Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction

Incremental prognostic value of speckle tracking echocardiography and early follow-up echo assessment in predicting left ventricular recovery after reperfusion for ST-segment elevation myocardial infarction (STEMI)

PURPOSE

Up to 50% of patients do not achieve significant left ventricular ejection fraction (LVEF) recovery after primary percutaneous intervention (PPCI) for STEMI. We aimed to identify the echocardiographic predictors for LVEF recovery and assess the value of early follow-up echocardiography (Echo) in risk assessment of post-myocardial infarction (MI) patients.

METHODS

One hundred one STEMI patients undergoing PPCI were enrolled provided EF below 50%. Baseline echocardiography assessed LVEF, volumes, wall motion score index (WMSI), global longitudinal strain (GLS), global circumferential strain (GCS), and E/e'. Follow-up echocardiography after 6 weeks reassessed left ventricular volumes, LVEF and GLS.GCS was not assessed at follow up. Patients were classified into recovery and non-recovery groups. Predictors of LVEF recovery and major adverse cardiovascular events (MACE) at 6 months were analysed.

RESULTS

The mean change of EF was 8.04 ± 3.32% in group I versus -.39 ± 5.09 % in group II (p < .001). Recovered patients had better baseline GLS, baseline GCS, E/e', and follow-up GLS. Multivariate regression analysis revealed E/e', GCS, and follow-up GLS after 6 weeks to be strong independent predictors for LVEF recovery. Composite MACE was considerably higher in group II (32.7% vs. 4.1%, p < .001) mainly driven by higher heart failure hospitalisation Multivariate regression analysis revealed baseline GLS, E/e', and ejection fraction (EF) percentage recovery as strong independent predictors for MACE.

CONCLUSIONS

Multiparametric echocardiographic approach incorporating LVEF, strain parameters, and diastolic function could allow early optimal risk stratification after STEMI treated with PPCI. Follow-up GLS and LVEF percentage change are the strongest predictors for early LV recovery and long term clinical outcome, respectively.

The relationship of systemic and pulmonary arterial parameters with HFpEF scores (H2 FPEF, HFA-PEFF) and diastolic dysfunction parameters in heart failure patients with preserved ejection fraction

OBJECTIVE

We aimed to show the relationship between pulmonary pulse wave transit time (pPTT), pulmonary artery stiffness (PAS), and aortic stiffness parameters measured by non-invasive methods, HFpEF patients, and HFpEF scores (H2 FPEF, HFA-PEFF).

METHOD

A total of 101 patients were included in our study, 52 of whom were HFpEF patients and 49 were control groups without heart failure. Echocardiographic parameters for PAS and pPTT were calculated, along with diastolic parameters that support the diagnosis of HFpEF. Aortic stiffness was assessed using a PWA monitor. Demographic features, laboratory findings, aortic stiffness parameters, and echocardiographic findings including pulmonary artery parameters were compared with the control group.

RESULTS

PAS, pPTT, PWV were significantly higher in the HFpEF group than in the control group (p < 0.001). PAS and pPTT correlated positively with HFpEF scores. In linear regression analysis for PAS, a directly positive correlation was found between E/e' and PAS, independent of aortic stiffness.

CONCLUSION

These parameters can be used as a predictive value in the diagnosis process of patients with suspected HFpEF. A significant relationship between PAS and ventricular stiffness (E/e') was shown independently of aortic stiffness.

Comprehensive diagnostic workup in patients with suspected heart failure and preserved ejection fraction

Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging and it could require different tests, some of which are affected by limited availability. Nowadays, considering that new therapies are available for HFpEF and related conditions, a prompt and correct diagnosis is relevant. However, the diagnostic role of biomarker level, imaging tools, score-based algorithms and invasive evaluation, should be based on the strengths and weaknesses of each test. The aim of this review is to help the clinician in diagnosing HFpEF, overcoming the diagnostic uncertainty and disentangling among the different underlying causes, in order to properly treat this kind of patient.

Dobutamine effects on systolic and diastolic left ventricular long-axis excursion and timing - significance for the interpretation of s' and e'

BACKGROUND

Dobutamine effects on the relationships of the peak velocity of left ventricular (LV) long-axis systolic motion (s') with systolic excursion (SExc), systolic duration (SDur) and heart rate, of LV long-axis early diastolic excursion (EDExc) with SExc, and of the peak velocity of LV long-axis early diastolic motion (e') with EDExc, early diastolic duration (EDDur) and isovolumic relaxation time (IVRT') are unknown.

METHODS

Two groups of adult subjects, one young and healthy (n = 10), and one with impaired LV long-axis function (n = 10), were studied, with the aim of identifying consistent findings for the two groups and for the septal and lateral walls. Dobutamine was infused at doses of 5 and 10 µg/kg/min. The relationships between tissue Doppler imaging (TDI) variables acquired before and during dobutamine infusion were analysed using mixed effect multivariate regression modelling.

RESULTS

In both groups, heart rate increased and SDur decreased during dobutamine infusion, and there were independent inverse correlations of SDur with heart rate and dobutamine dose. In contrast, there was no change in EDDur during dobutamine infusion, and no consistent changes in IVRT' independent of heart rate. s' was positively correlated with SExc and inversely correlated with SDur, and there were positive correlations between EDExc and SExc and between e' and EDExc.

CONCLUSION

Dobutamine increases s' due to effects on both systolic excursion and duration and it increases e' due to the associated increases in systolic and early diastolic excursion. A lack of effect on diastolic times does not support the presence of a lusitropic effect of dobutamine.

Association of left ventricular strain-volume loop characteristics with adverse events in patients with heart failure with preserved ejection fraction

AIMS

Patients with heart failure with preserved ejection fraction (HFpEF) are characterized by impaired diastolic function. Left ventricular (LV) strain-volume loops (SVL) represent the relation between strain and volume during the cardiac cycle and provide insight into systolic and diastolic function characteristics. In this study, we examined the association of SVL parameters and adverse events in HFpEF.

METHODS AND RESULTS

In 235 patients diagnosed with HFpEF, LV-SVL were constructed based on echocardiography images. The endpoint was a composite of all-cause mortality and Heart Failure (HF)-related hospitalization, which was extracted from electronic medical records. Cox-regression analysis was used to assess the association of SVL parameters and the composite endpoint, while adjusting for age, sex, and NYHA class. HFpEF patients (72.3% female) were 75.8 ± 6.9 years old, had a BMI of 29.9 ± 5.4 kg/m2, and a left ventricular ejection fraction of 60.3 ± 7.0%. Across 2.9 years (1.8-4.1) of follow-up, 73 Patients (31%) experienced an event. Early diastolic slope was significantly associated with adverse events [second quartile vs. first quartile: adjusted hazards ratio (HR) 0.42 (95%CI 0.20-0.88)] after adjusting for age, sex, and NYHA class. The association between LV peak strain and adverse events disappeared upon correction for potential confounders [adjusted HR 1.02 (95% CI 0.96-1.08)].

CONCLUSION

Early diastolic slope, representing the relationship between changes in LV volume and strain during early diastole, but not other SVL-parameters, was associated with adverse events in patients with HFpEF during 2.9 years of follow-up.

Tumor Necrosis Factor-α Mediates Inflammation-induced Early-Stage Left Ventricular Systolic Dysfunction

ABSTRACT

Elevated systemic inflammation contributes to pathogenesis of heart failure with preserved ejection fraction (HFpEF), but molecular mechanisms are poorly understood. Although left ventricular (LV) diastolic dysfunction is the main cause of HFpEF, subclinical systolic dysfunction also contributes. We have previously shown that rats with collagen-induced arthritis (CIA) have systemic inflammation, LV diastolic dysfunction, and that increased circulating TNF-α contributes to inflammation-induced HFpEF pathogenesis, but does not mediate LV diastolic dysfunction in CIA rats. Contribution of systemic inflammation to dysfunction of the active process of LV diastolic and systolic function are unknown. In the present study, we used the CIA rat model to investigate the effects of systemic inflammation and TNF-α blockade on systolic function, and mRNA expression of genes involved in active diastolic relaxation and of myosin heavy chain (MyHC) isoforms. Collagen inoculation and TNF-α blockade did not affect LV mRNA expression of genes that mediate active LV diastolic function. Collagen-induced inflammation impaired LV global longitudinal strain ( P = 0.03) and velocity ( P = 0.04). This impairment of systolic function was prevented by TNF-α blockade. Collagen inoculation decreased mRNA expression of α-MyHC ( Myh6, P = 0.03) and increased expression of β-MyHC ( Myh7, P = 0.0002), a marker, which is upregulated in failing hearts. TNF-α blockade prevented this MyHC isoform-switch. These results show that increased circulating TNF-α changes the relative expression of MyHC isoforms, favoring β-MyHC, which may underlie changes in contractile function that impair systolic function. Our results indicate that TNF-α initiates early-stage LV systolic, rather than LV diastolic dysfunction.

The role of conventional echocardiographic parameters on detecting subclinical anthracycline therapy related cardiac dysfunction—The SATRACD study

Background

Subclinical anthracycline therapy related cardiac dysfunction (ATRCD) can be detected with speckle tracking echocardiographic image (STE), which is not widely available in Uganda. We aimed to investigate the role of the two conventional echocardiographic parameters [mitral annular plane systolic excursion (MAPSE) and mitral annular peak systolic tissue Doppler velocity (S’)] on diagnosing subclinical ATRCD.

Method and results

207 cancer patients who underwent anthracycline based chemotherapy were recruited at baseline and followed up until 6 months after ending anthracycline therapy. Comprehensive echocardiographic data were collected at each visit. Global longitudinal strain (GLS) by STE was used as the gold standard diagnostic test to define the case of subclinical ATRCD. Data of the 200 patients who had no evidence of clinical ATRCD were analyzed. One hundred and seventy-two (86.0%) were female, with a median age of 42 years and 47 (23.5%) patients were diagnosed with subclinical ATRCD at the end of anthracycline therapy by GLS criteria. The area under the curve (AUC), cutoff point, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of reduction of MAPSE (ΔMAPSE) were 0.6736 (95% CI: 0.5885, 0.7587), ≥ 2 mm, 74.5% (95% CI: 59.7%, 86.1%), 54.9% (95% CI: 46.7%, 63.0%), 33.7% (95% CI: 24.7%, 43.6%), and 87.5% (95% CI: 79.2%, 93.4%). The AUC, cutoff point, sensitivity, specificity, PPV, and NPV of reduction of S’ (ΔS’) were 0.6018 (95% CI: 0.5084, 0.6953), ≥ 0.5 cm/s, 61.7% (95% CI: 46.4%, 75.5%), 52.7% (95% CI: 44.4%, 60.9%), 29.0% (95% CI: 20.4%, 38.9%), and 76.1% (95% CI: 72.4%, 88.6%). When ΔMAPSE and ΔS’ are used as parallel test, the net sensitivity and specificity is 89.4% and 28.8%, respectively, the net PPV and NPV is 27.8% and 90.0%, respectively.

Conclusion

The ΔMAPSE and ΔS’ showed fairly good accuracy, sensitivity and NPV to detect subclinical ATRCD in Ugandan cancer patients. These conventional echocardiographic parameters may serve as screening tools for detecting subclinical ATRCD in resource limited settings.

Development of systolic dysfunction unrelated to myocardial infarction in treated hypertensive patients with left ventricular hypertrophy. The LIFE Study

Aim: While it is commonly thought that left ventricular (LV) systolic function may insidiously deteriorate in hypertensive patients, few prospective data are available to support this notion. Methods: We evaluated 680 hypertensive patients (66 ± 7 years; 45% women) with electrocardiographic (ECG)-LV hypertrophy (ECG-LVH) enrolled in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echo-sub-study free of prevalent cardiovascular disease and with baseline ejection fraction (EF) ≥ 55%. Echocardiographic examinations were performed annually for 5 years during anti-hypertensive treatment. Development of reduced systolic function was defined as incident EF < 50%. Results: During a mean follow-up of 4.8 ± 1 years, 37 patients developed reduced EF without an inter-current myocardial infarction (5.4%). In analysis of covariance, patients who developed reduced EF were more often men, had greater baseline LV diameter and LV mass, lower mean EF (all P < 0.05), and similar diastolic function indices. At the last available examination before EF reduction, independently of covariates, patients with reduced EF showed a significant increase in left atrium (LA) size, LV diameter, end-systolic stress and mitral E/A ratio, as compared to those who did not develop reduced EF (all P < 0.05). In time-varying Cox regression analysis, also controlling for baseline EF, predictors of developing reduced EF were higher in-treatment LV diameter [hazard ratio (HR) = 5.19 per cm; 95% confidence interval (CI): 2.58–10.41] and higher in-treatment mitral E/A ratio (HR = 2.37 per unit; 95% CI: 1.58–3.56; both P < 0.0001). Conclusions: In treated hypertensive patients with ECG-LVH at baseline, incident reduced EF is associated with the development of dilated LV chamber and signs of increased LV filling pressure (ClinicalTrials.gov identifier: NCT00338260).

Role of strain echocardiography in patients with hypertension

Hypertension is a well-recognized risk factor for the development of cardiovascular disease, and the early detection of cardiac changes from hypertension can allow reversing these. Hypertensive heart diseases (HHD) refer to the complex and diverse change of the cardiac structure and function secondary to hypertension. Although conventional echocardiography is the most common imaging modality in detecting HHD, it cannot detect subtle changes of cardiac structure in subclinical states. Because strain echocardiography is another echocardiographic modality can detect subclinical myocardial dysfunction by measuring intrinsic myocardial deformation, it became more and more popular in clinical and research fields. In this review article, we described the basic concept of strain echocardiography and summarized several clinical studies showing its clinical utilities in the detection of HHD.

Do the Current Guidelines for Heart Failure Diagnosis and Treatment Fit with Clinical Complexity?

Heart failure (HF) is a clinical syndrome defined by specific symptoms and signs due to structural and/or functional heart abnormalities, which lead to inadequate cardiac output and/or increased intraventricular filling pressure. Importantly, HF becomes progressively a multisystemic disease. However, in August 2021, the European Society of Cardiology published the new Guidelines for the diagnosis and treatment of acute and chronic HF, according to which the left ventricular ejection fraction (LVEF) continues to represent the pivotal parameter for HF patients’ evaluation, risk stratification and therapeutic management despite its limitations are well known. Indeed, HF has a complex pathophysiology because it first involves the heart, progressively becoming a multisystemic disease, leading to multiorgan failure and death. In these terms, HF is comparable to cancer. As for cancer, surviving, morbidity and hospitalisation are related not only to the primary neoplastic mass but mainly to the metastatic involvement. In HF, multiorgan involvement has a great impact on prognosis, and multiorgan protective therapies are equally important as conventional cardioprotective therapies. In the light of these considerations, a revision of the HF concept is needed, starting from its definition up to its therapy, to overcome the old and simplistic HF perspective.

Effects of late, repetitive remote ischaemic conditioning on myocardial strain in patients with acute myocardial infarction

Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks' daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5-7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from - 16.2 ± 5.2 at baseline to - 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from - 15.5 ± 4.0 to - 15.2 ± 4.7, p = 0.81; for change: - 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (- 1.2 ± 4.4 versus - 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611 .

Basal Septal Hypertrophy as the Early Imaging Biomarker for Adaptive Phase of Remodeling Prior to Heart Failure

Hypertension plays a dominant role in the development of left ventricular (LV) remodeling and heart failure, in addition to being the main risk factor for coronary artery disease. In this review, we focus on the focal geometric and functional tissue aspects of the LV septal base, since basal septal hypertrophy (BSH), as the early imaging biomarker of LV remodeling due to hypertensive heart disease, is detected in cross-sectional clinic studies. In addition, the validation of BSH by animal studies using third generation microimaging and relevant clinical observations are also discussed in the report. Finally, an evaluation of both human and animal quantitative imaging studies and the importance of combined cardiac imaging methods and stress-induction in the separation of adaptive and maladaptive phases of the LV remodeling are pointed out. As a result, BSH, as the early imaging biomarker and quantitative follow-up of functional analysis in hypertension, could possibly contribute to early treatment in a timely fashion in the prevention of hypertensive disease progression to heart failure. A variety of stress stimuli in etiopathogenesis and the difficulty of diagnosing pure hemodynamic overload mediated BSH lead to an absence of the certain prevalence of this particular finding in the population.

Impaired myocardial work efficiency in heart failure with preserved ejection fraction

AIMS

Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem. Impairment in left ventricular (LV) diastolic function has been proposed as a key pathophysiologic determinant. However, the role of concomitant systolic dysfunction despite preserved LV ejection fraction (LVEF) has not been well characterized. To analyse LV myocardial deformation, diastolic function, and contractile reserve (CR) in patients with HFpEF at rest and while during exercise, as well as their correlation with functional capacity.

METHODS AND RESULTS

Standard echo, lung ultrasound, LV 2D speckle-tracking strain, and myocardial work efficiency (MWE) were performed at rest and during exercise in 230 patients with HFpEF (female sex 61.2%; 71.3 ± 5.3 years) in 150 age- and sex-comparable healthy controls. LV mass index and LAVI were significantly increased in HFpEF. Conversely, global longitudinal strain (GLS) and MWE were consequently reduced in HFpEF patients. During effort, HFpEF showed reduced exercise time, capacity, and VO2 peak. Increase in LVEF and LV GLS was significantly lower in HFpEF patients, while LV E/e' ratio, pulmonary pressures, and B-lines by lung ultrasound rose. A multivariable analysis outlined that LV MWE at rest was closely related to maximal Watts reached (beta coefficient: 0.43; P < 0.001), peak VO2 (beta: 0.50; P < 0.001), LV E/e' (beta: 0.52, P < 0.001), and number of B-lines during effort (beta: -0.36; P < 0.01).

CONCLUSIONS

The lower resting values of LV GLS and MWE in HFpEF patients suggest an early subclinical myocardial damage, which seems to be closely associated with lower exercise capacity, greater pulmonary congestion, and blunted LV contractile reserve during effort.

Effects of exercise training on diastolic and systolic dysfunction in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is a complex syndrome characterized by a progressive reduction of the left ventricular (LV) contractility, low exercise tolerance, and increased mortality and morbidity. Diastolic dysfunction (DD) of the LV, is a keystone in the pathophysiology of CHF and plays a major role in the progression of most cardiac diseases. Also, it is well estimated that exercise training induces several beneficial effects on patients with CHF.

AIM

To evaluate the impact of a cardiac rehabilitation program on the DD and LV ejection fraction (EF) in patients with CHF.

METHODS

Thirty-two stable patients with CHF (age: 56 ± 10 years, EF: 32% ± 8%, 88% men) participated in an exercise rehabilitation program. They were randomly assigned to aerobic exercise (AER) or combined aerobic and strength training (COM), based on age and peak oxygen uptake, as stratified randomization criteria. Before and after the program, they underwent a symptom-limited maximal cardiopulmonary exercise testing (CPET) and serial echocardiography evaluation to evaluate peak oxygen uptake (VO_2peak), peak workload (W_peak), DD grade, right ventricular systolic pressure (RVSP), and EF.

RESULTS

The whole cohort improved VO_2peak, and W_peak, as well as DD grade (P < 0.05). Overall, 9 patients (28.1%) improved DD grade, while 23 (71.9%) remained at the same DD grade; this was a significant difference, considering DD grade at baseline (P < 0.05). In addition, the whole cohort improved RVSP and EF (P < 0.05). Not any between-group differences were observed in the variables assessed (P > 0.05).

CONCLUSION

Exercise rehabilitation improves indices of diastolic and systolic dysfunction. Exercise protocol was not observed to affect outcomes. These results need to be further investigated in larger samples.

Poorer Exercise Accommodation of Regional Systolic Myocardial Motion after Spironolactone Treatment in Heart Failure Patients with Preserved Ejection Fraction and Ventricular Dyssynchrony

Patients with heart failure and preserved ejection fraction (HFpEF) are known to have reduced systolic myocardial velocity (Sm) with impaired accommodation to exercise. We tested the impact of an aldosterone antagonist on Sm at rest and post-exercise. Forty-nine HFpEF patients (65 ± 11 years, 24 male) with HF signs/symptoms, mitral E/Ea (annular early diastolic velocity) > 8, and left ventricular (LV) EF > 50% were randomized to spironolactone (25 mg/day, 25 patients) or the Control. At baseline and 6 months, we analyzed Sm of basal LV segments at rest and after a 6 min treadmill exercise. At 6 months, post-exercise mean Sm in the spironolactone group became greater than that in the Control (9.2 ± 1.6 vs. 8.3 ± 1.0 cm/s, p = 0.021), mainly due to the increment of post-exercise % increase of lateral Sm (44 ± 30 vs. 30 ± 19% at baseline, p = 0.045). Further analyses showed the presence of systolic dyssynchrony (standard deviation of electromechanical delay of 6-basal LV segments > 35 ms) was independently associated with a poorer response to spironolactone, defined as a post-exercise % increase of lateral Sm < 50% (OR = 2.7, 95% CI = 1.8–4.2) and the increment of Ea < 1.5 cm/s (OR = 1.5, 95% CI = 1.1–2.3). Spironolactone could improve exercise accommodation of regional systolic myocardial velocity for HFpEF patients. However, its benefits could be decreased in those with ventricular dyssynchrony. This suggested possible therapeutic impacts from underlying heterogeneity within HFpEF patients.

Increased long-term mortality in women with high left ventricular ejection fraction: data from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) long-term registry

AIMS

There are significant sex-specific differences in left ventricular ejection fraction (LVEF), with a higher LVEF being observed in women. We sought to assess the clinical relevance of an increased LVEF in women and men.

METHODS AND RESULTS

A total of 4632 patients from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry (44.8% women; mean age 58.7 ± 13.2 years in men and 59.5 ± 13.3 years in women, P = 0.05), in whom LVEF was measured by cardiac computed tomography, were categorized according to LVEF (low <55%, normal 55-65%, and high >65%). The prevalence of high LVEF was similar in both sexes (33.5% in women and 32.5% in men, P = 0.46). After 6 years of follow-up, no difference in mortality was observed in patients with high LVEF in the overall cohort (P = 0.41). When data were stratified by sex, women with high LVEF died more often from any cause as compared to women with normal LVEF (8.6% vs. 7.1%, log rank P = 0.032), while an opposite trend was observed in men (5.8% vs. 6.8% in normal LVEF, log rank P = 0.89). Accordingly, a first order interaction term of male sex and high LVEF was significant (hazard ratios 0.63, 95% confidence intervals 0.41-0.98, P = 0.043) in a Cox regression model of all-cause mortality adjusted for age, cardiovascular risk factors, and severity of coronary artery disease (CAD).

CONCLUSION

Increased LVEF is highly prevalent in patients referred for evaluation of CAD and is associated with an increased risk of death in women, but not in men. Differentiating between normal and hyperdynamic left ventricles might improve risk stratification in women with CAD.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT01443637.

Machine Learning of ECG Waveforms to Improve Selection for Testing for Asymptomatic Left Ventricular Dysfunction Prompt

OBJECTIVES

To identify whether machine learning from processing of continuous wave transforms (CWTs) to provide an "energy waveform" electrocardiogram (ewECG) could be integrated with echocardiographic assessment of subclinical systolic and diastolic left ventricular dysfunction (LVD).

BACKGROUND

Asymptomatic LVD has management implications, but routine echocardiography is not undertaken in subjects at risk of heart failure. Signal processing of the surface ECG with the use of CWT can identify abnormal myocardial relaxation.

METHODS

EwECG and echocardiography were undertaken in 398 participants at risk of heart failure (HF). Reduced global longitudinal strain (GLS ≤16%)), diastolic abnormalities (E/e' >15, left atrial enlargement with E/e' >10 or impaired relaxation) or LV hypertrophy defined LVD. EwECG feature selection and supervised machine-learning by random forest (RF) classifier was undertaken with 643 CWT-derived features and the Atherosclerosis Risk in Communities (ARIC) heart failure risk score.

RESULTS

The ARIC score and 18 CWT features were selected to build a RF predictive model for LVD in a training dataset (n = 287; 60% female, median age 71 [interquartile range: 68 to 74] years). Model performance was tested in an independent group (n = 111; 49% female, median age 61 years [59 to 66 years]), demonstrating 85% sensitivity and 72% specificity (area under the receiver-operating characteristic curve [AUC]: 0.83; 95% confidence interval [CI]: 0.74 to 0.92). With ARIC score removed, sensitivity was 88% and specificity, 70% (AUC: 0.78; 95% CI: 0.70 to 0.86). RF models for reduced GLS and diastolic abnormalities including similar features had sensitivities that were unsuitable for screening. Conventional candidates for LVD screening (ARIC score, N-terminal pro-B-type natriuretic peptide, and standard automated ECG analysis) had inferior discriminative ability. Integration of ewECG in screening of people at risk of HF would reduce need for echocardiography by 45% while missing 12% of LVD cases.

CONCLUSIONS

Machine learning applied to ewECG is a sensitive screening test for LVD, and its integration into screening of patients at risk for HF would reduce the number of echocardiograms by almost one-half.

Relationship between oxidative stress and nuclear factor-erythroid-2-related factor 2 signaling in diabetic cardiomyopathy (Review)

Diabetic cardiomyopathy (DCM) is the leading cause of death worldwide, and oxidative stress was discovered to serve an important role in the pathophysiology of the condition. An imbalance between free radicals and antioxidant defenses is known to be associated with cellular dysfunction, leading to the development of various types of cardiac disease. Nuclear factor-erythroid-2-related factor 2 (NRF2) is a transcription factor that controls the basal and inducible expression levels of various antioxidant genes and other cytoprotective phase II detoxifying enzymes, which are ubiquitously expressed in the cardiac system. Kelch-like ECH-associated protein 1 (Keap1) serves as the main intracellular regulator of NRF2. Emerging evidence has revealed that NRF2 is a critical regulator of cardiac homeostasis via the suppression of oxidative stress. The activation of NRF2 was discovered to enhance specific endogenous antioxidant defense factors, one of which is antioxidant response element (ARE), which was subsequently illustrated to detoxify and counteract oxidative stress-associated DCM. The NRF2 signaling pathway is closely associated with the development of various types of cardiac disease, including ischemic heart disease, heart failure, myocardial infarction, atrial fibrillation and myocarditis. Therefore, it is hypothesized that drugs targeting this pathway may be developed to inhibit the activation of NRF2 signaling, thereby preventing the occurrence of DCM and effectively treating the disease.

Clinical Utility of Echocardiographic Strain and Strain Rate Measurements

PURPOSE OF REVIEW

Assessment of left ventricular function is pivotal in many decisions, but ejection fraction has fundamental limitations for assessment of mild dysfunction, and especially for repeated assessments. Myocardial deformation imaging using speckle-tracking is widely available on modern echocardiography systems, and is now feasible as a clinical, rather than purely a research tool. Strain can be measured in all cardiac chambers, most commonly as a systolic parameter, although it can be measured in diastole. Generally, speckle tracking is more effective at measuring strain than strain-rate, which requires a higher temporal resolution. The purpose of this review is to help clinicians understand the main situations where strain provides incremental value to standard echocardiographic measurements.

RECENT FINDINGS

The normal range of LV global longitudinal strain (GLS) has now been defined as -18% and lower (ie more negative), abnormal as -16% or higher (ie less negative), with -16 to -18% being borderline. The variation between different vendors is now small for global parameters, but regional strain measurement remains unreliable - and therefore its use for stress echocardiography remains problematic. The most valuable indications for measuring strain are subclinical LV dysfunction (eg., GLS in HFpEF, stage B heart failure, aortic stenosis, mitral regurgitation), RV dysfunction (RV strain in pulmonary hypertension), atrial fibrillation (LA strain) and sequential follow-up (cardiotoxicity). Strain measurements have clinical utility in a number of settings and should be considered as part of the standard echocardiogram.

Assessment of left-ventricular diastolic function in pediatric intensive-care patients: a review of parameters and indications compared with those for adults

BACKGROUND

The incidence of diastolic heart failure has increased over time. The evaluation of left-ventricular diastolic function is complex, ongoing, and remains poorly performed in pediatric intensive-care patients. This study aimed to review the literature and to provide an update on the evaluation of left-ventricular diastolic function in adults and children in intensive care.

DATA SOURCES

We searched data from PubMed/Medline. Thirty-two studies were included. Four pragmatic questions were identified: (1) What is the physiopathology of diastolic dysfunction? (2) Which tools are required to evaluate diastolic function? (3) What are the echocardiographic criteria needed to evaluate diastolic function? (4) When should diastolic function be evaluated in pediatric intensive care?

RESULTS

Early diastole allows characterization of relaxation, whereas compliance assessments and filling pressures are evaluated during late diastole. The evolution of diastolic function differs between adults and children. Unlike in adults, decreased compliance occurs at the same time as delayed relaxation in children. Diastolic function can be evaluated by Doppler echocardiography. The echocardiographic criteria for ventricular relaxation include the E wave, E/A wave ratio, and isovolumic relaxation time. Ventricular compliance can be assessed by the E/e' wave ratio, atrial volume, and Ap wave duration during pulmonary vein flow. In adult intensive-care patients, the E/e' ratio can be used as an index of tolerance for volume expansion in septic patients and to adjust the inotropic support.

CONCLUSION

Clinical studies would allow some of these parameters to be validated for use in children in intensive care.

Detection of persistent systolic and diastolic abnormalities in asymptomatic pediatric repaired tetralogy of Fallot patients with preserved ejection fraction: a CMR feature tracking study

OBJECTIVES

A fast cardiovascular magnetic resonance (CMR) feature tracking was applied to assess ventricular systolic and diastolic function. This study sought to detect right ventricular (RV) systolic and diastolic abnormalities in asymptomatic pediatric repaired tetralogy of Fallot (rTOF) patients with preserved RV ejection fraction (EF).

METHODS

One hundred asymptomatic pediatric rTOF patients with preserved RVEF ≥ 45% and 52 control subjects underwent cine CMR examinations. Tricuspid annular plane systolic excursion (TAPSE); peak tricuspid annular systolic (S_m), early diastolic (E_m), and late diastolic (A_m) velocities; and biventricular global radial (GRS), circumferential (GCS), and longitudinal strains (GLS) were analyzed using CMR feature tracking.

RESULTS

TAPSE, S_m, E_m, A_m, and RV GLS were significantly lower in rTOF patients compared with controls (all p < 0.01). The lower limits (mean-2·standard deviations) of TAPSE, S_m, E_m, and A_m among controls were 10.9 mm, 6.3 cm/s, 8.9 cm/s, and 2.4 cm/s, respectively, and 78%, 75%, 75%, and 19% of rTOF patients had corresponding measurements below these thresholds. Among rTOF patients, RV GLS was significantly lower in females than in males (p < 0.05).

CONCLUSIONS

Despite preserved RVEF, there was a high prevalence of RV systolic and diastolic dysfunction among pediatric rTOF patients, which was detected using fast CMR feature tracking.

KEY POINTS

• There was high prevalence of systolic and diastolic dysfunction in asymptomatic pediatric repaired tetralogy of Fallot (rTOF) patients despite preserved right ventricular (RV) ejection fraction (EF). • Significant correlations were observed between right ventricular (RV) measurements (strains, tricuspid annular plane systolic excursion (TAPSE), peak tricuspid annular early diastolic velocity (E_m), peak tricuspid annular late diastolic velocity (A_m)), and left ventricular (LV) strain measurements, which indicates ventricular-ventricular interactions at systolic and diastolic function level. • Right ventricular (RV) global longitudinal strain (GLS) was lower in female repaired tetralogy of Fallot (rTOF) patients than in males, suggesting females with rTOF may be at a higher risk of developing RV systolic dysfunction than males.

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.

Relationships of global longitudinal strain with s`, long-axis systolic excursion, left ventricular length and heart rate

Background

Longitudinal left ventricular (LV) contraction can be impaired in the presence of a normal LV ejection fraction (LVEF), and abnormalities have been reported in global longitudinal strain (GLS), long-axis systolic excursion (SExc), and the peak systolic velocity (s`) of mitral annular motion using tissue Doppler imaging (TDI). However, the relationships of GLS with s` and SExc have not been systematically evaluated in subjects with a normal LVEF, and whether these relationships might be affected by variations in LV end-diastolic length (LVEDL) and heart rate is unknown.

Methods

We investigated the univariate and multivariate correlations of GLS with TDI measurements of s` and SExc (both using averages of the septal and lateral walls), LVEDL and heart rate in subjects with a normal LVEF (>50%) but a low peak early diastolic mitral annular velocity (septal e`≤ 7.0 cm/s and lateral e`≤ 9 cm/s), and thus an increased risk of a future cardiac event.

Results

84 subjects (age 66±8 years, 29 males) with a LVEF of 62±6% and GLS of -17.5±2.3% were studied. On univariate analysis the absolute value of GLS was positively correlated with s`(r = 0.28, p<0.01) and SExc (r = 0.50, p<0.001) and inversely correlated with heart rate (r = -0.36, p = 0.001), but was not correlated with LVEDL (r = -0.15). In multivariate models, SExc explained more of the variance in GLS than s`, and absolute GLS was not only positively correlated with SExc, but also inversely correlated with LVEDL. Heart rate was an independent inverse correlate of GLS in conjunction with LVEDL and either s` or SExc, but made a larger contribution in models which included s`. Interobserver correlations were close for s` and SExc (r = 0.89–0.93), but only moderate for GLS (r = 0.71).

Conclusion

In subjects with a normal LVEF but reduced e`, the absolute value of GLS is more closely related to SExc than s`, and is also independently and inversely related to LVEDL and heart rate. Measurement of SExc may provide a useful additional or alternative technique to GLS for the assessment of LV long-axis function.

Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications

Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.

Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

Background Paradoxical low-flow (LF) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) may have poorer prognosis than normal-flow (NF) AS, though its pathophysiology remained unclear. In particular, LV stiffness has not been compared between LF vs NF. We used a novel echocardiography-derived index of LV stiffness to compare between these groups. Consecutive patients with medically-managed isolated severe AS (aortic valve area < 1 cm²) and preserved LVEF (>50%) were studied. Echocardiographic LV stiffness index was measured by a method previously validated against cardiac catheterization. We compared LF (stroke volume index, SVI < 35 ml/m²) and NF severe AS. Of the 352 patients, 121 (34%) were LF. Both LF and NF groups had similar demographics, valve areas and indices. Compared to NF, LF severe AS had higher LV stiffness indices (>0.11 ml^-1 OR 3.067, 95% CI 1.825-5.128, p < 0.001). Increased LV stiffness was associated with concentric remodelling and more severe diastolic dysfunction, especially in LF AS. An LV stiffness index of > 0.11 ml^-1 was independently associated with increased mortality, after adjusting for age, clinical and echocardiographic parameters (HR 2.283 95% CI 1.318-3.968, p = 0.003). Non-invasive echocardiographic-derived index of LV stiffness may be important in LF AS. Increased LV stiffness was related to LV concentric remodelling and diastolic dysfunction, and associated with poorer clinical outcomes in medically-managed AS.

Fast long-axis strain: a simple, automatic approach for assessing left ventricular longitudinal function with cine cardiovascular magnetic resonance

OBJECTIVES

In some cardiac pathologies, impairment of left ventricular (LV) longitudinal function may precede reduction in LV ejection fraction. This study investigates the effectiveness of a fast method to quantify long-axis LV function compared to conventional feature tracking and manual approaches.

METHODS

The study consisted of 50 normal controls and 100 heart failure (HF) patients including 40 with reduced ejection fraction (HFrEF), 30 with mid-range ejection fraction (HFmrEF), and 30 with preserved ejection fraction (HFpEF). Parameters including fast long-axis strain (FLAS) at end-systole and peak strain rates during systole (FLASR_s), early diastole (FLASR_e), and atrial contraction (FLASR_a) were derived by a fast semi-automated approach on cine cardiovascular magnetic resonance.

RESULTS

FLAS exhibited good agreement with strain values obtained using conventional feature tracking (bias - 2.9%, limits of agreement ± 3.0%) and the manual approach (bias 0.6%, limits of agreement ± 2.1%), where FLAS was more reproducible and required shorter measurement time. The mean FLAS (HFrEF < HFmrEF < HFpEF < controls; 6.1 ± 2.4 < 9.9 ± 2.4 < 11.0 ± 2.5 < 16.9 ± 2.3%, all p < 0.0001) was decreased in all the HF patient groups. A FLAS of 12.3% (mean-2SD of controls) predicted the presence of systolic dysfunction in 67% of patients with HFpEF, and 87% with HFmrEF. Strain parameters using the fast approach were superior to those obtained by conventional feature tracking and manual approaches for discriminating HFpEF from controls. Notable examples are area under the curve, sensitivity, and specificity for FLAS (0.94, 93%, and 86%) and FLASR_e (0.96, 90%, and 94%).

CONCLUSIONS

The fast approach-derived LV strain and strain rate parameters facilitate reproducible, reliable, and effective LV longitudinal function analysis.

KEY POINTS

• Left ventricular long-axis strain can be rapidly derived from cine CMR with shorter measurement time and higher reproducibility compared to conventional feature tracking and the manual approach. • Progressive reductions in left ventricular long-axis strain and strain rate measurements were observed from HFpEF, HFmrEF, to HFrEF group. • Based on long-axis strain, systolic abnormalities were evident in HFmrEF and HFpEF indicating common coexistence of systolic and diastolic dysfunction in the HF phenotypes.

Left Ventricular Systolic Dysfunction Is a Possible Independent Risk Factor of Radiation Pneumonitis in Locally Advanced Lung Cancer Patients

Objectives: To assess the association between left ventricular (LV) systolic and diastolic dysfunction and grade ≥2 radiation pneumonitis (RP) for locally advanced lung cancer patients receiving definitive radiotherapy. Materials and Methods: A retrospective analysis was carried out for 260 lung cancer patients treated with definitive radiotherapy between 2015 and 2017. RP was evaluated according to Radiation Therapy Oncology Group (RTOG) toxicity criteria. Logistic regression analysis, 10-fold cross validation, and external validation were performed. The prediction model's discriminative performance was evaluated using the area under the receiver operating characteristic curve (AUC), and calibration of the model was assessed by the Hosmer-Lemeshow test and the calibration curve. Results: Within the first 6 months after radiotherapy, 70 patients (26.9%) developed grade ≥2 RP. Reduced left ventricular ejection fraction (LVEF) before radiotherapy was detected in 53 patients (20.4%). The odds ratio (OR) of developing RP for patients with LVEF <50% was 3.42 [p < 0.001, 95% confidence interval (CI), 1.85-6.32]. Multivariate analysis showed that forced expiratory volume in the first second/forced vital capacity (FEV1/FVC), LVEF, Eastern Cooperative Oncology Group (ECOG) performance status, chemotherapy, and mean lung dose (MLD) were significantly associated with grade ≥2 RP. The AUC of a model including the above five variables was 0.835 (95% CI, 0.778-0.891) on 10-fold cross validation and 0.742 (95% CI, 0.633-0.851) on the external validation set. The p-value for the Hosmer-Lemeshow test was 0.656 on 10-fold cross validation and 0.534 on the external validation set. Conclusion: LV systolic dysfunction is a possible independent risk factor for RP in locally advanced lung cancer patients receiving definitive radiotherapy.

Clinical value of myocardial performance index in patients with isolated diastolic dysfunction

AIMS

The Doppler-derived myocardial performance index (MPI) has been considered as a diagnostic and prognostic Doppler marker for many different clinical conditions. The purpose of this study was to determine the diagnostic accuracy of traditional Pulsed-wave Doppler (PWD-MPI) and Pulsed-wave tissue Doppler imaging (TDI-MPI) and the degree of agreement between these methods in patients with grade-I diastolic dysfunction (DDI) and a normal ejection fraction.

METHODS

Forty-seven consecutive ambulatory patients with DDI were compared to 51 healthy subjects with normal echocardiograms. All subjects underwent measurement of time intervals and MPI with PWD and pulsed TDI.

RESULTS

TDI-MPI and PWD-MPI were significantly higher in patients with DDI than in control subjects: 0.49 ± 0.14 vs. 0.40 ± 0.09 (P < 0.001) and 0.45 ± 0.11 vs. 0.37 ± 0.08 (P < 0.001), respectively. Cutoff values of TDI-MPI > 0.42 and PWD-MPI > 0.40 identified DDI subjects, with sensitivities of 74 and 64%; specificities of 61 and 69%; positive likelihood ratios of 1.9 and 2.0; and negative likelihood ratios of 0.42 and 0.53, respectively; no significant difference was noted between the areas under the ROC curves of TDI-MPI and PWD-MPI (P = 0.77). Bland-Altman plots showed wide limits of agreement between these indices: - 0.17 to 0.23 in healthy subjects and - 0.24 to 0.32 in DDI patients.

CONCLUSION

PWD-MPI and TDI-MPI showed poor clinical agreement and were not reliable parameters for the assessment of left ventricular diastolic function.

Low-Grade Albuminuria Is Associated with Left Ventricular Hypertrophy and Diastolic Dysfunction in Patients with Hypertension

INTRODUCTION

Microalbuminuria is a risk factor for cardiovascular morbidity and mortality in hypertensive patients. However, the relationship between low-grade albuminuria, a higher level of albuminuria below microalbuminuria threshold, and hypertension-related organ damage is unclear. Left ventricular (LV) hypertrophy (LVH) is well recognized to be a subclinical organ damage of hypertension, and LV diastolic dysfunction is also reported to be an early functional cardiac change of hypertension that predicts heart failure. The present study aimed to investigate the association of low-grade albuminuria with LVH and LV diastolic dysfunction in hypertensive patients.

METHODS

This cross-sectional observational clinical study was retrospectively performed in 870 hypertensive patients admitted to our hospital. Urinary albumin to creatinine ratio (UACR) was calculated to assess the levels of albuminuria: macroalbuminuria (≥300 mg/g), microalbuminuria (≥30 mg/g, but <300 mg/g), and normal albuminuria (<30 mg/g). Low-grade albuminuria was defined as sex-specific highest tertile within normal albuminuria (8.1-29.6 mg/g in males and 11.8-28.9 mg/g in females). LVH and LV diastolic dysfunction were identified as recommended by American Society of Echocardiography.

RESULTS

Of the 870 patients, 765 (87.9%) had normal albuminuria, 77 (8.9%) had microalbuminuria, and 28 (3.2%) had macroalbuminuria. Percentage of LVH and LV diastolic dysfunction was increased with ascending UACR. UACR was independently associated with LVH and LV diastolic dysfunction, even in patients with normal albuminuria. Multivariable logistic regression showed that the patients with the highest tertile within normal albuminuria had nearly 80% increase in LVH and nearly 60% increase in LV diastolic dysfunction (adjusted OR for LVH 1.788, 95% CI 1.181-2.708, p = 0.006; adjusted OR for LV diastolic dysfunction 1.567, 95% CI 1.036-2.397, p = 0.034). After further stratification analyses in patients with normal albuminuria, it was shown that this independent association persisted in female patients, those who were younger than 70 years old, and those with duration of hypertension <15 years.

CONCLUSION

Low-grade albuminuria was associated with LVH and LV diastolic dysfunction in hypertensive patients, especially in patients younger than 70 years old, and those with duration of hypertension <15 years.

Ablation of brainstem C1 neurons improves cardiac function in volume overload heart failure

Activation of the sympathetic nervous system is a hallmark of heart failure (HF) and is positively correlated with disease progression. Catecholaminergic (C1) neurons located in the rostral ventrolateral medulla (RVLM) are known to modulate sympathetic outflow and are hyperactivated in volume overload HF. However, there is no conclusive evidence showing a contribution of RVLM-C1 neurons to the development of cardiac dysfunction in the setting of HF. Therefore, the aim of this study was to determine the role of RVLM-C1 neurons in cardiac autonomic control and deterioration of cardiac function in HF rats. A surgical arteriovenous shunt was created in adult male Sprague-Dawley rats to induce HF. RVLM-C1 neurons were selectively ablated using cell-specific immunotoxin (dopamine-β hydroxylase saporin [DβH-SAP]) and measures of cardiac autonomic tone, function, and arrhythmia incidence were evaluated. Cardiac autonomic imbalance, arrhythmogenesis and cardiac dysfunction were present in HF rats and improved after DβH-SAP toxin treatment. Most importantly, the progressive decline in fractional shortening observed in HF rats was reduced by DβH-SAP toxin. Our results unveil a pivotal role played by RVLM-C1 neurons in cardiac autonomic imbalance, arrhythmogenesis and cardiac dysfunction in volume overload-induced HF.

Évaluation de la fonction diastolique du ventricule gauche en réanimation pédiatrique : quelles indications, quels paramètres mesurer ?

L’incidence des patients avec une insuffisance cardiaque diastolique a augmenté au cours des dernières années. De nombreuses études épidémiologiques, physiopathologiques, cliniques ou pronostiques ont été menées pour comprendre cette nouvelle entité. L’étude et l’analyse de la fonction diastolique (FD) sont devenues des temps essentiels de l’examen échocardiographique. Cet article a pour objectifs : 1) de faire le point sur la physiologie de la FD du ventricule gauche (VG) et sur son évaluation chez l’enfant ; 2) d’envisager des applications cliniques en réanimation pédiatrique pour lesquelles son évaluation est importante. L’évaluation de la FD du VG est complexe, en plein essor et encore peu réalisée en pédiatrie. De plus, la tachycardie chez l’enfant et les particularités pédiatriques encore méconnues rendent difficile l’analyse de certains paramètres. L’ETT est l’examen complémentaire incontournable pour évaluer la FD du VG, mais en cours d’étude chez l’enfant. L’évaluation de la FD du VG devrait faire partie intégrante des paramètres échocardiographiques à prendre en considération pour certaines situations (évaluation de la réponse au remplissage vasculaire et de la sevrabilité à la ventilation mécanique, ajustement des traitements…) afin de mieux comprendre sa mesure et l’utiliser en routine clinique. On retiendra que pour l’évaluation échocardiographique chez l’enfant de réanimation : dans un premier temps évaluer la fonction systolique puis s’efforcer d’évaluer l’évolution de la FD par les pressions de remplissage par des paramètres simples (doppler mitral et tissulaire) ajustés au Z-score (urihttp://www.parameterz.comhttp://www.parameterz.com) tels que les rapports E/e’ et E/A, le volume indexé de l’OG, le tout assorti au contexte clinique et à la cinétique des paramètres biologiques (BNP, NT pro-BNP).

Role of global longitudinal strain in assessment of left ventricular systolic function in patients with heart failure with preserved ejection fraction

Objectives

To detect systolic dysfunction in heart failure with preserved ejection fraction (HFpEF) patients by using global longitudinal strain (GLS).

Methods

This study included 46 heart failure patients: 24 with heart failure with reduced ejection fraction (HFrEF) and 22 with heart failure with preserved ejection fraction (HFpEF), and 20 patients with similar risk factor but no symptoms or signs of heart failure, matched for age and sex, as controls. All patients were screened by echocardiography. The ejection fraction of left ventricle was measured using Simpson’s method and the GLS of the left ventricle was measured by using two-dimensional speckle tracking.

Results

Left ventricular ejection fraction (LVEF) was 61.90 ± 2.94% in the controls, 60.45 ± 7.4% in the HFpEF group (p = 0.421), and 32.75 ± 8.45% in the HFrEF group (p = 0.001). The value of left ventricle (LV) GLS (controls =  −19.74 ± 1.12%, HFpEF =  −15.03 ± 2.03%, HFrEF =  −10.72 ± 1.99%, p = 0.0001) was significantly impaired in the HFpEF group despite normal LVEF.

Conclusion

There is significant left ventricular systolic impairment detected by GLS despite preserved LVEF.

Age-related changes in four-dimensional CMR-derived atrioventricular junction velocities and displacements: Implications for the identification of altered annular dynamics for ventricular function assessment

Background

We determined the age-related changes in atrioventricular junction (AVJ) velocities and displacements by feature tracking cardiovascular magnetic resonance (FT-CMR) in a healthy community-based population. We also investigated the importance of age-matching for the identification of altered AVJ dynamics.

Methods

FT-CMR was performed in 230 controls (18-78 years) and in two patient groups each consisting of 40 subjects (group 1: 23-55 years, group 2: 56-80 years). AVJ dynamic parameters, including systolic velocity Sm, early diastolic velocity Em, late diastolic velocity Am, maximal systolic excursion MAPSE and the new parameter sweep surface area velocity SSAV were measured.

Results

Increasing age in the control group was significantly associated with reductions in Sm, Em, MAPSE (r = -0.40, -0.76, -0.34, all P < 0.001) and an increase in Am (r = 0.45, P < 0.001). For patient group 1, the selection of an age-unmatched control group (56-76 years) underestimated the number of patients with abnormal AVJ dynamics during systole and early diastole (38% vs. 70% for Sm; 20% vs. 60% for Em; 35% vs. 50% for MAPSE). In contrast, for patient group 2, the number of patients with systolic and early diastolic AVJ dynamic abnormalities was overestimated (88% vs. 63% for Sm; 90% vs. 68% for Em; 73% vs. 58% for MAPSE) when compared with age-unmatched controls (24-55 years). Fifty-percent (20/40) of the sub-group of patients with normal left ventricular ejection fraction exhibited abnormal systolic Sm or MAPSE measurements.

Conclusions

Significant correlations exist between age and AVJ dynamics. Age matching is important for evaluating AVJ long-axis function.

Association of High-Sensitivity Troponin T With Left Ventricular Dysfunction in Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a systemic inflammatory disease, and cardiac dysfunction has not been clearly described clinically. High-sensitivity cardiac troponin T (hs-cTnT) is a noninvasive marker for subclinical myocardial injury.

OBJECTIVE

In this study, we aimed to investigate any relationship between hs-cTnT and left ventricular (LV) function evaluated via tissue Doppler imaging in AS patients with no known cardiac risk factor.

METHODS

Our study used a cross-sectional case protocol design and was conducted between January 2016 and June 2016. In total, 40 AS patients (17 females and 23 males) were age and sex matched with healthy volunteers (20 females and 20 males) and enlisted for this study. Detailed transthoracic echocardiography was performed, and tissue Doppler imaging was used to assess systolic and diastolic functions. High-sensitivity cardiac troponin T levels were measured and compared between 2 groups.

RESULTS

Compared with control subjects, AS patients had lower early (Em)/late (Am) diastolic myocardial velocities, mitral annular plane systolic excursion, and end-diastolic distance from the mitral annulus to the LV apex. Conversely, they had greater systolic myocardial velocity (Sm), isovolumetric relaxation time, and displacement index (p < 0.001, for all). Higher hs-cTnT levels were measured in AS patients (0.45 ± 0.22 vs. 1.11 ± 0.27, p < 0.001), and multivariate logistic regression analyses revealed that hs-cTnT was an independent predictor of LV diastolic dysfunction in AS patients.

CONCLUSIONS

These data show that AS patients had impaired LV functions and increased hs-cTnT levels. Tissue Doppler imaging may be a useful tool for detection of early functional LV abnormalities, and hs-cTnT may be valuable biomarker of diastolic LV dysfunction in AS patients.

Association of left ventricular myocardial dysfunction with diabetic polyneuropathy

BACKGROUND

The pathogenesis of left ventricular (LV) dysfunction in diabetes has been attracting attention. It has been reported that LV longitudinal systolic myocardial function determined by speckle tracking echocardiography (STE) is associated with diabetic polyneuropathy (DPN). However, the relationship between the severity of peripheral neuropathy and LV myocardial dysfunction is unknown. This study examined the relationship between the severity of DPN and echocardiographic parameters as well as clinical features.

METHODS

The subjects were 166 patients (57 ± 14 years old) with diabetes who had a normal LV ejection fraction (≥ 55%). To assess LV longitudinal systolic function, global longitudinal strain (GLS) was calculated by two-dimensional STE as the average peak strain of 18 LV segments in three standard apical views. A nerve conduction study (NCS) was performed in each subject to assess the severity of neuropathy based on the NCS Baba Classification (Grade 0: no apparent abnormalities-Grade IV: abolition). Three nerves in the lower extremity were examined: tibial nerve (F-wave latency, motor nerve conduction velocity, and amplitude), sural nerve (sensory conduction velocity and amplitude), and peroneal nerve (motor nerve conduction velocity and amplitude).

RESULTS

Of the 166 subjects, 112 subjects (67.5%) were confirmed to have DPN, and all the subjects were divided into two groups according to the presence/absence of DPN. When multivariate analysis was performed using significant factors from univariate logistic regression analysis as explanatory variables, GLS was found to be an independent determinant of DPN (odds ratio: 0.55, p < 0.001). In multivariate analysis of NCS data, F-wave latency was the most important determinant of DPN (odds ratio: 1.43, p < 0.001). There was a significant negative correlation between F-wave latency and GLS (r = - 0.43, p < 0.001). Regarding the relation between GLS and the severity of DPN, GLS was significantly lower in patients with Grade I or higher DPN than in patients without DPN, but showed no significant difference between the grades of neuropathy. In addition, GLS was significantly lower when 2-3 lower extremity nerves were affected by DPN than in patients without DPN.

CONCLUSION

Patients with diabetes may already have subclinical LV myocardial dysfunction when DPN is Grade I. Assessment of LV longitudinal systolic function by GLS may be important in diabetic patients with DPN.

Relationship of Transmural Variations in Myofiber Contractility to Left Ventricular Ejection Fraction: Implications for Modeling Heart Failure Phenotype With Preserved Ejection Fraction

The pathophysiological mechanisms underlying preserved left ventricular (LV) ejection fraction (EF) in patients with heart failure and preserved ejection fraction (HFpEF) remain incompletely understood. We hypothesized that transmural variations in myofiber contractility with existence of subendocardial dysfunction and compensatory increased subepicardial contractility may underlie preservation of LVEF in patients with HFpEF. We quantified alterations in myocardial function in a mathematical model of the human LV that is based on the finite element method. The fiber-reinforced material formulation of the myocardium included passive and active properties. The passive material properties were determined such that the diastolic pressure-volume behavior of the LV was similar to that shown in published clinical studies of pressure-volume curves. To examine changes in active properties, we considered six scenarios: (1) normal properties throughout the LV wall; (2) decreased myocardial contractility in the subendocardium; (3) increased myocardial contractility in the subepicardium; (4) myocardial contractility decreased equally in all layers, (5) myocardial contractility decreased in the midmyocardium and subepicardium, (6) myocardial contractility decreased in the subepicardium. Our results indicate that decreased subendocardial contractility reduced LVEF from 53.2 to 40.5%. Increased contractility in the subepicardium recovered LVEF from 40.5 to 53.2%. Decreased contractility transmurally reduced LVEF and could not be recovered if subepicardial and midmyocardial contractility remained depressed. The computational results simulating the effects of transmural alterations in the ventricular tissue replicate the phenotypic patterns of LV dysfunction observed in clinical practice. In particular, data for LVEF, strain and displacement are consistent with previous clinical observations in patients with HFpEF, and substantiate the hypothesis that increased subepicardial contractility may compensate for subendocardial dysfunction and play a vital role in maintaining LVEF.

Impaired left ventricular diastolic function in T2DM patients is closely related to glycemic control

BACKGROUND

Left ventricular (LV) diastolic dysfunction commonly is observed in individuals with type 2 diabetes mellitus (T2DM). We employed transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMRI) to investigate the hypothesis that LV diastolic dysfunction in T2DM is associated with poor glycemic control.

METHODS

Forty subjects, 21 with normal glucose tolerance (NGT) and 19 with T2DM, were studied with CMRI and TTE to assess LV function. Early-to-late transmitral flow ratio (E/A) and deceleration time (DecT) were assessed with both modalities. Normalized (to body surface area) end-diastolic volume (EDV/BSA) and normalized peak LV filling rate (pLVFR/BSA) were assessed with CMRI. Early transmitral flow velocity to septal velocity (E/e') and isovolumetric relaxation time (IVRT) were measured using TTE. Dimensional parameters were normalized to body surface area (BSA).

RESULTS

CMRI measurements demonstrated impaired E/A (1.13 ± 0.34 vs 1.62 ± 0.42, P < .001), increased DecT (174 ± 46 ms vs 146 ± 15, P = .005), as well as lower EDV/BSA (63 ± 10 vs 72 ± 9 mL/m2, P < .01) and pLVFR/BSA (189 ± 46 vs 221 ± 48 mL s-1 m-2, P < .05) in T2DM subjects. TTE measurements revealed lower E/A (1.1 ± 0.4 vs 1.4 ± 0.2, P < .001) and E/e' (6.8 ± 1.5 vs 8.7 ± 2.0, P < .0001) with higher DecT (203 ± 22 ms vs 179 ± 18, P < .001) and IVRT (106 ± 14 ms vs 92 ± 10, P < .001) in T2DM. Multiple parameters of LV function: E/ACMRI (r = -.50, P = .001), E/ATTE (r = -.46, P < .005), pLVFR/BSA (r = -.35, P < .05), E/e' (r = -.46, P < .005), EDV/BSACMRI (r = -.51, P < .0001), EDV/BSATTE (r = -.42, P < .01) were negatively correlated with HbA1c. All but E/e' also were inversely correlated with fasting plasma glucose (FPG).

CONCLUSIONS

Impaired LV diastolic function (DF) was found in T2DM subjects with both CMRI and TTE, and multiple LVDF parameters correlated negatively with HbA1c and FPG. These results indicate that impaired LVDF is inversely linked to glycemic control in T2DM patients.

Left ventricular hypertrophy as protective factor after bypass grafting

Left ventricular hypertrophy (LVH) is a well established cardiovascular risk factor, accounting for an increase in cardiovascular morbid-mortality, although how much the magnitude and the kind of LVH could affect cardiovascular outcomes is in large part unknown. We speculate that mild LVH in absence of left ventricular (LV) chamber dilation, could play a protective role towards functional capacity, clinical outcome, cardiovascular and total morbi-mortality in conditions in which LV systolic function is generally reduced. Accordingly to many epidemiological observations, the availability of extra-quote of systolic function could lead to a significative improvement in the final outcome of some kinds of heart patients, as those undergoing bypass-grafting, where the stress for heart and cardiovascular system is always high. We suppose that the functional reserve available for patients with LVH could make the difference with respect to other patients undergoing myocardial revascularization. Similarly, the availability of a contractile reserve warranted by LVH could ensure a little gain in the outcome for patients after other major cardiovascular events (such as myocardial infarction or other heart surgery as surgical valve replacement). However, our hypothesis only involves mild LVH without LV chamber dilation, that is the initial stage of "non-dilated concentric" LVH and "non-dilated eccentric" LVH according to the new four-tiered classification of LVH based on relative wall thickness and LV dilation. Support for our hypothesis derives from the well-known protective role of systolic function that is a major factor in almost all cardiovascular diseases, where LV ejection fraction (LVEF) has shown to significantly improve quality of life, as well as morbidity and mortality. The knowledge that mild LVH in absence of LV chamber dilation is not as harmful in such conditions as believed at present could make avoidable some drugs prescription in some stages of the disease. Furthermore, it may allow a better evaluation of the risk profile of patients with LVH undergoing some cardiovascular major events like bypass grafting, myocardial infarction or surgical heart valve replacement.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Automatic Measurements of Mitral Annular Plane Systolic Excursion and Velocities to Detect Left Ventricular Dysfunction

The purpose of the study described here was to evaluate an automatic algorithm for detection of left ventricular dysfunction, based on measurements of mitral annular motion indices from color tissue Doppler apical four-chamber recordings. Two hundred twenty-one patients, among whom 49 had systolic and 11 had diastolic dysfunction, were included. Echocardiographic evaluation by cardiologists was the reference. Twenty patients were also examined by medical students. The ability of the indices to detect systolic and diastolic dysfunction were compared in receiver operating characteristic analyses, and the agreement between automatic and reference measurements was evaluated. Mitral annular plane systolic excursion ≤10 mm detected left ventricular dysfunction with 82% specificity, 76% specificity, 56% positive predictive value and 92% negative predictive value. The automatic measurements acquired from expert recordings better agreed better with the reference than those acquired from student recordings. We conclude that automatic measurements of systolic mitral annular motion indices can be helpful in detection of left ventricular dysfunction.

What is Heart Failure with Mid-range Ejection Fraction? A New Subgroup of Patients with Heart Failure

Since the publication of European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) in 2016, a new class of HF has been defined, namely HF with mildly reduced ejection fraction (HFmrEF). Although the name was new, there had long been awareness of the existence of a grey area between the two established classes of HF: HF with reduced ejection fraction and HF with preserved ejection fraction. Patients between these two classes were previously either excluded from HF studies or were included in the other groups. With the definition of this new group of patients, a door has opened for researchers to further explore their characteristics, treatment and outcomes. In this article we aim to clarify the existing literature on the clinical characteristics and pathophysiology of this newly-defined group of patients.

A Feline HFpEF Model with Pulmonary Hypertension and Compromised Pulmonary Function

Heart Failure with preserved Ejection Fraction (HFpEF) represents a major public health problem. The causative mechanisms are multifactorial and there are no effective treatments for HFpEF, partially attributable to the lack of well-established HFpEF animal models. We established a feline HFpEF model induced by slow-progressive pressure overload. Male domestic short hair cats (n = 20), underwent either sham procedures (n = 8) or aortic constriction (n = 12) with a customized pre-shaped band. Pulmonary function, gas exchange, and invasive hemodynamics were measured at 4-months post-banding. In banded cats, echocardiography at 4-months revealed concentric left ventricular (LV) hypertrophy, left atrial (LA) enlargement and dysfunction, and LV diastolic dysfunction with preserved systolic function, which subsequently led to elevated LV end-diastolic pressures and pulmonary hypertension. Furthermore, LV diastolic dysfunction was associated with increased LV fibrosis, cardiomyocyte hypertrophy, elevated NT-proBNP plasma levels, fluid and protein loss in pulmonary interstitium, impaired lung expansion, and alveolar-capillary membrane thickening. We report for the first time in HFpEF perivascular fluid cuff formation around extra-alveolar vessels with decreased respiratory compliance. Ultimately, these cardiopulmonary abnormalities resulted in impaired oxygenation. Our findings support the idea that this model can be used for testing novel therapeutic strategies to treat the ever growing HFpEF population.