Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction

Bioimpedance analysis predicts worsening events in outpatients with heart failure and reduced ejection fraction

AIMS

Heart failure (HF) with reduced left ventricle ejection fraction (LVEF) is an entity with poor prognosis characterized by decompensations. Bioelectrical impedance analysis (BIA) is used to assess volume overload (VO) and may be useful to identify apparently stable HF outpatients at risk of decompensation. The aim of this study is to analyse whether VO assessed by BIA is associated with worsening heart failure (WHF) in stable outpatients with HF and reduced LVEF (HFrEF).

METHODS AND RESULTS

This is a prospective single-centre observational study. Consecutive stable HF outpatients with LVEF below 40% underwent BIA, transthoracic echocardiography, blood sampling, and physical examination and were followed up for 3 months. VO was defined as the difference between the measured weight and the dry weight assessed by BIA. Demographic, clinical, anthropometric, echocardiographic, and analytical parameters were recorded. The primary endpoint was WHF, defined by visits to the emergency department for HF or hospitalization for HF. A total of 100 patients were included. The median VO was 0.5 L (interquartile range 0-1.6 L). Eleven patients met the primary endpoint. Univariate binary logistic regression analysis showed that left ventricle filling pressures assessed by E/e', N-terminal pro B-type natriuretic peptide, inferior vena cava dilatation (≥21 mm), signs of congestion, and VO were associated with the primary endpoint. Binary logistic regression multivariate analysis showed that VO was the only independent predictor for the primary endpoint (adjusted OR 2.7; 95% CI 1.30-5.63, P = 0.008). Multivariate Cox regression analysis also showed an adjusted hazard ratio (HR) for VO of 2.03; 95% CI 1.37-3.02, P < 0.001. Receiver-operating characteristic curve analysis showed an area under the curve for VO of 0.88 (95% CI 0.79-0.97, P < 0.001) with an optimal cut-off of 1.2 L.

CONCLUSIONS

VO assessed by BIA is independently associated with WHF in stable outpatients with HFrEF at 3 months.

Casting Light on Early Heart Failure: Unveiling the Prognostic Potential of the E/(e' × s') Index

It has been shown that patients with NYHA class I and II have a high morbidity and mortality burden. We investigated the value of a new tissue Doppler index, E/(e' × s'), to predict cardiac events in the long-term follow-up of patients at an early stage of heart failure (HF). Sequential echocardiography was conducted on a consecutive cohort of 212 hospitalized HF patients, pre-discharged and with three-month follow-up. The primary end point consisted of cardiac death or readmission due to HF worsening. During follow-up, cardiac events occurred in 99 patients (46.7%). The first cardiac event was represented by cardiac death in 8 patients (3.8%) and readmission for HF in 91 patients (42.9%). A Kaplan-Meier analysis did not show a significantly different event-free survival rate between patients with NYHA class I and II. The composite end point was significantly higher in patients with an E/(e' × s') >1.6. The E/(e' × s') at discharge was the best independent predictor of cardiac events. Those exhibiting an E/(e' × s') > 1.6 at discharge, with a subsequent deterioration after three months, displayed the poorest prognosis concerning cardiac events, HF-related rehospitalization, and cardiac mortality (all p < 0.05). In early-stage HF patients, an E/(e' × s') > 1.6 emerged as a robust predictor of clinical outcomes, especially when coupled with a deterioration in condition.

Automated multi-beat tissue Doppler echocardiography analysis using deep neural networks

Tissue Doppler imaging is an essential echocardiographic technique for the non-invasive assessment of myocardial blood velocity. Image acquisition and interpretation are performed by trained operators who visually localise landmarks representing Doppler peak velocities. Current clinical guidelines recommend averaging measurements over several heartbeats. However, this manual process is both time-consuming and disruptive to workflow. An automated system for accurate beat isolation and landmark identification would be highly desirable. A dataset of tissue Doppler images was annotated by three cardiologist experts, providing a gold standard and allowing for observer variability comparisons. Deep neural networks were trained for fully automated predictions on multiple heartbeats and tested on tissue Doppler strips of arbitrary length. Automated measurements of peak Doppler velocities show good Bland-Altman agreement (average standard deviation of 0.40 cm/s) with consensus expert values; less than the inter-observer variability (0.65 cm/s). Performance is akin to individual experts (standard deviation of 0.40 to 0.75 cm/s). Our approach allows for > 26 times as many heartbeats to be analysed, compared to a manual approach. The proposed automated models can accurately and reliably make measurements on tissue Doppler images spanning several heartbeats, with performance indistinguishable from that of human experts, but with significantly shorter processing time. HIGHLIGHTS: • Novel approach successfully identifies heartbeats from Tissue Doppler Images • Accurately measures peak velocities on several heartbeats • Framework is fast and can make predictions on arbitrary length images • Patient dataset and models made public for future benchmark studies.

Whole-cycle analysis of echocardiographic tissue Doppler velocities as a marker of biological age

Purpose

Tissue Doppler imaging (TDI) is a sensitive marker of impaired cardiac function and different phases of the TDI curve carry different prognostic information. It is not known how continuous TDI curves change with age in normal subjects, and whether these changes differ from changes seen in individuals at risk of future cardiac events.

Methods

A total of 1,763 individuals from the general population were examined with color TDI at the septal and lateral mitral sites. A low-risk group was defined as without cardiac risk factors (hypertension, diabetes or ischemic heart disease) at baseline and without any cardiac events (cardiovascular death or admission due to either heart failure or acute myocardial infarction) during 10-years follow-up. All TDI curves were corrected for heart rate, and whole-cycle analysis of age-related changes to TDI velocities was performed in both low-risk (n = 881) and high-risk individuals (n = 882).

Results

In the low-risk population, four phases where myocardial velocity differed most (p < 10^-10) according to age were identified [in a standardized cardiac cycle of 1 second (s)]: Systolic peak (0.09-0.13 s), systolic plateau (0.18-0.27 s), early diastole (0.43-0.54 s) and late diastole (0.88-0.95 s). With increasing age, systolic velocities decreased, early diastolic velocities decreased and had delayed peak, and late diastolic velocities increased until age 70 and then stopped increasing. In the high-risk population, comparison to corresponding age groups of the low-risk population showed: Lower early diastolic velocities in 20-40-year-olds; higher late diastolic velocities and lower peak systolic velocities in 40-60-year-olds; further decreased systolic velocities including the systolic plateau and decreased late diastolic velocities in 60-year-olds. The time segments around the systolic peak (p = 0.002) and early diastole (p < 0.001) differed significantly between the high-risk and low-risk population, thus making it possible to use the individual age gap between a TDI-derived biological age and the real chronological age as a tool to discriminate high-risk individuals from low-risk individuals.

Conclusion

We found that individuals with cardiac risk factors display findings compatible with an accelerated aging of the heart and thus propose TDI-derived biological age as a tool to identify high-risk patients.

Phenotyping the hypertensive heart

Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.

Subclinical Left Ventricular Dysfunction in Children and Adolescence With Thalassemia Intermedia

BACKGROUND

Cardiac complications are important causes of morbidity in patients with thalassemia intermedia (TI). We aimed to assess left ventricular (LV) function, using new tissue Doppler imaging (TDI) indices, in order to diagnose early ventricular impairment in asymptomatic children and adolescence with the TI.

MATERIALS AND METHODS

We investigated possible differences in echocardiographic systolic and diastolic parameters between a population of 28 asymptomatic patients (mean age, 13.6 ± 5.7 years) and 35 age-matched healthy control members. All of them underwent 2-D, pulsed Doppler, and tissue Doppler echocardiographic studies for the assessment of the LV mass, Trans-mitral velocities, mitral annular systolic and diastolic velocities, myocardial performance index (MPI), and myocardial acceleration during isovolumic contraction (IVA). The cardiac iron load was estimated by magnetic resonance imaging T2*.

RESULTS

Left ventricular hypertrophy (LVH) was found in 13 (46.4%) patients. We found significantly reduced TDI-derived peak systolic myocardial velocity (s') in patients, whereas no significant difference was identified between the patients and control group members when the IVA was compared. The ratio of peak mitral inflow velocity to annular early diastolic velocity (E/e') of the mitral valve as an index of the diastolic function was significantly higher in patients (9 ± 1 vs. 6 ± 1, p < 0.05). Choosing a TDI-derived MPI > 0.33 as a cutoff point, the global LV dysfunction was detected with a sensitivity of 78% and a specificity of 80%. The patients with LVH significantly exhibited higher values of TDI-MPI and lower values of s' velocity and IVA when compared against the subjects with normal LV mass.

CONCLUSION

Subtle LV systolic and diastolic dysfunction develops early in young patients with the TI who have normal cardiac iron concentration. Moreover, LV remodeling as a main cardiac adaptive response plays a principal role in developing myocardial impairment.

The Effects of Spironolactone and Eplerenone on Left Ventricular Function Using Echocardiography in Symptomatic Patients With New-Onset Systolic Heart Failure: A Comparative Randomised Controlled Trial

BACKGROUND

Heart failure (HF), as a serious health condition, is characterised by the decreasing ability of the heart to pump enough blood around the body. This study compared the effects of spironolactone and eplerenone on the echocardiographic variables of the left ventricular (LV) function in symptomatic patients diagnosed with new-onset systolic HF.

METHOD

This study was a randomised controlled trial, including 85 symptomatic patients with new-onset systolic HF (namely, dilated cardiomyopathy). The patients were then randomly assigned to two groups in a 1:1 ratio and received either spironolactone or eplerenone in addition to optimal HF therapy for 6 months. Echocardiography was performed to visualise alterations in two-dimensional, pulse Doppler, tissue Doppler, and deformation indices of LV function.

RESULTS

The results revealed that the group receiving eplerenone had a significantly greater increase in LV ejection fraction (LVEF) and a decrease in end-systolic LV internal diameter compared with the group receiving spironolactone (intergroup p=0.002 and p=0.006, respectively). There was a significant reduction in the end-diastolic LV internal diameter and the left atrial diameter, and a significant rise in tissue Doppler peak systolic mitral annular velocity in the group taking eplerenone; there were no significant changes in these variables in the group receiving spironolactone (intergroup p=0.006 and p=0.049, respectively). Accordingly, eplerenone had greater favourable effects on LVEF and the global longitudinal strain than spironolactone (B=5.207 [p<0.001] and B= -2.072 [p=0.044]), respectively.

CONCLUSIONS

This study established that adding eplerenone to optimal HF therapy might be associated with more improvements in echocardiographic variables of LV function than spironolactone in symptomatic patients with new-onset systolic HF.

Comparison of left ventricular longitudinal systolic function parameters in the prediction of adverse outcome in heart failure with preserved ejection fraction

AIMS

Several different diagnostic parameters can be used to assess left ventricular (LV) longitudinal systolic function, but no studies comparing their predictive value have been conducted. We sought to compare the prognostic value of LV long-axis function parameters at rest and exercise using the population with heart failure with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

Clinical and biochemical variables were collected at baseline in 201 patients with HFpEF. Echocardiography was performed at rest and immediately after exercise, with measurement of mitral annular plane systolic excursion, systolic tissue velocity (s'), global longitudinal strain (GLS), and global longitudinal strain rate (GLSR). Participants were followed for 48 (24-60) months for heart failure hospitalization and cardiovascular death. Seventy-four patients (36.8%) met the study endpoint. Cox regression analysis revealed that after adjustment for Meta-Analysis Global Group in Chronic Heart Failure risk score, brain natriuretic peptide (BNP), and peak VO₂ , heart failure hospitalization and cardiovascular death were significantly associated with GLS at rest [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.84-0.98; P = 0.016], GLS after exercise (HR 0.84; 95% CI 0.77-0.91; P < 0.001), and GLSR after exercise (HR 0.13; 95% CI 0.04-0.48; P = 0.002). The addition of each of the following: exercise GLS and GLSR and resting GLS to the base model including Meta-Analysis Global Group in Chronic Heart Failure, BNP, and peak VO₂ improved predictive power for the study endpoint [net reclassification improvement (NRI) = 49%, P < 0.001; NRI = 42%, P = 0.004; and NRI = 38%, P = 0.009, respectively]. Exercise GLS was the only longitudinal parameter significantly improving c-statistics of the base model (0.68 vs. 0.73; P = 0.047).

CONCLUSIONS

Echocardiographic parameters of LV longitudinal function are not equipotential in predicting adverse outcomes in HFpEF. LV deformation indices, especially assessed with exercise, show the highest predictive utility independent from and incremental to clinical data and BNP.

The predictive value of the combined systolic-diastolic index for atrial fibrillation after coronary artery bypass surgery

OBJECTIVE

Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is a factor that causes an increase in mortality and morbidity. Therefore, predicting post-CABG AF development is important for treatment management. In this study, we investigated the value of the ratio E/(Ea × Sa) as a combined systolic-diastolic index in predicting post-CABG AF development.

METHODS

This prospective study included 102 patients who underwent only isolated coronary bypass. Preoperative demographic features, biochemical, and hematological parameters, and the electrocardiographic data of all patients were recorded. The E/(Ea × Sa) indices were calculated from the echocardiographic measurements. Those who retained their postoperative sinus rhythm were defined as group 1, and those who developed AF were defined as group 2.

RESULTS

Group 2 had significantly higher lateral (group 1:1.14 ± 0.61 vs. group 2:1.47 ± 0.87; P = .02), medial (group 1:1.61 ± 0.70 vs. group 2:1.99 ± 0.91; P = .02), and mean (group 1:1.30 ± 0.58 vs. group 2:1.62 ± 0.74; P = .001) E/(Ea × Sa) indices than group 1. In the univariate analysis, age, CHA₂ DS₂ -VASc score, sPAP, IABP use, and mean E/(EaxSa) index were found to be significant predictors of post-CABG AF development. However, only the mean E/(EaxSa) index was found to be a significant predictor of post-CABG AF development in the multivariate analysis (OR: 2.19 95% CI 1.01-5.96; P = .045).

CONCLUSIONS

The combined systolic-diastolic index predicted the development of post-CABG AF.

Understanding cardiac systolic performance beyond left ventricular ejection fraction

Left ventricular ejection fraction is the critical parameter used for heart failure classification, decision making and assessing prognosis. It is defined as a volumetric ratio and is essentially a composite of arterial and ventricular elastances, but not intrinsic contractility. The clinician should be aware of its numerous limitations when measuring and reporting it. And make a step toward more insightful understanding of hemodynamics.

Automatic quantification of left ventricular function by medical students using ultrasound

BACKGROUND

Automatic analyses of echocardiograms may support inexperienced users in quantifying left ventricular (LV) function. We have developed an algorithm for fully automatic measurements of mitral annular plane systolic excursion (MAPSE) and mitral annular systolic (S') and early diastolic (e') peak velocities. We aimed to study the influence of user experience of automatic measurements of these indices in echocardiographic recordings acquired by medical students and clinicians.

METHODS

We included 75 consecutive patients referred for echocardiography at a university hospital. The patients underwent echocardiography by clinicians (cardiologists, cardiology residents and sonographers), who obtained manual reference measurements of MAPSE by M-mode and of S' and e' by colour tissue Doppler imaging (cTDI). Immediately after, each patient was examined by 1 of 39 medical students who were instructed in image acquisition on the day of participation. Each student acquired cTDI recordings from 1 to 4 patients. All cTDI recordings by students and clinicians were analysed for MAPSE, S' and e' using a fully automatic algorithm. The automatic measurements were compared to the manual reference measurements.

RESULTS

Correct tracking of the mitral annulus was feasible in 50 (67%) and 63 (84%) of the students' and clinicians' recordings, respectively (p = 0.007). Image quality was highest in the clinicians' recordings. Mean difference ± standard deviation of the automatic measurements of the students' recordings compared to the manual reference was - 0.0 ± 2.0 mm for MAPSE, 0.3 ± 1.1 cm/s for S' and 0.6 ± 1.4 cm/s for e'. The corresponding intraclass correlation coefficients for MAPSE, S' and e' were 0.85 (good), 0.89 (good) and 0.92 (excellent), respectively. Automatic measurements from the students' and clinicians' recordings were in similar agreement with the reference when mitral annular tracking was correct.

CONCLUSIONS

In case of correct tracking of the mitral annulus, the agreement with reference for the automatic measurements was overall good. Low image quality reduced feasibility. Adequate image acquisition is essential for automatic analyses of LV function indices, and thus, appropriate education of the operators is mandatory. Automatic measurements may help inexperienced users of ultrasound, but do not remove the need for dedicated education and training.

Normal ranges for automatic measurements of tissue Doppler indices of mitral annular motion by echocardiography. Data from the HUNT3 Study

BACKGROUND

Automatic quantification of left ventricular (LV) function could enhance workflow for cardiologists and assist inexperienced clinicians who perform focused cardiac ultrasound. We have developed an algorithm for automatic measurements of the mitral annular plane systolic excursion (MAPSE) and peak velocities in systole (S') and early (e') and late (a') diastole. We aimed to establish normal reference values for the automatic measurements and to compare them with manual measurements.

METHODS AND RESULTS

Healthy participants (n = 1157, 52.5% women) from the HUNT3 cross-sectional population study in Norway were included. The mean age ± standard deviation (SD) was 49 ± 14 (range: 19-89) years. The algorithm measured MAPSE, S', e', and a' from apical 4-chamber color tissue Doppler imaging (cTDI) recordings. The manual measurements were obtained by two echocardiographers, who measured MAPSE by M-mode and the velocities by cTDI. For men and women, age-specific reference values were created for groups (mean ± 1.96SD) and by linear regression (mean, 95% prediction interval). Age was negatively correlated with MAPSE, S', and e' and positively correlated with a'. There were small differences between genders. Normal reference ranges were created. The coefficients of variation between automatic and manual measurements ranged from 5.5% (S') to 11.7% (MAPSE).

CONCLUSION

Normal reference values for automatic measurements of LV function indices are provided. The automatic measurements were in line with the manual measurements. Implementing automatic measurements and comparison with normal ranges in ultrasound scanners can allow for quick and precise interpretation of LV function.

Echocardiographic assessment of left ventricular systolic function in neonatal calves with naturally occurring sepsis or septic shock due to diarrhea

Sepsis is associated with clinically relevant cardiovascular changes. The objectives of this study were to evaluate the clinical value of echocardiography for monitoring left ventricular (LV) systolic function in septic calves. A prospective longitudinal study was performed using a convenience sample. Twenty septic calves and 10 healthy calves were enrolled in the study. Arterial blood pressure (BP) was measured and M-mode echocardiography performed to characterize LV systolic function; the latter included measurement of ejection fraction, EF; stroke volume, SVI and cardiac output indexed to body weight, CI; E-point of septal separation, EPSS; pre-ejection period, PEP; ejection time, LVET; ratio of PEP to LVET; velocity of circumferential shortening, Vcf, LV end-diastolic volume index (LVEDVI) and LV end-systolic volume index (LVESVI) on admission and 6, 24, 48 and 72 h later in septic calves and once in healthy calves. Admission data were compared using the Mann-Whitney U test and P < .05 was considered significant. Decreased preload and afterload were present in septic calves, as indicated by marked decreases in BP, LVEDVI, LVESVI, SVI, CI, EPSS when compared to healthy calves. Systolic function appeared adequate in septic calves, based on EF and FS compared to control calves. There was no difference in heart rate, LVET, PEP:LVET, or Vcf between septic and health calves. We conclude that circulatory dysfunction, rather than systolic dysfunction predominates in septic calves. Positive associations on admission between CI and LVEDVI, LVESVI, and SVI support this conclusion. Echocardiographic determination of LVEDVI and CI appears useful in directing treatment in septic calves.

Pharmacodynamic Analysis of the Influence of Propofol on Left Ventricular Long-Axis Systolic Performance in Cardiac Surgical Patients

BACKGROUND

Propofol induced a decline in the left ventricular (LV) systolic performance in non-cardiac surgery. We tested the hypothesis that propofol decreased the LV contractile function by dose dependent manner in cardiac surgery patients.

METHODS

Anesthesia was maintained with target-controlled infusions of propofol and remifentanil in cardiac surgery patients. With a fixed effect-site concentration (Ce) of remifentanil (20 ng/mL) after sternotomy, the Ce of propofol was adjusted to maintain a Bispectral index of 40-60 (Ce1). Mitral annular Doppler tissue image tracings and other echocardiographic variables, including end-diastolic and end-systolic volumes, stroke volume, and mitral inflow pulse wave Doppler profile at Ce1, were recorded using transesophageal echocardiography. Echocardiographic recordings were repeated after the Ce-values of propofol were doubled and tripled at 10-minute intervals (defined as Ce2 and Ce3, respectively). Serial changes in echocardiographic variables for each Ce of propofol were assessed using generalized linear mixed effect modeling. The pharmacodynamic relationship between the Ce of propofol and peak systolic mitral annular velocity (Sm) was analyzed by logistic regression using non-linear mixed effect modeling (NONMEM).

RESULTS

Means of Ce1, Ce2, and Ce3 were 0.8, 1.6, and 2.4 μg/mL, respectively, and their means of Sm (95% confidence interval) were 9.7 (9.3-10.2), 8.7 (8.2-9.1), and 7.5 cm/sec (7.0-8.0), respectively (P < 0.01). Ce values of propofol and Sm showed a significant inter-correlation and predictability (intercept, 10.8; slope-1.0 in generalized mixed linear modeling; P < 0.01). Ce values producing 10% and 20% decline of Sm with 50%-probability were 1.4 and 2.1 μ/mL, respectively.

CONCLUSION

Propofol reduces LV systolic long-axis performance in a dose-dependent manner.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01826149.

Evaluation of Left Ventricular Systolic Function and Mass in Primary Hypertensive Patients by Echocardiography

Hypertension is an independent risk factor for cardiovascular diseases. The accurate evaluation of cardiovascular risk is of paramount importance in the management of hypertensive patients. Conventional echocardiographic methods have provided the assessment of left ventricular systolic function and mass for many years. Tissue Doppler imaging, 3-dimensional echocardiography, and speckle tracking echocardiography are newer echocardiographic modalities for the left ventricular systolic function and mass quantification. The major emphasis of this review is to evaluate the left ventricular systolic function and mass by conventional and newly developed echocardiographic in hypertensive patients.

Correlation between Myocardial Velocity Measured using Tissue Doppler Imaging in the Left Ventricular Lead-Implanted Segment and Response to Cardiac Resynchronization Therapy

OBJECTIVES

This study investigated whether tissue Doppler imaging parameters, especially the peak systolic velocity of the left ventricular lead-implanted segment (Ss), affect cardiac resynchronization therapy response.

METHODS

In this case-control study, 110 enrolled patients were divided into cases (responder group, n=65) and controls (nonresponder group, n=45) based on whether their left ventricular end-systolic volume was reduced by ≥15% at 6 months after surgery. Preoperative clinical and echocardiographic data were collected. Multivariate logistic regression models were used to analyze the factors affecting the response to cardiac resynchronization therapy, and receiver operating characteristic curves were plotted to evaluate their diagnostic values.

RESULTS

The proportion of patients with left bundle branch block in the case group was higher than that in the control group. The control group showed a higher left atrial volume index, E/A ratio and E/Em ratio but lower Ss than that of the case group. A multivariate regression analysis showed that left bundle branch block, Ss, and an E/Em ratio>14 were independent risk factors affecting the response to cardiac resynchronization therapy. Ss=4.1 cm/s was the best diagnostic threshold according to the receiver operating characteristic curve.

CONCLUSIONS

Ss is an important factor affecting the response to cardiac resynchronization therapy. Patients with heart failure associated with Ss<4.1 cm/s have a higher risk of nonresponse.

Mitral Annular Plane Systolic Excursion as a Predictor of Mortality in Children With Septic Shock

OBJECTIVES

Myocardial dysfunction is well recognized in severe sepsis and septic shock. Echocardiography provides rapid, noninvasive, and bedside evaluation of cardiac function in patients with hemodynamic instability. Mitral annular plane systolic excursion is an M-mode-derived echocardiographic variable used to assess longitudinal left ventricular systolic function. No data are available about the uses of mitral annular plane systolic excursion in children with septic shock. Therefore, we aimed to assess the prognostic significance of mitral annular plane systolic excursion in children with septic shock and to correlate it with the most commonly used measures of left ventricular systolic function and myocardial injury.

DESIGN

A prospective cohort study.

SETTING

The study carried out at the PICU of Menoufia University Hospital in the period from March 2015 to September 2016.

PATIENTS

We serially enrolled 50 children with septic shock.

INTERVENTIONS

Complete diagnostic workup was performed for each patient including calculation of Pediatric Risk of Mortality III score. Transthoracic echocardiography was done to obtain mitral annular plane systolic excursion and the left ventricular ejection fraction measurement within 24 hours of inclusion then repeated on third and fifth days. Patients were followed up until hospital discharge or death. The predictive power of mitral annular plane systolic excursion was determined using the receiver operating characteristic curve.

MEASUREMENTS AND MAIN RESULTS

Mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors (p < 0.001). Receiver operating characteristic curve analysis showed an area under the curve of 0.892 for mitral annular plane systolic excursion on day 1. The cut-off point was 7.9 mm with 82.76% sensitivity and 80.95% specificity. Furthermore, follow-up of the patient's systolic function showed that mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors on days of follow-up, whereas left ventricular ejection fraction was not significantly different between survivors and nonsurvivors at any day. Mitral annular plane systolic excursion was positively correlated with left ventricular ejection fraction (p = 0.044) and duration of hospital stay (p < 0.001) and negatively correlated with Pediatric Risk of Mortality III score (p < 0.001) and cardiac troponin I level (p < 0.001).

CONCLUSIONS

Measurement of mitral annular plane systolic excursion at admission added a prognostic value in septic shock children. Compared with the left ventricular ejection fraction, longitudinal systolic function might be more sensitive in the detection of myocardial dysfunction in critically ill children and should receive more attention.

Diastolic wall strain is associated with incident heart failure in African Americans: Insights from the atherosclerosis risk in communities study

BACKGROUND

Increased left ventricular (LV) myocardial stiffness may be associated with impaired LV hemodynamics and incident heart failure (HF). However, an indicator that estimates LV myocardial stiffness easily and non-invasively is lacking. The purpose of this study was to determine whether diastolic wall strain (DWS), an echocardiographic estimator of LV myocardial stiffness, is associated with incident HF in a middle-aged community-based cohort of African Americans.

METHODS AND RESULTS

We investigated associations between DWS and incident HF among 1528 African Americans (mean age 58.5 years, 66% women) with preserved LV ejection fraction (EF ≥50%) and without a history of cardiovascular disease in the Atherosclerosis Risk in Communities Study. Participants with the smallest DWS quintile (more LV myocardial stiffness) had a higher LV mass index, higher relative wall thickness, and lower arterial compliance than those in the larger four DWS quintiles (p<0.01 for all). Over a mean follow-up of 15.6 years, there were 251 incident HF events (incidence rate: 10.9 per 1000 person-years). After adjustment for traditional risk factors and incident coronary artery disease, both continuous and categorical DWS were independently associated with incident HF (HR 1.21, 95%CI 1.04-1.41 for 0.1 decrease in continuous DWS, p=0.014, HR 1.40, 95%CI 1.05-1.87 for the smallest DWS quintile vs other combined quintiles, p=0.022).

CONCLUSIONS

DWS was independently associated with an increased risk of incident HF in a community-based cohort of African Americans. DWS could be used as a qualitative estimator of LV myocardial stiffness.

Cardiac function during weaning failure: the role of diastolic dysfunction

Background

Cardiac dysfunction is a common cause of weaning failure. Weaning shares some similarities with a cardiac stress test and may challenge active phases of the cardiac cycle-like ventricular contractility and relaxation. This study aimed at assessing systolic and diastolic function during the weaning process and scrutinizing their dynamics during weaning trials.

Methods

Echocardiography was performed during baseline ventilator settings to assess cardiac function at the initiation of the weaning process and at the start and the end of consecutive weaning trials (performed at day-1, day-2, and before extubation if applicable) to explore the evolution of left ventricle contractility and relaxation in a subset of patients.

Results

Among 67 patients included, weaning was prolonged (≥ 7 days) in 18 (27%) patients and short (< 7 days) in 49 (73%). Prevalence of systolic dysfunction and isolated diastolic dysfunction before the initiation of weaning process were 37 and 17%, respectively. Isolated diastolic dysfunction was more frequent in patients with prolonged weaning as compared to their counterparts. Thirty-one patients were explored by echocardiography during consecutive weaning trials. An increase in filling pressures with an alteration of ventricular relaxation (as assessed by a decrease in tissue Doppler early mitral diastolic wave velocity) was found during failed weaning trials.

Conclusions

Isolated diastolic dysfunction was associated with a prolongation of weaning. Increased filling pressures with left ventricle relaxation impairment may be a key mechanism of weaning trial failure.

Electronic supplementary material

The online version of this article (10.1186/s13613-017-0348-4) contains supplementary material, which is available to authorized users.

Modern Imaging Techniques in Cardiomyopathies

Modern advanced imaging techniques have allowed increasingly more rigorous assessment of the cardiac structure and function of several types of cardiomyopathies. In contemporary cardiology practice, echocardiography and cardiac magnetic resonance imaging are widely used to provide a basic framework in the evaluation and management of cardiomyopathies. Echocardiography is the quintessential imaging technique owing to its unique ability to provide real-time images of the beating heart with good temporal resolution, combined with its noninvasive nature, cost-effectiveness, availability, and portability. Cardiac magnetic resonance imaging provides data that are both complementary and uniquely distinct, thus allowing for insights into the disease process that until recently were not possible. The new catchphrase in the evaluation of cardiomyopathies is multimodality imaging, which is purported to be the efficient integration of various methods of cardiovascular imaging to improve the ability to diagnose, guide therapy, or predict outcomes. It usually involves an integrated approach to the use of echocardiography and cardiac magnetic resonance imaging for the assessment of cardiomyopathies, and, on occasion, single-photon emission computed tomography and such specialized techniques as pyrophosphate scanning.

Risk stratification in patients with heart failure: the value of considering both global longitudinal left ventricular strain and mechanical dispersion

In previous studies, mechanical dispersion (MD) predicted ventricular arrhythmias independently of left ventricular ejection fraction (LVEF). Moreover, the combination of MD and global longitudinal strain (GLS) increased the prediction of arrhythmic events. We investigated the prognostic value of a new 2-dimensional strain index, GLS/MD, in patients with heart failure (HF). We analyzed 340 consecutive HF outpatients in sinus rhythm. Echocardiography was performed at 1.6 ± 0.4 months after hospital discharge. The end point included sudden cardiac death, ventricular fibrillation, and sustained ventricular tachycardia (SCD/VA). During the follow-up period (36 ± 9 months), SCD/VA occurred in 48 patients (14.1%). A multivariate Cox regression analysis, which included LVEF, early diastolic transmitral / mitral annular velocity ratio (E/E'), GLS, MD, and GLS/MD in the model, revealed that GLS/MD was the best independent predictor of SCD/VA (HR = 3.22, 95% confidence interval = 1.72-6.15, p = 0.03). Separate inclusion of LVEF, systolic mitral annular velocity, E/E', GLS, and MD together with GLS/MD showed that GLS/MD remained the best predictor of SCD/VA (each p < 0.05). The optimal GLS/MD cutoff value to predict SCA/VA was -0.20%/ms (80% sensitivity, 76% specificity). Irrespective of LVEF, free survival was significantly better in patients with GLS/MD ≤ -0.2%/ms (log-rank test, p < 0.001). In conclusion, GLS/MD may improve cardiovascular risk stratification in subjects with HF.

Left ventricular long axis tissue Doppler systolic velocity is independently related to heart rate and body size

Background

The physiological factors which affect left ventricular (LV) long-axis function are not fully defined. We investigated the relationships of resting heart rate and body size with the peak velocities and amplitudes of LV systolic and early diastolic long axis motion, and also with long-axis contraction duration.

Methods

Two groups of adults free of cardiac disease underwent pulsed-wave tissue Doppler imaging at the septal and lateral mitral annular borders. Group 1 (n = 77) were healthy subjects <50 years of age and Group 2 (n = 65) were subjects between 40–80 years of age referred for stress echocardiography. Systolic excursion (SExc), duration (SDur) and peak velocity (s') and early diastolic excursion (EDExc) and peak velocity (e') were measured.

Results

SExc was not correlated with heart rate, height or body surface area (BSA) for either LV wall in either group, but SDur was inversely correlated with heart rate for both walls and both groups, and after adjustment for heart rate, males in both groups had a shorter septal SDur. Septal and lateral s` were independently and positively correlated with SExc, heart rate and height in both groups, independent of sex and age. There were no correlations of heart rate, height or BSA with either e` or EDExc for either wall in either group.

Conclusion

Heart rate and height independently modify the relationship between s` and SExc, but neither are related to EDExc or e`. These findings suggest that s` and SExc cannot be used interchangeably for the assessment of LV long-axis contraction.

Systolic mitral annulus velocity is a sensitive index for changes in left ventricular systolic function during inotropic therapy in patients with acute heart failure

BACKGROUND

Echocardiography is recommended for assessment of left ventricular systolic function in patients with acute heart failure but few randomised trials have validated techniques like tissue Doppler (TDI) and speckle tracking (STE) in patients with acute heart failure following ST-elevation myocardial infarction.

METHODS

This was a substudy from the LEAF (LEvosimendan in Acute heart Failure following myocardial infarction) trial (NCT00324766 ), which randomised 61 patients developing acute heart failure, including cardiogenic shock, within 48 hours after ST-elevation myocardial infarction, double-blind to a 25-hour infusion of levosimendan or placebo. TDI-derived systolic mitral annulus velocity (S'), STE-derived global longitudinal strain (S_l) and strain rate (SR_l) were measured at baseline, day 1, day 5 and after 42 days.

RESULTS

Datasets rejected for analyses were 2% (TDI) and 17% (STE). S' increased by 23% in the levosimendan group versus 8% in the placebo group from baseline to day 1 ( p= 0.011) and by 30% vs. 3% from baseline to day 5 ( p <0.0005). Significant, but less pronounced, improvements in global S_l ( p = 0.025 and p = 0.032) and in global SR_l ( p = 0.046 and p = 0.001) in favour of levosimendan were also present.

CONCLUSION

S' by TDI and STE-derived S_l and SR_l were sensitive indices for changes in left ventricular systolic function related to treatment with levosimendan. However, S' by TDI was more feasible and sensitive and might be preferred for assessment of changes in left ventricular systolic function in critically ill patients with acute heart failure receiving inotropic therapy.

Relation Between Echocardiogram-Based Cardiac Parameters and Outcome in Heart Failure With Preserved and Reduced Ejection Fraction

The purposes of this study were to investigate whether heart failure (HF) with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) share echocardiographic predictors and elucidate E/(e' × s') that predicts major adverse cardiovascular events (MACE) independent of other echocardiographic parameters in each HF group. We assessed tissue Doppler-derived parameters [E/e', E/(e' × s')] and left ventricular and right ventricular longitudinal strains in HFrEF (n = 340) and HFpEF (n = 102). Left ventricular and right ventricular longitudinal strains were significantly higher and E/(e' × s') was lower in patients with HFpEF compared with those with HFrEF, whereas E/e' was similar between the groups. During a median follow-up of 342 days, MACE developed in 95 patients with HFrEF and 29 with HFpEF. The univariable analysis revealed similar echocardiographic predictors between the 2 groups, including E/e', E/(e' × s') and pulmonary artery systolic pressure. No 2-dimensional speckle tracking-derived parameter remained significant in multivariable models in each HF group. E/(e' × s') was an only independent predictor with an incremental prognostic value over the Meta-analysis Global Group in Chronic Heart Failure score and was superior to the E/e' ratio in both HFrEF and HFpEF. In conclusion, despite differences in echocardiography-based cardiac function parameters between HFrEF and HFpEF, these HF phenotypes shared the same echocardiographic predictors of future MACE. E/(e' × s') was an only independent predictor for future cardiac events in both HF populations.

Assessment of the left ventricular function in normotensive prediabetics: a tissue Doppler echocardiography study

OBJECTIVE

Several studies have shown that left ventricular (LV) dysfunction is increased in individuals with diabetes. However, there are scarce data about LV function in prediabetics. This study assessed the early changes in LV diastolic and systolic myocardial function in normotensive prediabetics using tissue Doppler echocardiography (TDE).

SUBJECTS AND METHODS

We evaluated 94 patients with prediabetes (mean age of 50.8 ± 6.9 years, 78 female) without known cardiovascular diseases and 70 healthy volunteers with similar demographic characteristics. Systolic and diastolic function of the left ventricle was evaluated with transthoracic echocardiography according to the latest consensus recommendations including TDE.

RESULTS

The mean results of septal and lateral parts of the mitral annulus Pulsed wave TDE showed that myocardial systolic wave (Sm), myocardial early diastolic wave (Em) and Em to atrial peak velocity (Am) ratio were significantly lower whereas early diastolic peak flow velocity (E) to Em ratio, myocardial isovolumetric relaxation time (IVRTm), myocardial isovolumetric contraction time (IVCTm) and myocardial performance index (MPI) values were significantly higher in patients with prediabetes (preDM). In addition, mean left atrium (LA) diameter measured with M-mode echocardiography was significantly higher in prediabetics than controls.

CONCLUSION

PreDM is associated with subclinical LV systolic and diastolic dysfunction as evaluated by TDE.

Recommendations on the Use of Echocardiography in Adult Hypertension: A Report from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE)

Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment.

Association of left ventricular structure and function with peripheral blood mitochondrial DNA content in a general population

BACKGROUND/OBJECTIVES

mtDNA content might be an important biomarker in heart disease prediction and to date no population studies are available on the association of mtDNA content with cardiac structure and function. We, therefore, investigated in a general population in cross-sectional and longitudinal studies whether echocardiographic indexes of LV structure and function are associated with mtDNA content measured in peripheral blood cells.

METHODS

At baseline we performed echocardiography in 701 randomly selected individuals (50.9% women, mean age, 53.2years) from a Flemish population. Relative mtDNA copy number compared to nuclear DNA was measured by quantitative real-time PCR in peripheral blood cells.

RESULTS

With adjustments applied, we observed significant inverse association of LV diastolic and systolic diameters (P≤0.028) and volumes (P=0.013) with mtDNA content. Moreover, for a 1-SD increment in mtDNA (0.37), we found an increase in Tissue Doppler s' velocity by 0.093cm/s (P=0.019) and a decrease in E/e' ratio by 0.18 (P=0.008). In 223 subjects with available echocardiography and mtDNA content at baseline and follow-up, we observed that higher baseline mtDNA content was associated with less increase in 2D LV diastolic volume (P=0.0003), M-mode LV diameter (P=0.046) and LV mass (P=0.003) during the follow-up period.

CONCLUSIONS

In the general population, higher mtDNA content was associated with smaller LV diastolic and systolic diameters and volumes and better LV systolic and diastolic function. Moreover, we observed that baseline mtDNA content was a significant predictor of longitudinal changes of LV diastolic volume and dimension, and LV mass.

[Echocardiographic evaluation of systolic left ventricular function in heart failure: value of alternative parameters for determination of ejection fraction]

Assessment of the left ventricular ejection fraction plays a key role in the echocardiographic diagnosis of heart failure. The parameter most commonly used is the ejection fraction computed with the biplane disc summation method of Simpson; however, there are numerous limitations to this method, such as the assumption of geometrical symmetry, a substantial intraobserver and interobserver variability, foreshortening of the left ventricle and insufficient image quality for endocardial tracking. Alternative parameters for the evaluation of left ventricular function should be taken into consideration. Speckle tracking echocardiography has proven to be a reliable prognostic factor and a good tool for differentiating cardiomyopathies. Simple measurements, which are also feasible with poor image quality, are mitral annular plane systolic excursion (MAPSE) and the velocity of mitral annular movement (Sm or S'). In mitral regurgitation, left ventricular dP/dt represents the time to build up a certain pressure gradient and is therefore a measure of the contractile force exerted. Three-dimensional echocardiography has proven to be an important tool not only for three-dimensional measurement of the left ventricular ejection fraction but also for multivectoral speckle tracking analysis.

Tissue Doppler echocardiography predicts acute myocardial infarction, heart failure, and cardiovascular death in the general population

AIMS

To improve risk prediction of cardiovascular morbidity and mortality, we need sensitive markers of cardiac dysfunction; Echocardiographic Tissue Doppler Imaging (TDI) is feasible and harmless and may be ideal for this purpose.

METHODS AND RESULTS

Within the community-based Copenhagen City Heart Study, 2064 participants were examined by echocardiography including TDI and followed (median 10.9 years) with regard to cardiovascular death, heart failure, or acute myocardial infarction (n = 277). Impaired systolic (s') and diastolic (e' and a') function according to age and sex as assessed by TDI was associated with increased risk of the combined end point, even in the subgroup of persons with a normal conventional echocardiographic examination [per 1 cm/s decrease: s': HR 1.32 (1.12-1.57), P < 0.001; e': HR 1.17(1.04-1.31), P < 0.01; a': HR 1.17 (1.06-1.30), P < 0.005]. Interestingly, reduced early diastolic myocardial velocity (e') was associated with risk of acute myocardial infarction, whereas reduced systolic (s') or late diastolic function (a') was associated with heart failure and cardiovascular death independently of traditional risk factors, plasma proBNP, and conventional echocardiographic measures. Combining information on early and late diastolic function by TDI provided incremental prognostic information and improved risk classification (net reclassification improvement: 27%; P < 0.001) and remained a significant predictor of the combined end point even in the subgroup with a normal conventional echocardiographic examination [per cm/s decrease: HR 1.18 (1.08-1.28), P < 0.001].

CONCLUSION

In the general population, TDI identifies individuals with cardiac dysfunction and high risk of cardiovascular morbidity and mortality independently of traditional risk factors, even in persons with a normal conventional echocardiographic examination.

Identification of Mitral Annulus Hinge Point Based on Local Context Feature and Additive SVM Classifier

The position of the hinge point of mitral annulus (MA) is important for segmentation, modeling and multimodalities registration of cardiac structures. The main difficulties in identifying the hinge point of MA are the inherent noisy, low resolution of echocardiography, and so on. This work aims to automatically detect the hinge point of MA by combining local context feature with additive support vector machines (SVM) classifier. The innovations are as follows: (1) designing a local context feature for MA in cardiac ultrasound image; (2) applying the additive kernel SVM classifier to identify the candidates of the hinge point of MA; (3) designing a weighted density field of candidates which represents the blocks of candidates; and (4) estimating an adaptive threshold on the weighted density field to get the position of the hinge point of MA and exclude the error from SVM classifier. The proposed algorithm is tested on echocardiographic four-chamber image sequence of 10 pediatric patients. Compared with the manual selected hinge points of MA which are selected by professional doctors, the mean error is in 0.96 ± 1.04 mm. Additive SVM classifier can fast and accurately identify the MA hinge point.

Principles of transthoracic echocardiographic evaluation

Transthoracic echocardiography is the most widely used imaging test in cardiology. Although completely noninvasive, transthoracic echocardiography has a well-established role in the diagnosis of numerous cardiovascular diseases, and also provides critical qualitative and quantitative information on their prognosis and pathophysiological processes. The aim of this Review is to outline the broad principles of transthoracic echocardiography, including the traditional techniques of two-dimensional, colour, and spectral Doppler echocardiography, and newly developed advances including tissue Doppler, myocardial deformation imaging, torsion, stress echocardiography, contrast and three-dimensional echocardiography. The advantages and disadvantages, clinical application, prognostic value, and salient research findings of each modality are described. Advances in complex imaging techniques are expected to continue unabated, and this Review highlights technical improvements that will influence the diagnosis and improve our understanding of cardiovascular function and disease.

Prognostic importance of tissue velocity imaging during exercise echocardiography in patients with systolic heart failure

Resting echocardiography measurements are poor predictors of exercise capacity and symptoms in patients with heart failure (HF). Stress echocardiography may provide additional information and can be expressed using left ventricular ejection fraction (LVEF), or diastolic parameters (E/E'), but LVEF has some major limitations. Systolic annular velocity (S') provides a measure of longitudinal systolic function, which is relatively easy to obtain and shows a good relationship with exercise capacity. The objective of this study was to investigate the relationship among S', E/E' and LVEF obtained during stress echocardiography and both mortality and hospitalisation. A secondary objective was to compare S' measured using a simplified two-wall model. A total of 80 patients with stable HF underwent exercise stress echocardiography and simultaneous cardiopulmonary exercise testing. Volumetric and tissue velocity imaging (TVI) measurements were obtained, as was peak oxygen uptake (VO2 peak). Of the total number of patients, 11 died and 22 required cardiac hospitalisation. S' at peak exertion was a powerful predictor for death and hospitalisation. Cut-off points of 5.3 cm/s for death and 5.7 cm/s for hospitalisation provided optimum sensitivity and specificity. This study suggests that, in patients with systolic HF, S' at peak exertion calculated from the averaged spectral TVI systolic velocity of six myocardial segments, or using a simplified measure of two myocardial segments, is a powerful predictor of future events and stronger than LVEF, diastolic velocities at rest or exercise and VO2 peak. Results indicate that measuring S' during exercise echocardiography might play an important role in understanding the likelihood of adverse clinical outcomes in patients with HF.

A new tissue Doppler index to predict cardiac death in patients with heart failure

Background

It has been shown that a new tissue Doppler index, E/(E'×S'), including the ratio between early diastolic transmitral and mitral annular velocity (E/E'), and the systolic mitral annular velocity (S'), has a good accuracy to predict left ventricular filling pressure.

Objectives

We investigated the value of E/(E'×S') to predict cardiac death in patients with heart failure.

Methods

Echocardiography was performed in 339 consecutive hospitalized patients with heart failure, in sinus rhythm, after appropriate medical treatment, at discharge and after one month. Worsening of E/(E'×S') was defined as any increase of baseline value. The end point was cardiac death.

Results

During the follow-up period (35.2 ± 8.8 months), cardiac death occurred in 51 patients (15%). The optimal cut-off value for the initial E/(E'×S') to predict cardiac death was 2.83 (76% sensitivity, 85% specificity). At discharge, 252 patients (74.3%) presented E/(E'×S') ≤ 2.83 (group I) and 87 (25.7%) presented E/(E'×S') > 2.83 (group II), respectively. Cardiac death was significantly higher in group II than in group I (38 deaths, 43.7% vs 13 deaths, 5.15%, p < 0.001). By multivariate Cox regression analysis, including variables that affected outcome in univariate analysis, E/(E'×S') at discharge was the best independent predictor of cardiac death (hazard ratio = 3.09, 95% confidence interval = 1.81-5.31, p = 0.001). Patients with E/(E'×S') > 2.83 at discharge and its worsening after one month presented the worst prognosis (all p < 0.05).

Conclusions

In patients with heart failure, the E/(E'×S') ratio is a powerful predictor of cardiac death, particularly if it is associated with its worsening.

Usefulness of right ventricular tissue Doppler imaging for diagnosis of right ventricular myocardial infarction

BACKGROUND

Right ventricular myocardial infarction (RVMI) is a complication of acute inferior myocardial infarction and sometimes causes severe hemodynamic disturbance. It is therefore important to promptly detect RVMI and assess the severity of right ventricular (RV) dysfunction. Tissue Doppler imaging (TDI) is a useful method to assess left ventricular function and RV function. In this study, we investigated the possibility of diagnosing RVMI using tricuspid annular velocity determined by TDI.

METHODS

Thirty consecutive patients with first acute inferior myocardial infarction were studied. The diagnosis of RVMI was based on an ST-segment elevation of at least 0.1 mV in lead V4R. The patients were classified into 12 patients with RVMI (the RVMI group) and 18 patients without RVMI (non-RVMI group). All patients underwent two-dimensional echocardiography, pulsed Doppler and TDI, and coronary angiography within 48 h after onset of myocardial infarction. Tricuspid inflow velocity was recorded by pulsed Doppler and early diastolic tricuspid inflow velocity (TVE) was measured. Peak early diastolic velocity of the tricuspid annulus (TVe') at the RV free wall was recorded using TDI. The ratio of TVE to TVe' (TVE/TVe') was calculated.

RESULTS

TVe' was significantly lower in the RVMI group compared to that in the non-RVMI group (5.9 ± 1.3 vs. 9.1 ± 3.1; p = 0.0025). On the basis of a TVe' cutoff value of less than 8.3 cm/s, RVMI was diagnosed with 100 % sensitivity and 61 % specificity.

CONCLUSIONS

The early diastolic tricuspid annular velocity determined by TDI is a noninvasive and sensitive index for diagnosing RVMI.

Relationship of left ventricular hypertrophy and diastolic function with cardiovascular and renal outcomes in African Americans with hypertensive chronic kidney disease

African Americans with hypertension are at high risk for adverse outcomes from cardiovascular and renal disease. Patients with stage 3 or greater chronic kidney disease have a high prevalence of left ventricular (LV) hypertrophy and diastolic dysfunction. Our goal was to study prospectively the relationships of LV mass and diastolic function with subsequent cardiovascular and renal outcomes in the African American Study of Kidney Disease and Hypertension cohort study. Of 691 patients enrolled in the cohort, 578 had interpretable echocardiograms and complete relevant clinical data. Exposures were LV hypertrophy and diastolic parameters. Outcomes were cardiovascular events requiring hospitalization or causing death; a renal composite outcome of doubling of serum creatinine or end-stage renal disease (censoring death); and heart failure. We found strong independent relationships between LV hypertrophy and subsequent cardiovascular (hazard ratio, 1.16; 95% confidence interval, 1.05-1.27) events, but not renal outcomes. After adjustment for LV mass and clinical variables, lower systolic tissue Doppler velocities and diastolic parameters reflecting a less compliant LV (shorter deceleration time and abnormal E/A ratio) were significantly (P<0.05) associated with future heart failure events. This is the first study to show a strong relationship among LV hypertrophy, diastolic parameters, and adverse cardiac outcomes in African Americans with hypertension and chronic kidney disease. These echocardiographic risk factors may help identify high-risk patients with chronic kidney disease for aggressive therapeutic intervention.

Failing heart of patients with type 2 diabetes mellitus can adapt to extreme short-term increases in circulating lipids and does not display features of acute myocardial lipotoxicity

BACKGROUND

Circulating lipid levels and myocardial lipid content (MyLC) is increased in type 2 diabetes mellitus. This may cause a state of lipotoxicity that compromises left ventricular function and aggravate heart failure. We investigated the relationship among circulating lipid levels, MyLC, and cardiac function together with the acute cardiac effects of high as opposed to low circulating free fatty acid (FFA) and triglyceride levels in patients with type 2 diabetes mellitus and heart failure.

METHODS AND RESULTS

Eighteen patients underwent 8-hour intralipid/heparin-infusion (high FFA) and hyperinsulinemic-euglycemic clamping (low FFA) in a randomized crossover-designed study. We applied magnetic resonance proton spectroscopy to measure MyLC. Cardiac function was assessed by advanced echocardiography, cardiopulmonary exercise, and MRI. MyLC correlated positively with circulating triglyceride (r=0.47; r(2)=0.22; P=0.003) and FFA (r=0.45; r(2)=0.20; P=0.001) levels and inversely with left ventricular ejection fraction (r=-0.54; r(2)=0.29; P=0.004). Circulating FFA concentrations differed between study arms (0.05 ± 0.04 mmol/L [low FFA] versus 1.04 ± 0.27 mmol/L [high FFA]; P<0.001) and MyLC increased from 0.78 ± 0.59% (low FFA) to 1.16 ± 0.73% (high FFA; P<0.01). Resting left ventricular ejection fraction and global strain did not differ between high and low FFA, whereas resting systolic mitral plane velocity (S'max) was highest during high FFA (3.6±0.8 cm/s [low FFA] versus 3.8±0.7 cm/s [high FFA]; P=0.02). Peak exercise capacity and oxygen consumption did not differ between the study arms, and neither did postexercise measurements of left ventricular ejection fraction, global strain, and S'max.

CONCLUSIONS

Our findings indicate that the failing heart of patients with type 2 diabetes mellitus can adapt to short-term extreme changes in circulating substrates and does not display features of acute myocardial lipotoxicity. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01192373.