Ten Years of 2D Longitudinal Strain for Early Myocardial Dysfunction Detection: A Clinical Overview

Echocardiographic Indices in Patients with End-Stage Renal Disease and Their Association with Hemodialysis-to-Hemodiafiltration Transfer: A Prospective Observational Study

Background and Objectives: The assessment of cardiac function in patients with end-stage renal disease (ESRD) is vital due to their high cardiovascular risk. However, contemporary echocardiographic indices and their association with hemodialysis-to-hemodiafiltration transfer are underreported in this population. Materials and Methods: This prospective cohort study enrolled 36 ESRD patients undergoing hemodialysis-to-hemodiafiltration transfer, with baseline and 3-month post-transfer comprehensive echocardiographic assessments. The key parameters included the global work index, global constructed work, global wasted work (GWW), global work efficiency (GWE), and global longitudinal strain (GLS), with secondary measures from conventional echocardiography. The baseline measures were compared to general population reference values and changes pre- to post-transfer were analyzed using the Mann-Whitney U test. Results: Patients exhibited significant deviations from reference ranges in GWW (179.0 vs. 53.0-122.2 mmHg%), GWE (90.0 vs. 53.0-122.2%), and GLS (-16.0 vs. -24.0-(-16.0)%). Post-transfer left ventricular myocardial work and longitudinal strain remained unchanged (p > 0.05), except for increased GWW (179.0, IQR 148.0-217.0 to 233.5, IQR 159.0-315.0 mmHg%, p = 0.037) and improved mid-inferior peak systolic longitudinal strain ((-17.0, IQR -19.0-(-11.0) to -18.7, IQR -20.0-(-18.0)%, p = 0.016). The enrolled patients also showed higher left atrial diameters, left ventricular volumes, and mass, with impaired systolic function in both ventricles compared to reference values. Conclusions: This study highlights baseline impairments in contemporary echocardiographic measures (GWW, GWE, GLS) in ESRD patients versus reference values, but found no association between hemodialysis-to-hemodiafiltration transfer and most myocardial work and strain parameters.

Myocardial work alterations with progressive left ventricular hypertrophy in patients with hypertension

Left ventricular (LV) hypertrophy (LVH) is frequently observed in patients with hypertension (HTN). LV myocardial work (MW) has recently emerged as a non-invasive method to assess systolic myocardial deformation relative to afterload conditions. The authors investigated the characteristics of myocardial work with different degrees of LVH in HTN patients. From December 2020 to February 2024, 255 HTN patients and 26 healthy controls undergoing transthoracic echocardiography were included in the current study. Hypertension patients were divided into quintile groups based on left ventricular mass index (LVMI), for the first to fourth LVMI quantiles, global work index (GWI) and global constructive work (GCW) were higher compared to the control group, but the difference was not statistically significant. In the sixth LVMI quantile, GWI and GCW showed a significant decrease. The restricted cubic splines showed that both GWI and GCW exhibited an inverted U-shaped relationship with LVMI. A LVMI of >151.39 g/m2 could accurately predict reduction both in GWI and GCW (Sensitivity: 0.78, Specificity: 0.89, AUC: 0.90, P < .001; Sensitivity: 0.81, Specificity: 0.92, AUC: 0.92, P < .001, respectively). As LVH progressed in HTN patients, both GWI and GCW initially demonstrated an increase, followed by a subsequent decrease. Myocardial work provides additional insights into assessment of cardiac function in HTN patients.

Clinical Applications of Myocardial Work in Echocardiography: A Comprehensive Review

Left ventricular (LV) global longitudinal strain (GLS) has recently garnered attention as a reliable and objective method for evaluating LV systolic function. One of the key advantages of GLS is its ability to detect subtle abnormalities even when the ejection fraction (EF) appears to be preserved. However, it is important to note that GLS, much like LVEF, is significantly influenced by load conditions. In recent years, researchers and clinicians have been exploring noninvasive myocardial work (MW) quantification as an innovative tool for assessing myocardial function. This method integrates measurements of strain and LV pressure, providing a comprehensive evaluation of the heart's performance. Notably, MW offers an advantage over GLS and LVEF because it provides a load-independent assessment of myocardial performance. The implementation of commercial echocardiographic software that facilitates the noninvasive calculation of MW has significantly broadened the scope of its application. This advanced technology is now being utilized in multiple clinical settings, including ischemic heart disease, valvular diseases, cardiomyopathies, cardio-oncology, and hypertension. One of the fundamental aspects of MW is its correlation with myocardial oxygen consumption, which allows for the assessment of work efficiency. Understanding this relationship is crucial for diagnosing and managing various cardiac conditions. The aim of this review is to provide an overview of the noninvasive assessment of myocardial by echocardiography, from basic principles and methodology to current clinical applications.

Effects of a Transoceanic Rowing Challenge on Cardiorespiratory Function and Muscle Fitness

Ultra-endurance sports and exercise events are becoming increasingly popular for older age groups. We aimed to evaluate changes in cardiac function and physical fitness in males aged 50-60 years who completed a 50-day transoceanic rowing challenge. This case account of four self-selected males included electro- and echo-cardiography (ECG, echo), cardiorespiratory and muscular fitness measures recorded nine months prior to and three weeks after a transatlantic team-rowing challenge. No clinically significant changes to myocardial function were found over the course of the study. The training and race created expected functional changes to left ventricular and atrial function; the former associated with training, the latter likely due to dehydration, both resolving towards baseline within three weeks post-event. From race-start to finish all rowers lost 8.4-15.6 kg of body mass. Absolute cardiorespiratory power and muscular strength were lower three weeks post-race compared to pre-race, but cardiorespiratory exercise economy improved in this same period. A structured program of moderate-vigorous aerobic endurance and muscular training for>6 months, followed by 50-days of transoceanic rowing in older males proved not to cause any observable acute or potential long-term risks to cardiovascular health. Pre-event screening, fitness testing, and appropriate training is recommended, especially in older participants where age itself is an increasingly significant risk factor.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Quantitative assessment of left ventricular myocardial work in patients with different types of atrial fibrillation by non-invasive pressure-strain loop technique

OBJECTIVE

This study aimed to analyze myocardial work in patients with atrial fibrillation (AF) using a noninvasive pressure strain loop (PSL) technique to provide a basis for the quantitative assessment of left ventricular (LV) systolic function.

METHODS

LV myocardial work of 107 AF patients (56 with paroxysmal atrial fibrillation and 51 with persistent atrial fibrillation) and 55 healthy individuals were assessed by the noninvasive PSL and then compared.

RESULTS

Global longitudinal strain (GLS) in absolute values, global work index (GWI), global constructive work (GCW), and global work efficiency (GWE) were significantly lower in the AF group than control group, whereas peak strain dispersion (PSD) and global wasted work (GWW) were significantly higher (P < .05). Further subdivision according to the AF type revealed that, compared with the controls, GLS in absolute values and GWE decreased significantly; PSD and GWW increased significantly in the paroxysmal AF group (P < .05). Nevertheless, GWI and GCW were not significantly different between paroxysmal AF and control groups (P > .05). Compared to paroxysmal AF, persistent AF induced a further decrease in absolute GLS and GWE and a further increase in GWW (P < .05), but PSD did not increase further (P > .05). Multiple linear regression analysis showed that GWI and GCW were independently associated with systolic blood pressure. GWW was associated with types of AF and left atrial volume index (LAVI). GWE was correlated with age, types of AF, disease duration, and LAVI. Receiver operating characteristic curve analysis showed that the area under the curve predicting myocardial injury was higher for GWE and GWW than for GLS (area under the curve:  .880,  .846, and  .821, respectively).

CONCLUSIONS

Non-invasive PSL can quantitatively assess LV systolic function in patients with different kinds of AF and detect early subclinical myocardial injury in patients with paroxysmal AF. GWE and GWW outperform GLS and LV ejection fraction when assessing myocardial injury. Systolic blood pressure, type of AF, LVAI, disease duration, and age may be associated with myocardial injury in patients with AF.

Echocardiography-guided percutaneous intramyocardial alginate hydrogel implants for heart failure: canine models with 6-month outcomes

Background

Echocardiography-guided percutaneous intramyocardial alginate-hydrogel implantation (PIMAHI) is a novel treatment approach for heart failure (HF). We validated PIMAHI safety and efficacy in canine HF models.

Methods

Fourteen canines with HF [produced by coronary artery ligation, left ventricular ejection fraction (LVEF) < 35%] were randomised to PIMAHI treatment (n = 8) or controls (n = 6). Echocardiography, two-dimensional speckle tracking echocardiography, and pathological examinations after a 6-month follow-up were performed. Repeated-measures analysis of variance was used for within-group comparisons.

Results

At 6-month follow-up, PIMAHI treatment reversed LV dilation and remodelling, increasing LV free wall thickness (LVFW, p = 0.002) and interventricular septum thickness (IVS, p < 0.001) and reducing LV end-diastolic volume (EDV, p = 0.008) and end-systolic volume (ESV, p = 0.004). PIMAHI significantly improved LV systolic function, increasing LVEF (EF, p = 0.004); enhanced LV myocardial contractility, including increased LV global longitudinal strain (GLS, p < 0.001), global circumferential strain (GCS, p = 0.006), and mitral annulus displacement (MAD, p = 0.001). Compared with controls at 6-month, PIMAHI group significantly increased LVFW thickness (8.5 ± 0.3 vs. 6.8 ± 0.2 mm, p = 0.002) and IVS (7.9 ± 0.1 vs. 6.1 ± 0.2 mm, p < 0.001); decreased LVEDV (30.1 ± 1.6 vs. 38.9 ± 4.5 ml, p = 0.049) and ESV (17.3 ± 1.2 vs. 28.7 ± 3.6 ml, p = 0.004); increased LV systolic function (42.7 ± 1.5 vs. 26.7 ± 1.1% in EF, p = 0.001); and enhanced LV myocardial contractility including GLS (13.5 ± 0.8 vs. 8.4 ± 0.6%, p = 0.002), GCS (16.5 ± 1.4 vs. 9.2 ± 0.6%, p = 0.001), and MAD (11.4 ± 3.5vs 4.6 ± 2.5 mm, p = 0.003). During PIMAHI treatment, no sustained arrhythmia, pericardial, or pleural effusion occurred.

Conclusions

PIMAHI in canine HF models was safe and effective. It reversed LV dilation and improved LV function.

Abnormal inter-ventricular diastolic mechanical delay in patients with ST-segment elevation myocardial infarction

BACKGROUND

This study aimed to investigate the ventricular mechanical relaxation pattern and its clinical influence in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

Echocardiography was performed to measure mitral and tricuspid diastolic opening times. Left ventricular diastolic mechanical delay (LVMDd) was defined as diastolic filling of the right ventricle earlier than that of the left ventricle, and right ventricular diastolic mechanical delay (RVMDd) was defined as the right ventricular diastolic filling later than left ventricular filling.

RESULTS

Among 152 patients with STEMI, 100 (65.8%) had LVMDd, and 47 (30.9%) had RVMDd. In-hospital complications were significantly increased in patients with RVMDd (61.6% vs. 41.0%, P = 0.017). Those with RVMDd exhibited significantly lower left ventricular global longitudinal strain (11.7 ± 4.1% vs. 13.2 ± 4.0%, P = 0.035), global work index (913.8 ± 365.9 vs. 1098.9 ± 358.8 mmHg%, P = 0.005) and global constructive work (1218.6 ± 392.8 vs. 1393.7 ± 432.7 mmHg%, P = 0.021). Mitral deceleration time significantly decreased (127.4 ± 33.5 vs. 145.6 ± 41.7 ms, P = 0.012), and the ratio of early mitral inflow to early mitral annular velocity (E/E') significantly increased [13.0(11.0-20.0) vs. 11.9(9.3-14.3), P = 0.006] in the RVMDd group. Logistic regression analysis showed that age (odds ratio [OR]:0.920; P = 0.001), brain natriuretic peptide level (OR: 1.1002; P = 0.036) and mitral E/E' (OR: 1.187; P = 0.003) were independently associated with RVMDd.

CONCLUSIONS

Delayed right ventricular filling is related to more severe left ventricular systolic and diastolic dysfunction in STEMI patients. More attention should be paid to patients with RVMDd to prevent adverse events during hospitalization.

The effects of obesity on longitudinal ventricular and atrial strain in a rural population of Spanish children and adolescents, evaluated by a new strain software

BACKGROUND AND OBJECTIVES

Research on the relationship between body mass index (BMI) and strain values in children and adolescents is limited. Our aim was to analyse the relationship between BMI and strain values of both ventricles and left atrium in children and adolescents.

METHODS

Both ventricles and left atrial strain values were compared among different BMI categories in children and adolescents from a town in the South of Spain.

RESULTS

Of the 198 subjects, aged 6-17 years, 53% were of normal weight, 26% were overweight and 21% had obesity. Lower absolute values of left ventricular global longitudinal strain (25.9 ± 2.0% vs. 26.9 ± 2.2%, p = 0.002) and right ventricular free wall longitudinal strain (29.5 ± 4.2% vs. 30.8 ± 4.5%, p = 0.04) were found in subjects with obesity and overweight versus subjects with normal weight. A lower right ventricular four-chamber longitudinal strain was also observed in males with obesity and overweight (24.8 ± 3.3% vs. 26.4 ± 3.6%, p = 0.03). Statistically significant negative correlations of BMI were found for all ventricular, but not atrial, strain values in univariate analysis. This association turned non-significant for right ventricular four-chamber longitudinal strain in multivariate analysis.

CONCLUSIONS

Utilizing this new strain software, children and adolescents with high BMI were associated with significantly lower values for left and right ventricular free wall longitudinal strain, without impact in left atrial strain.

Current national availability of advanced echocardiography imaging: real world data from an Italian Society of Echocardiography and Cardiovascular Imaging survey

Aims

Advanced echocardiographic imaging (AEI) techniques, such as three-dimensional (3D) and multi-chamber speckle-tracking deformation imaging (strain) analysis, have been shown to be more accurate in assessing heart chamber geometry and function when compared with conventional echocardiography providing additional prognostic value. However, incorporating AEI alongside standard examinations may be heterogeneous between echo laboratories (echo labs). Thus, our goal was to gain a better understanding of the many AEI modalities that are available and employed in Italy.

Methods and results

The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey over a month (November 2022) to describe the use of AEI in Italy. Data were retrieved via an electronic survey based on a structured questionnaire uploaded on the SIECVI website. Data obtained from 173 echo labs were divided into 3 groups, according to the numbers of echocardiograms performed: <250 exams (low-volume activity, 53 centres), between 251 and 550 exams (moderate-volume activity, 62 centres), and ≥550 exams (high-volume activity, 58 centres). Transthoracic echocardiography (TTE) 3D was in use in 75% of centres with a consistent difference between low (55%), medium (71%), and high activity volume (85%) (P = 0.002), while 3D transoesophageal echocardiography (TEE) was in use in 84% of centres, reaching the 95% in high activity volume echo labs (P = 0.006). In centres with available 3D TTE, it was used for the left ventricle (LV) analysis in 67%, for the right ventricle (RV) in 45%, and for the left atrium (LA) in 40%, showing greater use in high-volume centres compared with low- and medium-volume centres (all P < 0.04). Strain analysis was utilized in most echo labs (80%), with a trend towards greater use in high-volume centres than low- and medium-volume centres (77%, 74%, and 90%, respectively; P = 0.08). In centres with available strain analysis, it was mainly employed for the LV (80%) and much less frequently for the RV and LA (49% and 48%, respectively).

Conclusion

In Italy, the AEI modalities are more frequently available in centres with high-volume activity but employed only in a few applications, being more frequent in analysing the LV compared with the RV and LA. Therefore, the echocardiography community and SIECVI should promote uniformity and effective training across the Italian centres. Meanwhile, collaborations across centres with various resources and expertise should be encouraged to use the benefits of the AEI.

Estimation of left ventricular activation sequence in patients with heart failure using two-dimensional speckle tracking echocardiography

Evaluation of longitudinal strain (LS) from two-dimensional echocardiography is useful for global and regional left ventricular (LV) dysfunction assessment. We determined whether the LS reflects contraction process in patients with asynchronous LV activation. We studied 144 patients with an ejection fraction ≤ 35%, who had left bundle branch block (LBBB, n = 42), right ventricular apical (RVA) pacing (n = 34), LV basal- or mid-lateral pacing (n = 23), and no conduction block (Narrow-QRS, n = 45). LS distribution maps were constructed using 3 standard apical views. The times from the QRS onset-to-early systolic positive peak (Q-EPpeak) and late systolic negative peak (Q-LNpeak) were measured to determine the beginning and end of contractions in each segment. Negative strain in LBBB initially appeared in the septum and basal-lateral contracted late. In RVA and LV pacing, the contracted area enlarged centrifugally from the pacing site. Narrow-QRS showed few regional differences in strain during the systolic period. The Q-EPpeak and Q-LNpeak exhibited similar sequences characterized by septum to basal-lateral via the apical regions in LBBB, apical to basal regions in RVA pacing, and lateral to a relatively large delayed contracted area between the apical- and basal-septum in LV pacing. Differences in Q-LNpeaks between the apical and basal segments in delayed contracted wall were 107 ± 30 ms in LBBB, 133 ± 46 ms in RVA pacing, and 37 ± 20 ms in LV pacing (p < 0.05, between QRS groups). Specific LV contraction processes were demonstrated by evaluating the LS distribution and time-to-peak strain. These evaluations may have potential to estimate the activation sequence in patients with asynchronous LV activation.

Reference centiles for left ventricular longitudinal global and regional systolic strain by automated functional imaging in healthy Egyptian children

BACKGROUND

Two-dimensional speckle tracking echocardiography-derived left ventricular longitudinal systolic strain is an important myocardial deformation parameter for assessing the systolic function of the left ventricle. Strain values differ according to the vendor machine and software. This study aimed to provide normal reference values for global and regional left ventricular longitudinal systolic strain in Egyptian children using automated functional imaging software integrated into the General Electric healthcare machine and to study the correlation between the global longitudinal left ventricular systolic strain and age, body size, vital data, and some echocardiographic parameters.

METHODS

Healthy children (250) aged from 1 to 16 years were included. Conventional echocardiography was done to measure the left ventricular dimensions and function. Automated functional imaging was performed to measure the global and regional peak longitudinal systolic strain.

RESULTS

The global longitudinal strain was -21.224 ± 1.862%. The regional strain was -20.68 ± 2.11%, -21.06 ± 1.84%, and -21.86 ± 2.71% at the basal, mid, and apical segments, respectively. The mean values of the systolic longitudinal strain become significantly more negative from base to apex. Age differences were found as regard to global and regional longitudinal strain parameters but no gender differences. The global peak longitudinal systolic strain correlated positively with age. No correlations were found with either the anthropometric parameters or the vital data.

CONCLUSIONS

Age-specific normal values for two-dimensional speckle tracking-derived left ventricular longitudinal regional and global systolic strain are established using automated functional imaging.

Diagnostic Accuracy of Global Longitudinal Strain for Detecting Exercise Intolerance in Patients with Ischemic Heart Disease

Objective: Global longitudinal strain (GLS) is a sensitive and reproducible predictive factor in patients with ischemic heart disease (IHD), although its correlation with exercise tolerance is unknown. We aimed to identify the correlation between global longitudinal strain (GLS) and cardiopulmonary exercise testing (CPX) parameters and assess the prognostic implications and accuracy of GLS in predicting exercise intolerance in populations with ischemic heart disease (IHD) using CPET criteria. Methods: Prospectively, 108 patients with IHD underwent CPX and 2D speckle-tracking echocardiography. Correlation between GLS and multiple CPX variables was assessed using Spearman’s correlation analysis and univariate regression analysis. A receiver operating characteristic (ROC) curve analysis was performed on GLS to detect exercise intolerance. Results: GLS was correlated with peak oxygen uptake (peak VO2; r = −0.438, p = 0.000), %PPeak VO2 (−0.369, p = 0.000), peak metabolic equivalents (METs@peak; r = −0.438, p < 0.01), and the minute ventilation−carbon dioxide production (VE/VCO2) slope (r = 0.257, p < 0.01). Weak-to-moderate correlations were also identified for the respiratory exchange rate at the anaerobic threshold (RER@AT), end-tidal carbon dioxide at the anaerobic threshold (PETCO2@AT), oxygen consumption at the anaerobic threshold (VO2@AT), carbon dioxide production at the anaerobic threshold (VCO2@AT), and metabolic equivalents at the anaerobic threshold (METs@AT; p < 0.01). On multivariate analysis, the results showed that age, the BMI, and GLS are independent predictors for reduced exercise capacity in patients with IHD (p < 0.01). The area under the ROC curve value of GLS for identifying patients with a peak VO2 of <14 mL/kg/min was 0.73 (p = 0.000). Conclusion: As a sensitive echocardiographic assessment of patients with ischemic heart disease, global longitudinal strain is an independent predictor of reduced exercise capacity and has a sensitivity of 74.2% and a specificity of 66.7% to detect exercise intolerance.

IMproving PULmonary hypertension Screening by Echocardiography: IMPULSE

BACKGROUND

The world symposium on pulmonary hypertension (PH) has proposed that PH be defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg as assessed by right heart catheterisation (RHC). Transthoracic echocardiography (TTE) is an established screening tool used for suspected PH. International guidelines recommend a multi-parameter assessment of the TTE PH probability although effectiveness has not been established using real world data.

STUDY AIMS

To determine accuracy of the European Society of Cardiology (ESC) and British Society of Echocardiography (BSE) TTE probability algorithm in detecting PH in patients attending a UK PH centre. To identify echocardiographic markers and revised algorithms to improve the detection of PH in those with low/intermediate BSE/ESC TTE PH probability.

METHODS

TTE followed by RHC (within 4 months after) was undertaken in patients for suspected but previously unconfirmed PH. BSE/ESC PH TTE probabilities were calculated alongside additional markers of right ventricular (RV) longitudinal and radial function, and RV diastolic function. A refined IMPULSE algorithm was devised and evaluated in patients with low and/or intermediate ESC/BSE TTE PH probability.

RESULTS

Of 310 patients assessed, 236 (76%) had RHC-confirmed PH (average mPAP 42.8 ± 11.7). Sensitivity and specificity for detecting PH using the BSE/ESC recommendations was 89% and 68%, respectively. 36% of those with low BSE/ESC TTE probability had RHC-confirmed PH and BSE/ESC PH probability parameters did not differ amongst those with and without PH in the low probability group. Conversely, RV free wall longitudinal strain (RVFWLS) was lower in patients with vs. without PH in low BSE/ESC probability group (- 20.6 ± 4.1% vs - 23.8 ± 3.9%) (P < 0.02). Incorporating RVFWLS and TTE features of RV radial and diastolic function (RVFAC and IVRT) within the IMPULSE algorithm reduced false negatives in patients with low BSE/ESC PH probability by 29%. The IMPULSE algorithm had excellent specificity and positive predictive value in those with low (93%/80%, respectively) or intermediate (82%/86%, respectively) PH probability.

CONCLUSION

Existing TTE PH probability guidelines lack sensitivity to detect patients with milder haemodynamic forms of PH. Combining additional TTE makers assessing RV radial, longitudinal and diastolic function enhance identification of milder forms of PH, particularly in those who have a low BSE/ESC TTE PH probability.

Reliability and feasibility of automated function imaging for quantification in patients with left ventricular dilation: comparison with cardiac magnetic resonance

Automated function imaging (AFI, GE Healthcare) is a novel promising algorithm of speckle-tracking echocardiography that combines two-dimensional strain and AI technology. It shortens the analysis time, saves the cost associated with streamlining of image acquisition, rapid analysis, and reporting, and has greater accuracy and reproducibility of measurements. This study aimed to evaluate the reliability and feasibility of AFI for the quantification of left ventricular (LV) volumes and function in patients with LV dilation by comparison with CMR. We retrospectively studied 50 patients with LV dilation on echocardiography whom both underwent CMR and coronary angiography within three days. LV volumes, ejection fraction (EF), and global longitudinal strain (GLS) were measured from 3 long-axis cine-views via the AFI technique in two modes: without editing (auto-AFI) and with partial border editing (semi-auto-AFI). The LV volumes and EF were also measured with 2D Simpson's biplane method, and CMR, as the standard method, was used for comparison. The AFI method still had significantly underestimated the LV volumes compared with CMR (P<0.01), but there were no significant differences between the AFI method and the conventional Simpson's biplane method. There were no significant differences in EF between CMR and the AFI method with good correlations (auto-AFI: r = 0.81, semi-auto-AFI: r = 0.86). The auto-AFI method provided the most rapid analysis and excellent reproducibility, while the semi-auto-AFI method further improved measurement accuracy. However, there were no significant differences in LV volumes and EF between these two AFI methods. The accuracy of AFI seems to be more affected by the image quality than the left ventricular morphology.  AFI enables accurate, efficient, and rapid evaluation of LV volumes and EF in patients with dilated LV, with good reproducibility and correlations with CMR.

Advanced Echocardiography Techniques: The Future Stethoscope of Systemic Diseases

Cardiovascular disease (CVD) has been showing patterns of extensive rise in prevalence in the contemporary era, affecting the quality of life of millions of people and leading the causes of death worldwide. It has been a provocative challenge for modern medicine to diagnose CVD in its crib, owing to its etiological factors being attributed to a large array of systemic diseases, as well as its non-binary hideous nature that gradually leads to functional disability. Novel echocardiography techniques have enabled the cardiac ultrasound to provide a comprehensive analysis of the heart in an objective, feasible, time- and cost-effective manner. Speckle tracking echocardiography, contrast echocardiography, and 3D echocardiography have shown the highest potential for widespread use. The uses of novel modalities have been elaborately demonstrated in this study as a proof of concept that echocardiography has a place in routine general practice with supportive evidence being as recent as its role in the concurrent COVID-19 pandemic. Despite such evidence, many uses remain off-label and unexploited in practice. Generalization of echocardiography at the point of care can become a much-needed turning point in the clinical approach to case management. To actualize such aspirations, we recommend further prospective and interventional studies to examine the effect of implementing advanced techniques at the point of care on the decision-making process and evaluate their effectiveness in prevention of cardiovascular morbidities and mortalities.

Usefulness of echocardiographic myocardial work in evaluating the microvascular perfusion in STEMI patients after revascularization

Background

Left ventricular myocardial work (MW) assessed by echocardiography has recently been introduced as a new index of global and regional myocardial performance. The presence of microvascular obstruction after revascularization in ST-segment elevation myocardial infarction (STEMI) patients predicts poor clinical outcomes. This study aimed to explore the usefulness of MW in identifying impaired microvascular perfusion (MVP) in the patients with STEMI after revascularization.

Methods

One hundred and sixty STEMI patients who underwent myocardial contrast echocardiography (MCE) within 48 h after percutaneous coronary intervention (PCI) were included. Patients were divided into normal MVP and impaired MVP groups according to the myocardial perfusion score. The clinical data, coronary angiography results and echocardiographic data including Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were collected.

Results

Impaired MVP was found in 60% of patients. Compared with the normal MVP group, GWI (909.2 ± 287.6 mmHg% vs. 1191.2 ± 378.2 mmHg%), GCW (1198.3 ± 339.6 mmHg% vs. 1525.9 ± 420.5 mmHg%), GWE (82.7 ± 7.8% vs. 86.8 ± 5.6%) and GLS (− 11.0 ± 3.4% vs. − 14.4 ± 3.8%) were significantly reduced in the impaired MVP group. Whereas there was no statistically significant difference in left ventricular ejection fraction (LVEF) and GWW, multivariate logistic regression analysis showed that peak troponin I (OR 1.017, 95% CI 1.006–1.029; P = 0.004), final TIMI flow ≤ 2 (OR 16.366, 95% CI 1.998–134.06; P = 0.009), left ventricular end-diastolic volume index (LVEDVi) (OR 1.139 95% CI 1.048–1.239; P = 0.002), and GWI (OR 0.997 95% CI 0.994–1.000; P = 0.029) were independently associated with impaired MVP. GWI showed a good sensitivity (86.8%) but low specificity (53.7%) in identifying impaired MVP (AUC 0.712, 95% CI 0.620–0.804; P < 0.001). Combination with GWI can improve the diagnostic value of TNI or LVEVi for impaired MVP.

Conclusion

Impaired MVP is relatively common in STEMI patients after revascularization and independently associated with left ventricular GWI assessed by echocardiography. GWI confer incremental value to MVP assessment in STEMI patients.

Combining Stress Speckle Tracking with High-Sensitivity C-Reactive Protein in Diagnosis of Coronary Artery Disease

Introduction: CAD (coronary artery disease) is a leading cause of death and disability in developed nations. Exercise testing is recommended as a first-line diagnostic test for patients with stable angina pectoris. In addition to myocardial strain, high-sensitivity CRP (hs-CRP) can predict the presence of significant coronary artery disease. Aim of work: The purpose of this study was to demonstrate the utility of 2D-speckle tracking at rest and under stress along with hs-CRP for detection of CAD in patients who were referred to the chest pain unit with stable or low risk unstable angina pectoris. Methods: A total of 108 individuals met the inclusion criteria and gave their written consent to participate in this study. Coronary angiography was performed within 48 h after admission to the chest pain unit. Myocardial strain was recorded at rest and during dobutamine administration. Results: Global longitudinal strain at stress appeared to be moderately correlated with the presence of significant coronary artery disease (CAD); r = 0.41, p < 0.0001. A moderate correlation was also found between global longitudinal strain at stress and the severity of coronary occlusion; r = 0.62, p < 0.0001. With a cut-off value of −19.1, global longitudinal strain under stress had a sensitivity of 74.1% and a specificity of 76.7% for detecting significant CAD. Hs-CRP was significantly higher in patients with manifested CAD. Conclusion: Evaluation of longitudinal strain parameters at rest and under stress may predict coronary artery disease in patients with stable angina pectoris. A measurable Hs-CRP is a potential marker of coronary stenosis. Strain data could assist in diagnosing CAD severity.

Global Longitudinal Strain to Predict Respiratory Failure and Death in Patients Admitted for COVID-19-Related Disease

Evidence of the involvement of the cardiovascular system in patients with COVID-19 is increasing. The evaluation of the subclinical cardiac involvement is crucial for risk stratification at admission, and left ventricular global longitudinal strain (LVGLS) may be useful for this purpose. A total of 87 consecutive patients admitted to the COVID Center were enrolled from December 2020 to April 2021. A complete echocardiography examination was performed within 72 hours from admission. The main outcome was the need for mechanical ventilation by way of orotracheal intubation (OTI) and mortality, and the secondary outcome was the worsening of the respiratory function during hospitalization, interpreted as a decrease of the ratio between the partial pressure of oxygen and the fraction of inspired oxygen (P/F) <100. Of 87 patients, 14 had severe disease leading to OTI or death, whereas 24 had a P/F <100. LVGLS was significantly impaired in patients with severe disease. After adjustment for risk factors, by considering LVGLS as continuous variable, the latter remained significantly associated with severe acute respiratory distress syndrome (P/F <100) (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.18 to 1.88, p = 0.001) and OTI/death (HR 1.63, 95% CI 1.13 to 2.38, p = 0.012). When using an LVGLS cutoff of −16.1%, LVGLS ≥ −16.1% was independently associated with a higher risk of severe acute respiratory distress syndrome (HR 4.0, 95% CI 1.4 to 11.1, p= 0.008) and OTI/death (HR 7.3, 95% CI 1.6 to 34.1, p = 0.024). LVGLS can detect high-risk patients at the admission, which can help to guide in starting early treatment of the admitted patients.

Longitudinal systolic dysfunction in hypertensive cardiomyopathy with normal ejection fraction

BACKGROUND

The left ventricle (LV) journey in their transition from hypertrophy to heart failure is marked by many subcellular events partially understood yet. The moment in which the structural abnormalities reach the umbral to induce myocardial dysfunction remains elusive.

AIMS

To evaluate the anatomic-functional relationship between LV wall thickness and longitudinal systolic dysfunction.

MATERIAL AND METHODS

We prospectively performed clinical assessment and transthoracic echocardiogram on healthy individuals and hypertensive patients with left ventricle ejection fraction (LVEF) ≥50% and absence of heart failure symptoms.

RESULTS

A total of 226 patients and 101 healthy individuals were recruited. The distribution for sex was similar between groups. The mean age was 67±13 years old in the patients, and 44% had concentric LV hypertrophy. LVEF was identical in both groups (63±6%); in contrast, global longitudinal strain (GLS) (-18.8±2.5% vs -20.4±2%) and mitral annulus plane systolic excursion (MAPSE) (13.8±2.8 vs 15.5±2 mm) were lower. ROC curve optimally classified decreased GLS with LV septum thickness ≥13 mm and decreased MAPSE with thickness ≥14 mm. Multivariable logistic regression found that LV septum thickness is the only variable associated with longitudinal systolic dysfunction (OR = 1.1, CI_95%  =  1.05 - 1.15, P = 0.001, R squared = .38).

DISCUSSION

A progressive increase in LV wall thickness due to myocyte hypertrophy and interstitial expansion is associated with LV systolic longitudinal dysfunction.

CONCLUSIONS

Patients with moderate or severe ventricular hypertrophy (septum ≥13 mm) had longitudinal systolic dysfunction, GLS decreases with minor structural change than MAPSE, and LVEF is insensitive in detecting longitudinal myocardial dysfunction in patients with hypertension.

Cardiac involvement in patients recovered from COVID-19 identified using left ventricular longitudinal strain

Introduction

Coronavirus disease-19 (COVID-19) has been associated with subclinical myocardial dysfunction during its acute phase and a recurring pattern of reduced basal left ventricular longitudinal strain on speckle-tracking echocardiography (STE) in hospitalized patients. But a question still remains unanswered: speckle-tracking echocardiography might also be suitable to detect residual myocardial involvement after acute stage of COVID-19?

Methods and results

We studied 100 patients recovered from COVID-19 with STE to evaluate global (GLS) and segmentar longitudinal strain (LS) and compared with a control group of 100 healthy individuals. STE was performed at a median of 130.35 ± 76.06 days after COVID-19 diagnostic. Demographic and echocardiographic parameters are similar in both groups. Left ventricular ejection faction (LVEF) and GLS were normal in COVID-19 patients (66.20 ± 1.98% and − 19.51 ± 2.87%, respectively). A reduction in mean LS for the basal segments was found in COVID-19 (16.48 ± 5.41%) when compared to control group (19.09 ± 4.31%) (p < 0.001).

Conclusion

The present study suggests that COVID-19-induced cardiac involvement could persist after recovery of the disease and may be detected by deformation abnormalities using STE. COVID-19-induced myocardial involvement often shows specific LV deformation patterns due to pronounced edema and/or myocardial damage in basal LV segments.

Role of Two-Dimensional Speckle-Tracking Echocardiography in Early Detection of Left Ventricular Dysfunction in Dogs

Simple Summary

Two-dimensional speckle-tracking echocardiography represents an advanced imaging technique that allows the analysis of global and regional myocardial function, cardiac rotation and synchronicity using deformation imaging. It has gained growing importance over the last decade, especially in human medicine as a method of evaluating myocardial function. This review aims to give an overview of the current understanding of this technique and its clinical applicability in the field of veterinary medicine with a focus on early detection of left ventricular dysfunction in dogs.

Abstract

Two-dimensional speckle-tracking echocardiography (2D–STE) is an advanced echocardiographic technique based on deformation imaging that allows comprehensive evaluation of the myocardial function. Clinical application of 2D–STE holds great potential for its ability to provide valuable information on both global and regional myocardial function and to quantify cardiac rotation and synchronicity, which are not readily possible with the conventional echocardiography. It has gained growing importance over the past decade, especially in human medicine, and its application includes assessment of myocardial function, detection of subclinical myocardial dysfunction and serving as a prognostic indicator. This review illustrates the fundamental concepts of deformation analysis and gives an overview of the current understanding and its clinical application of this technique in veterinary medicine, with a focus on early detection of left ventricular (LV) dysfunction in dogs.

Myocardial work in Stage 1 and 2 hypertensive patients

AIMS

Myocardial work (MW) is a novel parameter that can be used in a clinical setting to assess left ventricular (LV) pressures and deformation. We sought to distinguish patterns of global MW index in hypertensive vs. non-hypertensive patients and to look at differences between categories of hypertension.

METHODS AND RESULTS

Sixty-five hypertensive patients (mean age 65 ± 13 years; 30 male) and 15 controls (mean age 38 ± 12 years; 7 male) underwent transthoracic echocardiography at rest. Hypertensive patients were subdivided into Stage 1 (n = 32) and Stage 2 (n = 33) hypertension based on 2017 American College of Cardiology guidelines. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, reduced ejection fraction, valvular heart disease, intracardiac shunt, and arrhythmia. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency were estimated from LV pressure-strain loops utilizing proprietary software from speckle-tracking echocardiography. LV systolic and diastolic pressures were estimated using non-invasive brachial artery cuff pressure. Global longitudinal strain and LV ejection fraction were preserved between the groups with no statistically significant difference, whereas there was a statically significant difference between the control and two hypertension groups in GWI (P = 0.01), GCW (P < 0.001), and GWW (P < 0.001).

CONCLUSION

Non-invasive MW analysis allows better understanding of LV response under conditions of increased afterload. MW is an advanced assessment of LV systolic function in hypertension patients, giving a closer look at the relationship between LV pressure and contractility in settings of increased load dependency than LV ejection fraction and global longitudinal strain.

Bicuspid aortic valve and aortopathy: novel prognostic predictors for the identification of high-risk patients

AIMS

Bicuspid aortic valve (BAV) may be complicated by aortic aneurysms and dissection. This study aimed to evaluate the prognostic efficacy of markers from cardiac imaging, as well as genetic and new biomarkers, to early predict aortic complications.

METHODS AND RESULTS

We re-evaluated after a mean time of 48 ± 11 months 47 BAV patients who had undergone previous echocardiography for evaluation of aortic stiffness and 2D aortic longitudinal strain (LS) (by speckle-tracking analysis), and who had given a blood sample for the assessment of a single-nucleotide polymorphism of elastin gene (ELN rs2 071307) and quantification of elastin soluble fragments (ESF). Surgical treatment of aortic aneurysm/dissection was the primary endpoint, and an aortic dimension increase (of one or more aortic segments) ≥1 mm/year was the secondary endpoint. Nine patients underwent surgical treatment of ascending aorta (AA) aneurysms. Out of the 38 patients who did not need surgical intervention, 16 showed an increase of aortic root and/or AA dimension ≥1 mm/year. At multivariate Cox regression analysis, an impaired AA LS was an independent predictor of aortic surgery [P = 0.04; hazard ratio (HR) 0.961; 95% confidence interval (CI) 0.924-0.984] and aortic dilatation (P = 0.007; HR 0.960; 95% CI 0.932-0.989). An increased quantity of ESF was correlated (P = 0.015) with the primary endpoint at univariate Cox regression analysis but it did not keep statistical significance at multivariate analysis.

CONCLUSION

In BAV patients, impairment of elastic properties of the AA, as assessed by 2D LS, is an effective predictor of aortic complications.

Inter-observer and Inter-vendor Variability in Strain Measurements in Patients with Single Right Ventricular Anatomy

Myocardial strain offers new insights into ventricular performance, There are software packages from several different companies used to ascertain this, and little data is available in patients with single right ventricle (sRV) physiology. We aimed to compare the analysis of two strain software applications using a cohort of patients with sRV for both inter-vendor and inter-observer variability. Echocardiograms from 85 patients with sRV (122 separate studies) were prospectively evaluated. All had Glenn and/or Fontan palliation. Longitudinal 4-chamber (4LS), inflow/outflow (IO), circumferential, and radial strain were assessed using Velocity Vector Imaging (VVI, Seimens, Munich) and Automated Functional Imaging (AFI, General Electric, Boston) software. In a subset of 45 patients (61 separate studies), strain measurements were obtained by two sonographers so a paired "inter-observer" analysis could be performed. A moderate correlation between measurements made by the two systems was observed. Circumferential strain assessment had the highest R value (0.77) with all others having R values < 0.6. Both software packages showed modest inter-observer reproducibility for longitudinal and circumferential strain. VVI intraclass correlation coefficients (ICC) for 4LS and average circumferential strain (ACS) were 0.6 and 0.58, compared to 0.68 and 0.59 for AFI. Other than radial strain and VVI IO inferior strain, mean strain differences between AFI and VVI were ≤ 1%. Inter-observer variability is modest, however, mean differences are minimal suggesting reasonable clinical reliability. Inter-vendor variability is greater and not as clinically reliable. In patients with sRV, serial assessments with strain should be performed using the same software.

Human dystrophin expressing chimeric (DEC) cell therapy ameliorates cardiac, respiratory, and skeletal muscle's function in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a progressive and lethal disease, caused by X‐linked mutations of the dystrophin encoding gene. The lack of dystrophin leads to muscle weakness, degeneration, fibrosis, and progressive loss of skeletal, cardiac, and respiratory muscle function resulting in premature death due to the cardiac and respiratory failure. There is no cure for DMD and current therapies neither cure nor arrest disease progression. Thus, there is an urgent need to develop new approaches and safer therapies for DMD patients. We have previously reported functional improvements which correlated with increased dystrophin expression following transplantation of dystrophin expressing chimeric (DEC) cells of myoblast origin to the mdx mouse models of DMD. In this study, we demonstrated that systemic‐intraosseous transplantation of DEC human cells derived from myoblasts of normal and DMD‐affected donors, increased dystrophin expression in cardiac, respiratory, and skeletal muscles of the mdx/scid mouse model of DMD. DEC transplant correlated with preservation of ejection fraction and fractional shortening on echocardiography, improved respiratory function on plethysmography, and improved strength and function of the limb skeletal muscles. Enhanced function was associated with improved muscle histopathology, revealing reduced mdx pathology, fibrosis, decreased inflammation, and preserved muscle morphology and architecture. Our findings confirm that DECs generate a systemic protective effect in DMD‐affected target organs. Therefore, DECs represents a novel therapeutic approach with the potential to preserve or enhance multiorgan function of the skeletal, cardiac, and respiratory muscles critical for the well‐being of DMD patients.

The Utility of Myocardial Work in Clinical Practice

Myocardial work (MW) is a novel technique used in the advanced assessment of left ventricular function. In the past few years, this invasive measure has evolved to become a more attainable noninvasive technique. MW has benefits over left ventricular ejection fraction and global longitudinal strain by speckle-tracking echocardiography, as it includes the afterload-dependent limitation and dynamic myocardial contraction in relationship to various loading conditions. In this article, the authors provide a summary overview and discuss the additive value noninvasive MW provides to left ventricular systolic function assessment. The authors explore the evolution of invasive to noninvasive MW, examine how to acquire and measure, discuss normal reference values, examine its role in a multitude of cardiac conditions that have been investigated in current research, review a variety of clinical applications, and discuss potential limitations. The goal is to allow the reader to see the benefits of this rapidly emerging application and be able to incorporate it into everyday practice.

The strain and strain rate imaging paradox in echocardiography: overabundant literature in the last two decades but still uncertain clinical utility in an individual case

Almost two decades ago strain and strain rate imaging were proposed as a new, potentially more sensitive modality for quantifying both regional and global myocardial function. Until now, however, strain and strain rate imaging have been slow to be incorporated into everyday clinical practice. More recently, two dimensional strain has been claimed as of greater clinical utility, given that it is angle independent, with improved feasibility and reproducibility as compared to tissue Doppler strain. Nevertheless, speckle tracking strain is reliant on 2D image quality and frame rates. Three dimensional speckle tracking could eliminate the problem of through-plane motion inherent in 2D imaging, but 3D strain is currently limited by low frame rates. Another limitation of strain imaging is that the results are dependent on the ultrasound machine on which analyses are performed, with variability in measurements between different vendors. Despite the diagnostic and prognostic advantages of 2D strain, there is a lack of specific therapeutic interventions based on strain and a paucity of long-term large-scale randomized trial evidence on cardiovascular outcomes. After overabundant literature the same definition of normal cut-off values is controversial and not univocal. Further studies are needed, involving both manufacturers and medical professionals, on the additive contribution, possibly different case by case, of interfering and artifactual factors, aside from myocardial function per se. These artifactual determinants and motion artifacts components could be dominant in individual cases and should always be taken into account in the clinical decision making process in a single case.

Pulmonary and cardiac variables associated with persistent dyspnea after pulmonary embolism

INTRODUCTION

Persistent dyspnea is common in follow-up after pulmonary embolism (PE), but the underlying mechanisms are poorly understood.

MATERIAL AND METHODS

This cross-sectional study included subjects aged 18-75 years with confirmed PE by computed tomography pulmonary angiography (CTPA) 6-72 months earlier. A total of 180 participants underwent clinical examination, incremental shuttle walk test, laboratory tests, transthoracic echocardiography, pulmonary function tests and ventilation/perfusion scintigraphy. In further analysis, we divided participants into two groups; "dyspnea" or "no dyspnea", based on interview and questionnaires at inclusion. The association of cardiac and pulmonary variables with persistent dyspnea was assessed using multiple logistic regression analysis.

RESULTS

In total, 44% (95% CI: 39%-51%) of the participants reported persistent dyspnea after PE. Age (adjusted odds ratio (aOR) 0.93 per year, 95% CI: 0.90-0.97, P = 0.001), body mass index (BMI) (aOR 1.14 per kg/m², 95% CI: 1.04-1.25, P = 0.004), recurrent venous thromboembolism (VTE) (aOR 3.69, 95% CI: 1.45-9.38, P = 0.006) and diffusion capacity of the lung for carbon monoxide (DLCO) (aOR 0.95 per increase of 1%, 95% CI: 0.92-0.98, P = 0.001) were independently associated with persistent dyspnea.

CONCLUSIONS

Persistent dyspnea was prevalent after PE. Age, BMI and recurrent VTE were independently associated with dyspnea. Apart from reduced DLCO, no other cardiac or pulmonary variables were associated with persistent dyspnea.

Speckle Tracking Echocardiography: Early Predictor of Diagnosis and Prognosis in Coronary Artery Disease

Echocardiography represents a first level technique for the evaluation of coronary artery disease (CAD) which supports clinicians in the diagnostic and prognostic workup of these syndromes. However, visual estimation of wall motion abnormalities sometimes fails in detecting less clear or transient myocardial ischemia and in providing accurate differential diagnosis. Speckle tracking echocardiography (STE) is a widely available noninvasive tool that could easily and quickly provide additive information over basic echocardiography, since it is able to identify subtle myocardial damage and to localize ischemic territories in accordance to the coronary lesions, obtaining a clear visualization with a "polar map" useful for differential diagnosis and management. Therefore, it has increasingly been applied in acute and chronic coronary syndromes using rest and stress echocardiography, showing good results in terms of prediction of CAD, clinical outcome, left ventricular remodeling, presence, and quantification of new/residual ischemia. The aim of this review is to illustrate the current available evidence on STE usefulness for the assessment and follow-up of CAD, discussing the main findings on bidimensional and tridimensional strain parameters and their potential application in clinical practice.

Asymptomatic Left Ventricular Dysfunction: Is There a Role for Screening in General Population?

Stage A and B heart failure (HF) include asymptomatic patients without and with structural cardiac disorder, respectively. Asymptomatic left ventricular (LV) dysfunction represents an early stage of HF that should be recognized to prevent overt HF development. Echocardiography plays a pivotal role in assessment of cardiac structure and function and represents the ideal imaging technique for screening in the general population, thanks to its availability, feasibility, and low cost. Traditional echocardiography, with LV systolic and diastolic function and cardiac remodeling assessment, is usually performed. Development of new technologies may offer additional information and insights in detection of early LV dysfunction.

Early Left Ventricular Global Longitudinal Strain Deterioration After Aortic Aneurysm Repair: Impact of Aortic Stiffness

PURPOSE

To associate the impact of aortic reconstruction using currently available grafts and endografts on pulse wave velocity in patients with abdominal aortic aneurysm (AAA) and to evaluate its effect on early cardiac systolic function indices.

MATERIALS AND METHODS

Seventy-three consecutive patients with AAA (mean age 70±8 years; all men) who underwent open (n=12) or endovascular repair (EVAR; n=61) were prospectively enrolled in an observational cohort study. Left ventricular global longitudinal strain (GLS; an important diagnostic and prognostic index of early systolic dysfunction) and carotid-femoral pulse wave velocity (cf-PWV) were estimated 1 week preoperatively, as well as at 1 and 6 months postoperatively.

RESULTS

A significant time effect was found for cf-PWV, which showed an increase at 1 month that remained through 6 months (p=0.007). Additionally, a deterioration in GLS values was revealed, with a significant change at 1 month that persisted 6 months later (p<0.001). No significant group effect was observed between EVAR and open repair (p=0.98), and there was no significant interaction (p=0.96). Notably, the difference in GLS between baseline and 6 months significantly correlated with the corresponding changes in cf-PWV (r=0.494, p<0.001).

CONCLUSION

AAA repair leads not only to an increase in aortic stiffness, as measured by the increase in pulse wave velocity, but also to reduced cardiac systolic function. Our findings highlight the need for a more intense cardiac surveillance program after aortic reconstruction. Further studies are needed to investigate how this may translate into long-term manifestations of cardiovascular complications and symptomatology.

Detection of Early Myocardial Injury in Children with Ventricular Septal Defect Using Cardiac Troponin I and Two-Dimensional Speckle Tracking Echocardiography

Children with ventricular septal defects (VSDs) are subjected to hemodynamic overload which causes myocardial injury and subsequent heart failure. Early stages of myocardial damage cannot be detected by conventional echocardiography. Two-dimensional speckle tracking echocardiography (2D-STE) and cardiac troponin I (cTnI) have been recently introduced as more accurate tools for early assessment of cardiovascular diseases. The purpose of this study is to evaluate the role of cardiac troponin I (cTnI) and 2D-STE in the early detection of VSD-induced myocardial injury. Thirty children with VSD (symptomatic and asymptomatic) and 30 controls were assessed serologically by measuring serum cTnI and by conventional echocardiography. STE was performed to measure the averaged global peak longitudinal systolic stain [G peak SL(AVG)]. Serum cTnI levels were significantly higher in patients when compared to controls (P < 0.05) and in the symptomatic group when compared to the asymptomatic group (P < 0.05). Serum cTn I level correlated positively with the left atrial (r = 0.37, P = 0.045) and left ventricular dimensions (r = 0.46, P = 0.01) and negatively with the G peak SL(AVG) (r = -0.39, P = 0.03). There were no statistically significant differences between patients and controls or between symptomatic and asymptomatic groups with regard to the G peak SL(AVG). The peak longitudinal systolic strain (measured by 2D-STE) is not affected despite the elevation of serum cTnI. Serum cTnI is a sensitive marker for early detection of myocardial injury in VSD patients even before the development of ventricular dilatation or dysfunction.

Prominent Longitudinal Strain Reduction of Basal Left Ventricular Segments in Patients With Coronavirus Disease-19

BACKGROUND

Coronavirus disease-19 (COVID-19) has been associated with overt and subclinical myocardial dysfunction. We observed a recurring pattern of reduced basal left ventricular (LV) longitudinal strain on speckle-tracking echocardiography in hospitalized patients with COVID-19 and subsequently aimed to identify characteristics of affected patients. We hypothesized that patients with COVID-19 with reduced basal LV strain would demonstrate elevated cardiac biomarkers.

METHODS AND RESULT

Eighty-one consecutive patients with COVID-19 underwent speckle-tracking echocardiography. Those with poor quality speckle-tracking echocardiography (n = 2) or a known LV ejection fraction of <50% (n = 4) were excluded. Patients with an absolute value basal longitudinal strain of <13.9% (2 standard deviations below normal) were designated as cases (n = 39); those with a basal longitudinal strain of ≥13.9% were designated as controls (n = 36). Demographics and clinical variables were compared. Of 75 included patients (mean age 62 ± 14 years, 41% women), 52% had reduced basal strain. Cases had higher body mass index (median 34.1; interquartile range 26.5-37.9 kg/m² vs median 26.9, interquartile range, 24.8-30.0 kg/m², P = .009), and greater proportions of Black (74% vs 36%, P = .0009), hypertensive (79% vs 56%, P = .026), and diabetic patients (44% vs 19%, P = .025) compared with controls. Troponin and N-terminal pro-brain natriuretic peptide levels trended higher in cases, but were not significantly different.

CONCLUSIONS

Reduced basal LV strain is common in patients with COVID-19. Patients with hypertension, diabetes, obesity, and Black race were more likely to have reduced basal strain. Further investigation into the significance of this strain pattern is warranted.

Global longitudinal strain in chronic asymptomatic aortic regurgitation: systematic review

Chronic aortic regurgitation (AR) patients typically remain asymptomatic for a long time. Left ventricular mechanics, namely global longitudinal strain (GLS), has been associated with outcomes in AR patients. The authors conducted a systematic review to summarize and appraise GLS impact on mortality, the need for aortic valve replacement (AVR) and disease progression in AR patients. A literature search was performed using these key terms 'aortic regurgitation' and 'longitudinal strain' looking at all randomized and nonrandomized studies conducted on chronic aortic regurgitation. The search yielded six observational studies published from 2011 and 2018 with a total of 1571 patients with moderate to severe chronic AR. Only two studies included all-cause mortality as their endpoint. The other studies looked at the association between GLS with AVR and disease progression. The mean follow-up period was 4.2 years. We noted a great variability of clinical, methodological and/or statistical origin. Thus, meta-analytic portion of our study was limited. Despite a relevant heterogeneity, an impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value in risk stratification and decision-making.

Cardiac Protection after Systemic Transplant of Dystrophin Expressing Chimeric (DEC) Cells to the mdx Mouse Model of Duchenne Muscular Dystrophy

Duchenne Muscular Dystrophy (DMD) is a progressive lethal disease caused by X-linked mutations of the dystrophin gene. Dystrophin deficiency clinically manifests as skeletal and cardiac muscle weakness, leading to muscle wasting and premature death due to cardiac and respiratory failure. Currently, no cure exists. Since heart disease is becoming a leading cause of death in DMD patients, there is an urgent need to develop new more effective therapeutic strategies for protection and improvement of cardiac function. We previously reported functional improvements correlating with dystrophin restoration following transplantation of Dystrophin Expressing Chimeric Cells (DEC) of myoblast origin in the mdx and mdx/scid mouse models. Here, we confirm positive effect of DEC of myoblast (MB^wt/MB^mdx) and mesenchymal stem cells (MB^wt/MSC^mdx) origin on protection of cardiac function after systemic DEC transplant. Therapeutic effect of DEC transplant (0.5 × 10⁶) was assessed by echocardiography at 30 and 90 days after systemic-intraosseous injection to the mdx mice. At 90 days post-transplant, dystrophin expression in cardiac muscles of DEC injected mice significantly increased (15.73% ± 5.70 –MB^wt/MB^mdx and 5.22% ± 1.10 – MB^wt/MSC^mdx DEC) when compared to vehicle injected controls (2.01% ± 1.36) and, correlated with improved ejection fraction and fractional shortening on echocardiography. DEC lines of MB and MSC origin introduce a new promising approach based on the combined effects of normal myoblasts with dystrophin delivery capacities and MSC with immunomodulatory properties. Our study confirms feasibility and efficacy of DEC therapy on cardiac function and represents a novel therapeutic strategy for cardiac protection and muscle regeneration in DMD.

Echocardiographic Characteristics of Subjects With COVID-19: A Case Series

Although coronavirus disease 2019 (COVID-19) manifests in most cases with respiratory symptoms, other presentations can occur. Direct damage to the cardiovascular system has been reported and recently, acute myocardial injury has been identified as a risk factor for mortality. Transthoracic echocardiography is a non-invasive tool that allows the detection of myocardial damage with validated markers (left ventricular ejection fraction and global longitudinal strain). Herein, we present the echocardiographic findings in four patients with COVID-19. All cases had acute respiratory distress syndrome (100%). Three out of four had elevated levels of creatine kinase and creatine kinase myocardial band. One case had ventricular concentric remodeling (25%). All cases (100%) had altered ventricular function: two had a reduced ejection fraction (50%) and, of those available for global longitudinal strain analysis, all had abnormal global longitudinal strain (100%). One case was found to have a tricuspid vegetation of 12 × 10 mm with no other manifestation of endocarditis. All of our cases had left ventricular dysfunction as assessed by echocardiography. One of our patients had a vegetation in the tricuspid valve. Two of our cases had a reduced ejection fraction. The importance of acute cardiac injury in COVID-19 has recently been established. A recent study found it to be an independent risk factor for mortality in patients with this disease. Information regarding echocardiographic characteristics of this population is scarce. Further research to elucidate the impact of these characteristics on morbidity and mortality is urgently needed.

Cardiac Iron Overload by MRI in Children With B-Thalassemia Major and its Correlation With Cardiac Function by Echocardiography

BACKGROUND

Serial echocardiography is strongly recommended in asymptomatic B-thalassemia major (TM) patients for early detection of subtle cardiac dysfunction. T2*magnetic resonance imaging (MRI) is a noninvasive measurement of myocardial iron burden. Yet, it is not always available in many centers. Our study aimed to evaluate the myocardial function in TM patients using different echocardiographic modalities and to correlate these findings with cardiac T2*MRI.

PATIENTS AND METHODS

This is a cross-sectional study that was carried out on 140 children with a mean age of 10.9±3.7 years. One hundred children with TM and 40 healthy children were matched for age and sex as a control group. Serum ferritin, serum iron, and iron-binding capacity were measured. Cardiac iron overload was assessed by T2*MRI and cardiac function was assessed by echocardiography. The local ethics committee approved the study.

RESULTS

Among 100 children with TM, only 32% had cardiac iron overload of 8.525±5.45 detected by cardiac T2*MRI. Iron deposition correlated significantly with age. Markers of iron overload were significantly correlated with cardiac T2*MRI. There were significantly lower values of myocardial performance index, longitudinal strain, circumferential strain, area strain, and radial strain in TM patients compared with the controls (P<0.001). Only the myocardial performance index was correlated with T2*MRI.

CONCLUSIONS

This study confirms that some parameters measured by tissue Doppler imaging such as the myocardial performance index could be useful for the early detection of cardiac impairment in asymptomatic TM patients when cardiac MRI is lacking. Further studies on a large scale to identify other parameters with high sensitivity are recommended.

Usefulness of speckle-tracking echocardiography for early detection in children with Duchenne muscular dystrophy: a meta-analysis and trial sequential analysis

Background

Duchenne muscular dystrophy (DMD) is the most common form of inherited muscle disease in children. The incidence of cardiomyopathy induced by DMD increases with age. Left ventricular ejection fraction usually fails to reflect the subclinical left ventricular dysfunction. Several studies have assessed this dysfunction using myocardial strain measured by speckle-tracking echocardiography (STE). However, the results were inconsistent and incomplete.

Methods

Several databases were searched from their inception to February 5, 2020. The summarized weighted mean difference (WMD) with 95% confidence intervals (CIs) were estimated for myocardial strain between DMD and healthy controls and a meta-analysis was conducted. Trial sequential analysis estimated whether the resulting evidence was sufficient.

Results

Eight studies with a total of 269 DMD children and 299 healthy participants were included. STE revealed that global longitudinal strain (GLS), global circumferential strain, average longitudinal strain (measured by two-dimensional STE at the apical four-chamber view), and average circumferential strain (measured by two-dimensional STE at the papillary muscle short-axis level) decreased (WMD = 4.17, 95% CI: 3.03–5.32; WMD = 3.98, 95% CI: 0.29–7.68; WMD = 4.18, 95% CI: 2.75–5.62; and WMD = 4.90, 95% CI: 2.38–7.43, respectively; all P < 0.05) compared with the controls and global radial strain was unchanged in the DMD group (WMD = − 4.33, 95% CI: − 9.53–0.87, P = 0.103). Trial sequential analysis indicated that available GLS samples were sufficient and confirmed that adequate evidence was accumulated. The credibility of other myocardial strains was questioned due to insufficiently involved studies.

Conclusion

GLS can be useful for early detection of left ventricle myocardial dysfunction in children with DMD.

Sex differences in anthracycline-induced cardiotoxicity: the benefits of estrogens

Anthracyclines are the cornerstone for many oncologic treatments, but their cardiotoxicity has been recognized for several decades. Female subjects, especially before puberty and adolescence, or after menopause, seem to be more at increased risk, with the prognostic impact of this sex issue being less consistent compared to other cardiovascular risk factors. Several studies imply that sex differences could depend on the lack of the protective effect of sex hormones against the anthracycline-initiated damage in cardiac cells, or on differential mitochondria-related oxidative gene expression. This is also reflected by the results obtained with different diagnostic methods, such as cardiovascular biomarkers and imaging techniques (echocardiography, magnetic resonance, and nuclear medicine) in the diagnosis and monitoring of cardiotoxicity, confirming that sex differences exist. The same is true about protective strategies from anthracycline cardiotoxicity. Indeed, first studied to withstand oxidative damage in response to ischemia/reperfusion (I/R) injury, cardioprotection has different outcomes in men and women. A number of studies assessed the differences in I/R response between male and female hearts, with oxidative stress and apoptosis being shared mechanisms between the I/R and anthracyclines heart damage. Sex hormones can modulate these mechanisms, thus confirming their importance in the pathophysiology in cardioprotection not only from the ischemia/reperfusion damage, but also from anthracyclines, fueling further cardio-oncologic research on the topic.

Precocious Preclinical Cardiovascular Sonographic Markers in Metabolically Healthy and Unhealthy Childhood Obesity

Background: Childhood obesity is related to a wide spectrum of cardiovascular and metabolic comorbidities. Objectives: (1) To identify precocious, preclinical, cardiovascular sonographic modifications, in a cohort of overweight (OW) and obese (OB) children and adolescents compared to lean controls; (2) to investigate the association between clinical and metabolic variables and cardiovascular sonographic parameters; (3) to evaluate their relation with two different phenotypes of obesity: metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUO). Materials and Methods: Fifty-nine OW and OB children and adolescents (9.8 ± 2.9 years) and 20 matched lean controls underwent anthropometric, biochemical, echocardiography assessment, and sonographic evaluation of carotid artery and ascending aorta (AA). OW and OB subjects were divided in MHO and MUO, according to the Camhi et al. definition. Results: OW and OB children showed significantly higher left ventricular (LV) dimensions and mass, carotid artery intima-media thickness (CIMT), carotid stiffness [β-index, pulse wave velocity (PWV)], significantly lower mitral peak early (E) and late (A) velocity ratio (E/A ratio), and significantly impaired global longitudinal strain (GLS) compared to controls. BMI SD and HOMA-IR were positively significantly related to LV dimensions, LA volume and epicardial adipose tissue (EAT), and negative to E/A ratio. Waist circumference (WC) was positively correlated to LV dimensions, LA volume, CIMT, PWV, AA diameter, and EAT. Furthermore, WC was a strong predictor of LV dimensions, LA volume and strain, AA stiffness and diameter; BMI SD was significantly associated with EAT, LVM index, and E/A ratio; HOMA-IR and triglycerides were significant predictors of GLS. MUO patients showed higher BMI SD (p = 0.02), WC (p = 0.001), WHtR (p = 0.001), HOMA-IR (p = 0.004), triglycerides (p = 0.01), SBP (p = 0.001), as well as LV dimensions, EAT (p = 0.03), CIMT (p = 0.01), AA diameter (p = 0.02), β-index (p = 0.03) and PWV (p = 0.002), AA stiffness (p = 0.006), and significantly impaired GLS (p = 0.042) compared to MHO. Conclusions: Severity of overweight, abdominal obesity, insulin resistance, and MUO phenotype negatively affect cardiovascular remodeling and subclinical myocardial dysfunction in OW and OB children. MUO phenotype is likely to increase the risk of developing cardiometabolic complications since the pediatric age. Distinction between MHO and MUO phenotypes might be useful in planning a personalized follow-up approach in obese children.

Right Heart Remodeling in Patients with End-Stage Alcoholic Liver Cirrhosis: Speckle Tracking Point of View

BACKGROUND

Data regarding cardiac remodeling in patients with alcoholic liver cirrhosis are scarce. We sought to investigate right atrial (RA) and right ventricular (RV) structure, function, and mechanics in patients with alcoholic liver cirrhosis.

METHODS

This retrospective cross-sectional investigation included 67 end-stage cirrhotic patients, who were referred for evaluation for liver transplantation and 36 healthy controls. All participants underwent echocardiographic examination including strain analysis, which was performed offline.

RESULTS

RV basal diameter and RV thickness were significantly higher in patients with cirrhosis. Conventional parameters of the RV systolic function were similar between the observed groups. Global, endocardial, and epicardial RV longitudinal strains were significantly lower in patients with cirrhosis. Active RA function was significantly higher in cirrhotic patients than in controls. The RA reservoir and conduit strains were significantly lower in cirrhotic patients, while there was no difference in the RA contractile strain. Early diastolic and systolic RA strain rates were significantly lower in cirrhotic patients than in controls, whereas there was no difference in the RA late diastolic strain rate between the two groups. Transaminases and bilirubin correlated negatively with RV global longitudinal strain and RV-free wall strain in patients with end-stage liver cirrhosis. The Model for End-stage Liver Disease (MELD) score, predictor of 3-month mortality, correlated with parameters of RV structure and systolic function, and RA active function in patients with end-stage liver cirrhosis.

CONCLUSIONS

RA and RV remodeling is present in patients with end-stage liver cirrhosis even though RV systolic function is preserved. Liver enzymes, bilirubin, and the MELD score correlated with RV and RA remodeling.