

RESULTS

Controlled and uncontrolled T2DM subgroups had impaired RV function as reflected by reduced RVFWLS and RVEF compared to the normal glucose metabolism group. The reduction in RVFWLS was more pronounced in the uncontrolled subgroup than in the controlled subgroup (P < .001), whereas no significant difference was found in RVEF between these 2 T2DM subgroups. Higher PASP and lower RVFWLS/PASP ratio were also noted in uncontrolled T2DM patients. Additionally, the incidence of RV dysfunction was significantly higher in the uncontrolled T2DM patients than in the controlled subgroup (43.1% vs 17.6%, P < .001). After adjustment for potential clinical confounders, PASP, and left ventricular parameters, HbA1c level was independently associated with RVFWLS (β = 0.290, P = .003) and RVFWLS/PASP ratio (β = 0.028, P = .006).

CONCLUSIONS

Subclinical RV myocardial dysfunction is present in T2DM patients and is more pronounced in patients with uncontrolled blood glucose. HbA1c level is independently associated with subclinical RV myocardial dysfunction, providing further insight into a possible link between poor glycemic control and diabetic cardiomyopathy.

Evaluation of right ventricular systolic and diastolic dysfunctions in patients with type 2 diabetes mellitus with poor glycemic control by layer specific global longitudinal strain and strain rate

BACKGROUND

In order to evaluate right ventricular (RV) systolic and diastolic dysfunctions in patients with type 2 diabetes mellitus (T2DM) with poor glycemic control by layer specific global longitudinal strain (GLS) and strain rate (GLSr).

METHODS

68 T2DM patients and 66 normal controls were enrolled for the present study. RV layer specific GLS (GLSEpi, GLSMid and GLSEndo represent the epimyocardial, middle layer and endomyocardial strains, respectively) and GLSr (GLSr-S, GLSr-E and GLSr-A represent the systole, early-diastole and late-diastole strain rate) were calculated by averaging each of the three regional peak systolic strains and strain rates along the entire RV free-wall (RVFW), entire RV free-wall and septal wall (RVFSW) on RV-focused view.

RESULTS

The absolute values of RV layer specific GLS (GLSEpi, GLSMid and GLSEndo) in RVFW in T2DM patients were significantly lower than normal controls (P < 0.01), while GLSr-A was significantly larger than normal controls (P < 0.001). The absolute values of RV layer specific GLS (GLSEpi and GLSMid) in RVFSW in T2DM patients were significantly lower than normal controls (P < 0.05), while GLSr-A was significantly larger than normal controls (P < 0.001). HbA1c were poor negatived correlated with GLSEpi in RVFW and RVFSW in T2DM patients (P < 0.05). ROC analysis showed that RV layer specific GLS and GLSr-A had a high diagnostic efficacy in T2DM patients, and GLSr-A in RVFSW have the best diagnostic value in RV diastolic function in T2DM patients (AUC: 0.773).

CONCLUSION

From the research, we found that layer specific GLS and GLSr could detect the RV myocardial dysfunctions and confirmed that the impaired RV systolic and diastole functions in T2DM patients with poor glycemic control. GLSr-A in RVFSW had the best diagnostic value in evaluating RV diastolic function in T2DM patients.

Associations of (pre)diabetes with right ventricular and atrial structure and function: the Maastricht Study

Backgrounds

The role of right ventricular (RV) and atrial (RA) structure and function, in the increased heart failure risk in (pre)diabetes is incompletely understood. The purpose of this study is to investigate the associations between (pre)diabetes and RV and RA structure and function, and whether these are mediated by left ventricular (LV) alterations or pulmonary pressure.

Methods

Participants of the Maastricht Study; a population-based cohort study (426 normal glucose metabolism (NGM), 142 prediabetes, 224 diabetes), underwent two-dimensional and tissue Doppler echocardiography. Multiple linear regression analyses with pairwise comparisons of (pre)diabetes versus NGM, adjusted for cardiovascular risk factors, and mediation analyses were used.

Results

In general, differences were small. Nevertheless, in individuals with prediabetes and diabetes compared to NGM; RA volume index was lower (both p < 0.01, p_trend < 0.01), RV diameter was lower (both p < 0.01, p_trend < 0.01) and RV length was significantly smaller in diabetes (p = 0.67 and p = 0.03 respectively, p_trend = 0.04), TDI S′RV was lower (p = 0.08 and p < 0.01 respectively, p_trend < 0.01), TDI E′RV was lower (p = 0.01 and p = 0.02 respectively, p_trend = 0.01) and TDI A′RV was lower (p < 0.01 and p = 0.07 respectively, p_trend = 0.04). Only the differences in RA volume index (7.8%) and RV diameter (6.2%) were mediated by the maximum tricuspid gradient, but no other LV structure and function measurements.

Conclusions

(Pre)diabetes is associated with structural RA and RV changes, and impaired RV systolic and diastolic function, independent of cardiovascular risk factors. These associations were largely not mediated by indices of LV structure, LV function or pulmonary pressure. This suggests that (pre)diabetes affects RA and RV structure and function due to direct myocardial involvement.

Cardiac magnetic resonance feature tracking for quantifying right ventricular deformation in type 2 diabetes mellitus patients

To determine the feasibility of deformation analysis in the right ventricle (RV) using cardiovascular magnetic resonance myocardial feature tracking (CMR-FT) in type 2 diabetes mellitus (T2DM) patients. We enrolled 104 T2DM patients, including 14 with impaired right ventricular ejection fraction (RVEF) and 90 with preserved RVEF, and 26 healthy controls in this prospective study. CMR was used to determine RV feature-tracking parameters. RV strain parameters were compared among the controls, patients with preserved and reduced RVEF. Binary logistic regression was used to predict RV dysfunction. Receiver operating characteristic analysis was used to assess the diagnostic accuracy. The agreement was tested by Bland-Altman analysis. Compared with controls, longitudinal and circumferential global peak strain (PS) and PS at mid-ventricular, apical slices were significantly decreased in T2DM patients with or without reduced RVEF (p < 0.05). Within the T2DM patients, the global longitudinal PS (GLPS) and the longitudinal PS at mid-ventricular segments were significantly reduced in the reduced RVEF group than in preserved RVEF groups (p < 0.05). GLPS was an independent predictor of RV dysfunction (odds ratio: 1.246, 95% CI: 1.037-1.496; p = 0.019). The GLPS demonstrated greater diagnostic accuracy (area under curve: 0.716) to predict RV dysfunction. On Bland-Altman analysis, global circumferential PS and GLPS had the best intra- and inter-observer agreement, respectively. In T2DM patients, CMR-FT could quantify RV deformation and identify subclinical RV dysfunction in those with normal RVEF. Further, RV strain parameters are potential predictors for RV dysfunction in T2DM patients.

Impact of diabetes mellitus on the contractile properties of the left and right atrial myofilaments

OBJECTIVES

The incidence of diabetes mellitus in patients with ischaemic cardiomyopathy is increasing. To evaluate the impact of diabetes mellitus on contractility, we examined the calcium-induced force in left and right atrial myofilaments of patients with and without diabetes.

METHODS

We included 149 patients (106 without diabetes, 43 with diabetes), scheduled for elective coronary artery bypass grafting from August 2016 to June 2017. The left and right atria were excised and prepared for skinned fibre measurements (pCa-force curve). The unit for the force measurements is Millinewton (mN). Comprehensive demographic data as well as echocardiographic findings of the patients were collected.

RESULTS

We observed a significant decrease of left atrial force values in patients with diabetes, averaged over all calcium concentrations (patients with diabetes 0.50 ± 0.19 mN vs 0.68 ± 0.23 mN in patients without diabetes, P = 0.002) as well as in right atrial fibres (patients with diabetes 0.35 ± 0.17 mN vs 0.47 ± 0.21 mN in patients without diabetes, P = 0.005). There was a significant influence of repeated measurements (of the calcium concentrations) on force in left atrial myofilaments (P < 0.001). There was also a significant impact of diabetes on the force values of the different calcium concentrations in left atrial myofilaments (P 0.002). In right atrial myofilaments we also found a significant influence of repeated measurements (of the calcium concentrations) on force (P < 0.001). Additionally the impact of diabetes on the force values was significant (P = 0.005).

CONCLUSIONS

We demonstrated that diabetes mellitus has a significantly negative impact on calcium-induced force development in left and right atrial myofilaments.

Impairment of left and right ventricular longitudinal strain in asymptomatic children with type 1 diabetes

Aim

The relationship between type 1 diabetes (T1DM) and cardiac function in children is not well established. The purpose of this study was to investigate whether children and adolescents with T1DM present early asymptomatic abnormalities of left ventricular (LV) and right ventricular (RV) function. In addition, we evaluated the relationship of any such abnormalities with glycemic control and diabetes duration.

Methods

This was a prospective study. Standard echocardiography, tissue Doppler imaging, and two-dimensional strain analysis were performed prospectively in 52 children with T1DM. The results were compared with those from 52 healthy children matched for age and sex.

Results

There were no significant differences between the two groups in LV ejection fraction or RV systolic function. There was a difference between the two study groups in transtricuspid flow: the E-wave and A-wave velocities were significantly higher in the diabetic group. Left ventricular global longitudinal strain (LV GLS) was significantly lower in children with T1DM (−20.01 ± 1.86% vs. −22.99 ± 0.98%, respectively; P < .001), as was RV free-wall longitudinal strain (RV FWLS) (−29.13 ± 1.85% vs. −30.22 ± 1.53%, respectively; P = .002). LV GLS was correlated with diabetes duration (r = 0.444, P < .001) and glycated hemoglobin (HbA1c) (r = 0.683, P < .001); however, no correlation was found between RV FWLS and HbA1c or diabetes duration.

Conclusions

Our findings suggest that LV GLS and RV FWLS are impaired in children with T1DM and that the decrease in LV GLS is correlated with diabetes duration and HbA1c levels.

The E/e' ratio difference between subjects with type 2 diabetes and controls. A meta-analysis of clinical studies

Type 2 diabetes is associated with an increased risk of heart failure. Left ventricular diastolic dysfunction and type 2 diabetes are frequently associated. Using echocardiography, we know that tissue Doppler imaging E/e’ ratio is a reliable predictor of left ventricular filling pressure. We performed a systematic review and meta-analysis to investigate the averaged E/e’ ratio value in patients with type 2 diabetes compared to non-diabetic controls. In the analysis we included cross-sectional studies providing the averaged E/e’ ratio. Subgroup/sensitivity analyses were conducted according to variables known to influence E/e’ ratio measurements. The analysis included 15 cross sectional studies with 877 type 2 diabetes patients and 1193 controls. The weighted mean difference showed higher values in diabetes (WMD 2.02; 95% CI 1.35, 2.70; p<0.001). The result was consistent in the subgroup/sensitivity analyses. Visual inspection of the funnel plot did not identify substantial asymmetry and the Egger test for funnel plot asymmetry showed a p value of 0.36. In conclusion, our assessment suggests that averaged E/e’ ratio is consistently increased in patients with type 2 diabetes compared to non-diabetic controls in the absence of cardiovascular diseases and complicated hypertension. This alteration may be a precocious diastolic alteration in the diabetic cardiomyopathy.

The influence of type 2 diabetes and arterial hypertension on right ventricular layer-specific mechanics

AIMS

The aim of the investigation was to evaluate layer-specific right ventricular (RV) deformation in normotensive and hypertensive subjects with type 2 diabetes mellitus (DM).

METHODS

This cross-sectional study included 129 subjects (40 controls, 42 normotensive DM and 47 hypertensive DM patients) who underwent complete two-dimensional echocardiographic examination (2DE) including multilayer strain analysis.

RESULTS

2DE RV global and free wall longitudinal strains were reduced in normotensive and hypertensive DM subjects than in controls. RV global longitudinal layer-specific strains (endo-, mid- and epicardial) were lower in normotensive and hypertensive DM patients than in controls. On the other side, layer-specific strains of RV free wall were lower in hypertensive DM patients than in controls, without significant difference between controls and normotensive DM subjects. Parameters of DM control (fasting glucose and glycosylated hemoglobin) were associated with 2DE RV global longitudinal endo- and mid-myocardial layer strain.

CONCLUSIONS

Diabetes and hypertension significantly influence RV mechanics assessed by 2DE conventional and 2DE multilayer strain. Hypertension has an additive unfavorable influence on RV deformation in diabetic patients. Laboratory parameters of diabetic control were associated with RV structure, diastolic function and mechanics assessed with complex 2DE strain analysis.

Evaluation of the Right Ventricular Function in Prediabetes: A 2-D Speckle Tracking Echocardiographic Study

Pre-diabetes is a common condition associated with cardiovascular changes. The aim of our study was to evaluate the right ventricular (RV) function as assessed by 2-D speckle tracking echocardiography in pre-diabetic patients. This study recruited 94 patients (33 normal patients, 31 pre-diabetic patients and 30 diabetic patients). The absolute amount of the global peak systolic strain, the systolic strain rate and the early diastolic strain rate of the RV free wall (RVFW) was higher in the control group than in the pre-diabetic and diabetic groups. These indices were not different between the pre-diabetic and diabetic groups. The global late diastolic strain rate of RVFW was the same between the three groups. Also, pre-diabetes and diabetes were the independent predictors of the RVFW global peak systolic strain, systolic strain rate and diastolic strain rate. Our study demonstrated that the RV systolic and diastolic functions were impaired in the pre-diabetic and diabetic patients without obstructive coronary artery disease. Also, pre-diabetes and diabetes were independent predictors of systolic and diastolic functions of the RV.

Tissue Doppler imaging is a sensitive echocardiographic technique to detect subclinical systolic and diastolic dysfunction of both ventricles in type 1 diabetes mellitus

Background

Subclinical left (LV) and right ventricular (RV) dysfunction has been demonstrated in type 2 diabetes mellitus and evidence indicates impaired LV diastolic function in type 1 diabetes mellitus (T1DM) as well. The aim of our study was to evaluate the role of tissue Doppler imaging (TDI) in assessment of global LV and RV function in T1DM patients.

Methods

A detailed two-dimensional, pulsed wave Doppler and pulsed wave TDI analysis was performed in 53 normotensive middle-aged T1DM patients and compared to healthy controls.

Results

In T1DM patients TDI analysis revealed reduced mean mitral septal and lateral E’ velocities as well as reduced mean tricuspid E˙t velocity compared to healthy controls (E’sept 8.89 ± 1.89 cm/s vs. 11.50 ± 2.41 cm/s, p < 0.001; E’lat 12.29 ± 2.58 cm/s vs.15.30 ± 2.95 cm/s, p < 0,001; E’t 13.56 ± 2.91 cm/s vs. 15.60 ± 2.99 cm/s, p = 0.001). Mean ratios E/E’sept, E/E’lat and E/E’t were significantly higher in diabetics with cutoff value of 7.4 for E/E’sept and 3.4 for E/E’t, differentiating diabetics with LV and RV diastolic impairement from matched healthy controls (sensitivity 76.5 %, specificity 73.8 % for E/E’sept and sensitivity 72.1 %, specificity 66.7 % for E/E’t). Myocardial acceleration during isovolumetric contraction (IVA) measured at the septal mitral (LV IVA) and lateral tricuspid annulus (RV IVA) was the only parameter indicating reduced contractility of both ventricles in diabetics compared to controls (LV IVA 230.70 ± 61.26 cm/s² vs. 283.32 ± 59.74 cm/s², p < 0,001; RV IVA 275.48 ± 68.08 cm/s² vs. 316.86 ± 80.95 cm/s², p = 0.011). LV IVA had better diagnostic accuracy than RV IVA to predict early contractile impairement in T1DM patients (area under the curve 0.758, p < 0.001 for LV IVA and 0.648, p = 0.017 for RV IVA).

Conclusions

TDI is essential to detect subclinical diastolic deterioration of both ventricles in T1DM patients. TDI-derived IVA might be useful to assess early systolic alterations of both ventricles in T1DM patients.

The effects of urgent percutaneous coronary intervention on right ventricular systolic functions in non-ST-elevation acute coronary syndromes

BACKGROUND

Although the importance of the right ventricle (RV) involvement has been known for many years in patients with ST-elevation myocardial infarction (STEMI), it is scarce in non-ST-elevation acute coronary syndrome (NSTE-ACS).

OBJECTIVES

We aimed to investigate the effects of urgent percutaneous coronary intervention (PCI) on the RV systolic functions in patients with NSTE-ACS.

MATERIALS AND METHODS

Ninety-five patients diagnosed with NSTE-ACS and who underwent urgent PCI were prospectively investigated. RV systolic functions were analyzed and compared before and after PCI in all patients by using RV index of myocardial performance (RIMP), tricuspid annular plane systolic excursion (TAPSE), two-dimensional (2D) RV fractional area change (FAC), and isovolumic acceleration (IVA) parameters with transthoracic echocardiography.

RESULTS

Among 95 NSTE-ACS patients, 31 had impaired RIMP, 13 had impaired TAPSE, 8 had decreased 2D FAC, and 32 had impaired IVA values at baseline. There was a significant increase in 2D FAC and IVA values after PCI.

CONCLUSIONS

The right ventricular functions may also be affected in patients with NSTE-ACS, and urgent PCI has a significant effect on the recovery of right ventricular systolic functions in patients with NSTE-ACS.

Right heart mechanics in untreated normotensive patients with prediabetes and type 2 diabetes mellitus: a two- and three-dimensional echocardiographic study

BACKGROUND

The aim of this study was to determine right ventricular (RV) and right atrial (RA) deformation assessed by two-dimensional echocardiographic and three-dimensional echocardiographic (3DE) imaging in patients with prediabetes and type 2 diabetes mellitus.

METHODS

This cross-sectional study included 47 untreated normotensive subjects with prediabetes, 57 recently diagnosed normotensive patients with diabetes, and 54 healthy controls of similar sex and age distributions. All subjects underwent laboratory analyses and complete two-dimensional echocardiographic and 3DE examinations.

RESULTS

Three-dimensional echocardiographic RV end-diastolic volume index gradually decreased from controls across patients with diabetes to those with diabetes (69 ± 10 vs 63 ± 8 vs 58 ± 8 mL/m(2), P < .001), whereas 3DE RV end-systolic volume index was higher in controls compared with patients with diabetes and those with diabetes (25 ± 4 vs 23 ± 4 vs 22 ± 4 mL/m(2), P < .001). However, there was no difference in 3DE RV ejection fraction among the three groups (63 ± 4% vs 62 ± 4% vs 61 ± 5%, P = .063). RV and RA global strain and systolic and early diastolic strain rates were decreased in patients with prediabetes and in those with diabetes compared with controls, whereas RV and RA late diastolic strain rates were increased in these patients. Multivariate regression analysis showed that RV global strain was associated with glycated hemoglobin, independent of left ventricular parameters.

CONCLUSIONS

RV and RA myocardial deformation and function obtained by 3DE and two-dimensional echocardiographic strain, even in normal ranges, were decreased in patients with prediabetes and in those with diabetes compared with controls. The long-term parameter of glucose control was correlated with the right heart mechanics.

Metabolic syndrome and right ventricle: an updated review

The cluster of metabolic and hemodynamic abnormalities which characterize the metabolic syndrome (MS) is responsible for subclinical cardiac and extra-cardiac damage such as left ventricular hypertrophy, diastolic dysfunction, carotid atherosclerosis and microalbuminuria. The development of different non-invasive imaging methods enabled a detail investigation of right ventricular structure and function, and revealed that right ventricular remodeling followed changes in the left ventricular structure and function in patients with arterial hypertension, diabetes or obesity. Previous investigations also reported that the coexistence of two components of the MS induced more significant cardiac remodeling than the presence of only one MS risk-factor. The relationship between different components of the MS (increased blood pressure, abdominal obesity, increased fasting glucose level and dyslipidemia) and right ventricular remodeling could be explained by several hemodynamic and non-hemodynamic mechanisms. However, the association between right ventricular remodeling and the MS has not been sufficiently investigated so far. The aim of this article was to review recent articles focusing on the association between metabolic syndrome components and the metabolic syndrome itself with impairments in right ventricular structure and function assessed by different imaging techniques.

Right ventricular involvement in diabetic cardiomyopathy

OBJECTIVE

To compare magnetic resonance imaging-derived right ventricular (RV) dimensions and function between men with type 2 diabetes and healthy subjects, and to relate these parameters to left ventricular (LV) dimensions and function.

RESEARCH DESIGN AND METHODS

RV and LV volumes and functions were assessed in 78 men with uncomplicated type 2 diabetes and 28 healthy men within the same range of age using magnetic resonance imaging. Steady-state free precession sequences were used to assess ventricular dimensions. Flow velocity mapping across the pulmonary valve and tricuspid valve was used to assess RV outflow and diastolic filling patterns, respectively. Univariate general linear models were used for statistical analyses.

RESULTS

RV end-diastolic volume was significantly decreased in patients compared with healthy subjects after adjustment for BMI and pulse pressure (177 ± 28 mL vs. 197 ± 47 mL, P < 0.01). RV systolic function was impaired: peak ejection rate across the pulmonary valve was decreased (433 ± 54 mL/s vs. 463 ± 71 mL/s, P < 0.01) and pulmonary flow acceleration time was longer (124 ± 17 ms vs. 115 ± 25 ms, P < 0.05). Indexes of RV diastolic function were impaired: peak filling rate and peak deceleration gradient of the early filling phase were 315 ± 63 mL/s vs. 356 ± 90 mL/s (P < 0.01) and 2.3 ± 0.8 mL/s(2) × 10(-3) vs. 2.8 ± 0.8 mL/s(2) × 10(-3) (P < 0.01), respectively. All RV parameters were strongly associated with its corresponding LV parameter (P < 0.001).

CONCLUSIONS

Diabetic cardiomyopathy affects the right ventricle, as demonstrated by RV remodeling and impaired systolic and diastolic functions in men with type 2 diabetes, in a similar manner as changes in LV dimensions and functions. These observations suggest that RV impairment might be a component of the diabetic cardiomyopathy phenotype.