Speckle tracking echocardiography: A new approach to myocardial function

An Optimization Approach for Creating Application-specific Ultrasound Speckle Tracking Algorithms

OBJECTIVE

Ultrasound speckle tracking enables in vivo measurement of soft tissue deformation or strain, providing a non-invasive diagnostic tool to quantify tissue health. However, adoption into new fields is challenging since algorithms need to be tuned with gold-standard reference data that are expensive or impractical to acquire. Here, we present a novel optimization approach that only requires repeated measurements, which can be acquired for new applications where reference data might not be readily available or difficult to get hold of.

METHODS

Soft tissue motion was captured using ultrasound for the medial collateral ligament (MCL) of three quasi-statically loaded porcine stifle joints, and medial ligamentous structures of a dynamically loaded human cadaveric knee joint. Using a training subset, custom speckle tracking algorithms were created for the porcine and human ligaments using surrogate optimization, which aimed to maximize repeatability by minimizing the normalized standard deviation of calculated strain maps for repeat measurements. An unseen test subset was then used to validate the tuned algorithms by comparing the ultrasound strains to digital image correlation (DIC) surface strains (porcine specimens) and length change values of the optically tracked ligament attachments (human specimens).

RESULTS

After 1500 iterations, the optimization routine based on the porcine and human training data converged to similar values of normalized standard deviations of repeat strain maps (porcine: 0.19, human: 0.26). Ultrasound strains calculated for the independent test sets using the tuned algorithms closely matched the DIC measurements for the porcine quasi-static measurements (R > 0.99, RMSE < 0.59%) and the length change between the tracked ligament attachments for the dynamic human dataset (RMSE < 6.28%). Furthermore, strains in the medial ligamentous structures of the human specimen during flexion showed a strong correlation with anterior/posterior position on the ligaments (R > 0.91).

CONCLUSION

Adjusting ultrasound speckle tracking algorithms using an optimization routine based on repeatability led to robust and reliable results with low RMSE for the medial ligamentous structures of the knee. This tool may be equally beneficial in other soft-tissue displacement or strain measurement applications and can assist in the development of novel ultrasonic diagnostic tools to assess soft tissue biomechanics.

Advances in the diagnosis of myocarditis in idiopathic inflammatory myopathies: an overview of diagnostic tests

Cardiac involvement in idiopathic inflammatory myopathies (IIM) purports to worse clinical outcomes, and therefore early identification is important. Research has focused on blood biomarkers and basic investigations such as ECG and echocardiography, which have the advantage of wide availability and low cost but are limited in their sensitivity and specificity. Imaging the myocardium to directly look for inflammation and scarring has therefore been explored, with a number of new methods for doing this gaining wider research interest and clinical availability. Cardiovascular magnetic resonance (CMR) with contemporary multiparametric mapping techniques and late gadolinium enhancement imaging, is an extremely valuable and increasingly used non-invasive imaging modality for the diagnosis of myocarditis. The recently updated CMR-based Lake Louise Criteria for the diagnosis of myocarditis incorporate the newer T1 and T2 mapping techniques, which have greatly improved the diagnostic accuracy for IIM myocarditis.18F-FDG-PET/CT is a well-utilized imaging modality in the diagnosis of malignancies in IIM, and it also has a role for the diagnosis of myocarditis in multiple systemic inflammatory diseases. Endomyocardial biopsy, however, remains the gold standard technique for the diagnosis of myocarditis and is necessary for the diagnosis of specific cases of myocarditis. This article provides an overview of the important tests and imaging modalities that clinicians should consider when faced with an IIM patient with potential myocarditis.

Myocardial strain of the left ventricle by speckle tracking echocardiography: From physics to clinical practice

Speckle tracking echocardiography (STE) is a reliable imaging technique of recognized clinical value in several settings. This method uses the motion of ultrasound backscatter speckles within echocardiographic images to derive myocardial velocities and deformation parameters, providing crucial insights on several cardiac pathological and physiological processes. Its feasibility, reproducibility, and accuracy have been widely demonstrated, being myocardial strain of the various chambers inserted in diagnostic algorithms and guidelines for various pathologies. The most important parameters are Global longitudinal strain (GLS), Left atrium (LA) reservoir strain, and Global Work Index (GWI): based on large studies the average of the lower limit of normality are -16%, 23%, and 1442 mmHg%, respectively. For GWI, it should be pointed out that myocardial work relies primarily on non-invasive measurements of blood pressure and segmental strain, both of which exhibit high variability, and thus, this variability constitutes a significant limitation of this parameter. In this review, we describe the principal aspects of the theory behind the use of myocardial strain, from cardiac mechanics to image acquisition techniques, outlining its limitation, and its principal clinical applications: in particular, GLS have a role in determine subclinical myocardial dysfunction (in cardiomyopathies, cardiotoxicity, target organ damage in ambulatory patients with arterial hypertension) and LA strain in determine the risk of AF, specifically in ambulatory patients with arterial hypertension.

The effect of increased plasma potassium on myocardial function; a randomized POTCAST substudy

Plasma potassium (p-K) in the high-normal range has been suggested to reduce risk of cardiovascular arrythmias and mortality through electrophysiological and mechanical effects on the myocardium. In this study, it was to investigated if increasing p-K to high-normal levels improves systolic- and diastolic myocardial function in patients with low-normal to moderately reduced left ventricular ejection fraction (LVEF). The study included 50 patients (mean age 58 years (SD 14), 81% men), with a mean p-K 3.95 mmol/l (SD 0.19), mean LVEF 48% (SD 7), and mean Global Longitudinal Strain (GLS) -14.6% (SD 3.1) patients with LVEF 35-55% from "Targeted potassium levels to decrease arrhythmia burden in high-risk patients with cardiovascular diseases trial" (POTCAST). Patients were given standard therapy and randomized (1:1) to an intervention that included guidance on potassium-rich diets, potassium supplements, and mineralocorticoid receptor antagonists targeting high-normal p-K levels (4.5-5.0 mmol/l). Echocardiography was done at baseline and after a mean follow-up of 44 days (SD 18) and the echocardiograms were analyzed for changes in GLS, mechanical dispersion, E/A, e', and E/e'. At follow-up, mean difference in changes in p-K was 0.52 mmol/l (95%CI 0.35;0.69), P<0.001 in the intervention group compared to controls. GLS was improved with a mean difference in changes of -1.0% (-2;-0.02), P<0.05 and e' and E/e' were improved with a mean difference in changes of 0.9 cm/s (0.02;1.7), P = 0.04 and ? 1.5 (-2.9;-0.14), P = 0.03, respectively. Thus, induced increase in p-K to the high-normal range improved indices of systolic and diastolic function in patients with low-normal to moderately reduced LVEF.

Assessment of subclinical left ventricular systolic dysfunction in patients with asymptomatic severe aortic stenosis with preserved left ventricular systolic function by three-dimensional speckle tracking echocardiography

OBJECTIVES

Left ventricular dysfunction and remodeling can occur as a result of aortic valve stenosis (AS). Three-dimensional speckle tracking echocardiography (3D-STE) can detect early left ventricular myocardial dysfunction even before ejection fraction declines. The purpose of this study was to look at the relationship between various myocardial strain parameters measured by 3D-STE in asymptomatic severe AS patients from Bangladesh.

METHODS

This study included 46 patients with asymptomatic severe AS but preserved LV systolic function (mean age 50.11 ± 12.66 years, LVEF 63.78 ± 3.95%, AS group) and 33 healthy subjects with no cardiovascular disease (mean age 48.21 ± 4.53 years, LVEF 65.15 ± 3.13%, control group). 3D-STE was used to measure left ventricular global myocardial strain parameters such as peak systolic longitudinal strain (PSLS), circumferential strain, radial strain, and area strain.

RESULTS

The AS group had significantly thicker interventricular septum and posterior ventricular wall than the control group (1.49 ± .19 cm vs. .81 ± .09 cm, p < .001; 1.73 ± 1.71 cm vs. .81 ± .10 cm, p = .003, respectively.) In the AS group, the Indexed Aortic Valve Area (AVA) was significantly lower than in the control group. (.29 ± .10 vs. 2.03 ± .18, p < .001, respectively). In terms of LVEF (p = .102), left ventricular end diastolic volume (p = .075), or left ventricular end systolic volume (p = .092), no significant inter-group difference was found. However, global PSLS (-10.75 ± 2.27 vs. -16.42 ± 2.76, p < .001), circumferential strain (-14.26 ± 3.40 vs. -16.64 ± 2.56, p = .001), area strain (-22.70 ± 4.19 vs. -26.45 ± 9.90, p = .024) and radial strain (32.20 ± 8.77 vs. 41.00 ± 7.52, p < .001) in the AS group were significantly lower than in the control group.

CONCLUSION

Our findings showed reductions in left ventricular global myocardial strains, particularly PSLS in patients suffering from asymptomatic severe AS in Bangladesh; this is consistent with other studies. Reduced area strain, detectable with 3D-STE, is also consistent with that pattern.

Correlation of Speckle-Tracking Echocardiography with Traditional Biomarkers in Predicting Cardiotoxicity among Pediatric Hemato-Oncology Patients: A Comprehensive Evaluation of Anthracycline Dosages and Treatment Protocols

Speckle tracking-echocardiography (STE) is a novel non-invasive imaging tool capable of quantifying myocardial deformation, and thus holds promise in detecting early subclinical myocardial injury. This study aimed to evaluate the correlation of STE with traditional biomarkers in predicting anthracycline-induced cardiotoxicity in the context of varying dosages and treatment protocols in pediatric hemato-oncology patients. We conducted a retrospective study involving pediatric hemato-oncology patients undergoing anthracycline-based chemotherapy. A total of 99 patients were included in the final analysis, with 82 receiving Doxorubicin, of which 58.5% were males, and 17 receiving Epirubicin, of which 70.6% were males, with a median of 10 years old. Traditional biomarkers, such as Troponin I (cTnI) and B-type natriuretic peptide (BNP), were compared with STE parameters, including the global longitudinal strain (GLS), Simpson method of discs (SMOD), and myocardial performance index (MPI). A comprehensive evaluation was conducted based on different dosages of anthracyclines and different treatment protocols, with a follow-up period of one year post-chemotherapy. It was observed that the cTnI levels in the Doxorubicin group were significantly higher (3.2 ng/mL, p = 0.002) than in the Epirubicin group (2.7 ng/mL). However, BNP and NT-proBNP levels were not significantly different between the two groups (p = 0.096 and p = 0.172, respectively). Regarding STE parameters, a significant negative correlation was observed between the anthracycline dose and GLS (Rho = -0.411, p = 0.001), indicating increased cardiotoxicity with dose elevation. The SMOD and MPI gave significantly better values in the Epirubicin group (59.2 and 0.41 vs. 54.4 and 0.36, respectively). However, the ROC analysis did not find GLS, SMOD, or MPI to be significant independent predictors of cardiotoxicity (p > 0.05). There was also considerable variation in cardiotoxicity between the Doxorubicin and Epirubicin study groups, suggesting that the risk of cardiotoxicity is not solely determined by dose. Our study underlines the potential of STE as a sensitive tool for the early detection and prediction of anthracycline-induced cardiotoxicity in pediatric hemato-oncology patients, but only in association with the clinical findings and cardiac biomarkers. While traditional biomarkers still play a role, STE can offer a more accurate prediction of cardiac risk, potentially leading to better management and outcomes for these patients.

Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis

BACKGROUND

Atrial cardiopathy (AC) has emerged as a potential pathological thrombogenic atrial substract of embolic stroke of undetermined source (ESUS), even in the absence of atrial fibrillation. Left atrium (LA) myocardial deformation analysis may be of value as a subclinical marker of AC and a predictor of ESUS.

AIMS

To compare LA mechanical function between ESUS cases and age and sex-matched controls.

METHODS

A single-center analytical study with case-control design was performed. Case group was composed by young patients admitted in the Neurology department from January 2017 to June 2021. Control group was composed by age and sex matched controls recruited from the community. All participants performed echocardiogram and a smaller sample underwent cardiac magnetic resonance.

RESULTS

We recruited 31 ESUS patients aged between 18 and 65 years and 31 age and sex matched controls. ESUS patients had a significantly higher prevalence of cardiovascular risk factors and patent foramen ovale (PFO). The prevalence of AC was not different between groups. Echocardiogram parameters, including strain analysis, were similar between groups, except for LA appendage (LAA) ostium variation which was significantly lower in ESUS patients (absolute: 6.5vs8.7mm, p<0.001; relative: 44.5%vs53.4%, p=0.002). After exclusion of patients with PFO, all the results were statistically similar. Regarding cardiac magnetic resonance analysis, there were no statistically significant differences between groups.

CONCLUSION

This study shows that in our population atria cardiopathy and atrial function was not associated with ESUS.LAA structural and functional abnormalities may play a major role. The role of LAA in ESUS warrants further studies.

Effects of Renin-Angiotensin System Inhibitors on Atrial Mechanics Parameters in Patients with Metabolic Syndrome

INTRODUCTION

Metabolic syndrome (MS) is associated with abnormalities in atrial mechanics, atrial remodeling, and an increased risk of heart rhythm disorders. One of the most commonly used approaches to the prevention of cardiac remodeling in arterial hypertension is the administration of renin-angiotensin system (RAS) inhibitors. Therefore, this study aimed to investigate the effects of RAS inhibitors on atrial mechanics parameters in patients with MS.

METHODS AND MATERIALS

This longitudinal observational study included 55 patients with hypertension and MS, as defined by the ATP III criteria. The patients were evaluated at the start of antihypertensive treatment with an RAS inhibitor. The patients' clinical characteristics, chosen pharmacological treatment, and transthoracic echocardiography findings were recorded at baseline and 6 months thereafter. A student's dependent sample t-test was used for comparisons between groups. Pearson correlation was used to evaluate the relationships between variables.

RESULTS

Patients with MS had higher peak atrial longitudinal strain (PALS) values at 6 months than at baseline. Meanwhile, systolic strain and peak late strain rates were lower at follow-up than at baseline. The different antihypertensive treatments had comparable effects on the PALS changes during the follow-up period. Higher high-density lipoprotein levels at baseline were correlated with changes in PALS.

CONCLUSION

The administration of RAS inhibitors improved atrial mechanics parameters in the early stages of antihypertensive management in MS.

The effect of paclitaxel plus carboplatin chemotherapy on subclinical cardiotoxicity in patients with non-small cell lung cancer: A speckle tracking echocardiography-based study

BACKGROUND

Although chemotherapy-induced cardiotoxicity is an emerging problem, limited information is available on the effects of chemotherapy on left ventricular (LV) mechanical functions in patients with non-small cell lung cancer (NSCLC).

OBJECTIVE

We aimed to explore chemotherapy-induced alterations in cardiac mechanical functions in patients with NSCLC using speckle tracking echocardiography (STE).

METHODS

Seventy-one patients with NSCLC and 34 age and sex matched control subjects were consecutively included. Based on their good performance status (Eastern Cooperative Oncology Group performance status), 39 patients were treated with paclitaxel plus carboplatin (PC) regimen and 32 patients were treated with vinorelbine plus cisplatin (VC) regimen. All patients and controls underwent conventional two-dimensional echocardiography and STE at baseline to assess their LV functions. The echocardiographic examinations of NSCLC patients were repeated after the chemotherapy regimens.

RESULTS

None of the NSCLC patients developed any signs or symptoms of clinical heart failure during or after the chemotherapy. There were not any significant differences in LV ejection fraction between NSCLC patients and controls before and after chemotherapy. There were not any significant differences in baseline LV global longitudinal strain (GLS), radial strain (RS), and circumferential strain (CS) between NSCLC patients and controls. However, all LV GLS, RS and CS significantly decreased in patients treated with the PC regimen resulting in a significant difference compared to both VC group and controls while no significant decreases were observed in strain measures in VC group.

CONCLUSION

Paclitaxel plus carboplatin, but not VC, may induce subclinical cardiotoxicity in patients with NSCLC, which may be detected by STE.

Difference in cardiac remodeling between female athletes and pregnant women: a case control study

OBJECTIVES

The aim of this study was to detect possible differences in reversible cardiac remodeling occurring in sport training and twin pregnancy.

BACKGROUND

cardiac remodeling occurs in athletes and pregnant women due to training and fetal requirements, respectively. These changes could be apparently similar.

METHODS

21 female elite athletes (23.2 ± 5.3 years), 25 women with twin pregnancies (35.4 ± 5.7 years) and 25 healthy competitive female athletes (controls), age-matched with pregnant women (34.9 ± 7.9 years), were enrolled. This latter group was included to minimize the effect of age on cardiac remodeling. All women evaluated through anamnestic collection, physical examination, 12 leads ECG, standard echocardiogram and strain analysis. Sphericity (SI) and apical conicity (ACI) indexes were also calculated.

RESULTS

Pregnant women showed higher LA dimension (p < 0.001) compared to both groups of athletes. LV e RV GLS were significantly different in pregnant women compared to female athletes (p = 0.02 and 0.03, respectively). RV GLS was also different between pregnant women and controls (p = 0.02). Pregnant women showed significantly higher S' wave compared to female athletes (p = 0.02) but not controls. Parameters of diastolic function were significantly higher in athletes (p = 0.08 for IVRT and p < 0.001 for E/A,). SI was lower in athletes in both diastole (p = 0.01) and systole (p < 0.001), while ACIs was lower in pregnant women (p = 0.04).

CONCLUSIONS

Cardiac remodeling of athletes and pregnant women could be similar at first sight but different in LV shape and in GLS, highlighting a profound difference in longitudinal deformation between athletes and pregnant women. This difference seems not to be related with age. These findings suggest that an initial maternal cardiovascular maladaptation could occur in the third trimester of twin pregnancies.

Case Report: Myocarditis After COVID-19 Vaccination - Case Series and Literature Review

BACKGROUND

The ongoing COVID-19 pandemic demands a series of measures and, above all, the vaccination of a substantial proportion of the population. Acute myocarditis is a rare complication of the widely used mRNA-based vaccines.

CASE PRESENTATION

We present a case series of four patients (three men and one woman, 16 to 47 years old) with acute pericarditis/myocarditis 3 to 17 days after mRNA vaccination. They presented with chest pain, fever, and flu-like symptoms. Diagnosis was made based on the synopsis of clinical presentation, elevated levels of troponin T and NT-proBNP, impaired systolic function on echocardiography, and findings in non-invasive tissue characterization by cardiovascular magnetic resonance imaging. Two patients also underwent endomyocardial biopsies. As none of the patients showed signs of cardiogenic shock, they were discharged from ward care only a few days after their initial presentations.

CONCLUSIONS

Our data are consistent with other case reports of myocarditis early after mRNA vaccination and demonstrate the need for multimodal diagnostics. In view of its rarity and mild course, the risk-benefit ratio of vaccination remains positive compared to potential SARS-CoV-2 infection.

Diabetic pregnancy as a novel risk factor for cardiac dysfunction in the offspring-the heart as a target for fetal programming in rats

AIMS/HYPOTHESIS

The impact of diabetic pregnancy has been investigated extensively regarding offspring metabolism; however, little is known about the influence on the heart. We aimed to characterise the effects of a diabetic pregnancy on male adult offspring cardiac health after feeding a high-fat diet in an established transgenic rat model.

METHODS

We applied our rat model for maternal type 2 diabetes characterised by maternal insulin resistance with hyperglycaemia and hyperinsulinaemia. Diabetes was induced preconceptionally via doxycycline-induced knock down of the insulin receptor in transgenic rats. Male wild-type offspring of diabetic and normoglycaemic pregnancies were raised by foster mothers, followed up into adulthood and subgroups were challenged by a high-fat diet. Cardiac phenotype was assessed by innovative speckle tracking echocardiography, circulating factors, immunohistochemistry and gene expression in the heart.

RESULTS

When feeding normal chow, we did not observe differences in cardiac function, gene expression and plasma brain natriuretic peptide between adult diabetic or normoglycaemic offspring. Interestingly, when being fed a high-fat diet, adult offspring of diabetic pregnancy demonstrated decreased global longitudinal (-14.82 ± 0.59 vs -16.60 ± 0.48%) and circumferential strain (-23.40 ± 0.57 vs -26.74 ± 0.34%), increased relative wall thickness (0.53 ± 0.06 vs 0.37 ± 0.02), altered cardiac gene expression, enlarged cardiomyocytes (106.60 ± 4.14 vs 87.94 ± 1.67 μm), an accumulation of immune cells in the heart (10.27 ± 0.30 vs 6.48 ± 0.48 per fov) and higher plasma brain natriuretic peptide levels (0.50 ± 0.12 vs 0.12 ± 0.03 ng/ml) compared with normoglycaemic offspring on a high-fat diet. Blood pressure, urinary albumin, blood glucose and body weight were unaltered between groups on a high-fat diet.

CONCLUSIONS/INTERPRETATION

Diabetic pregnancy in rats induces cardiac dysfunction, left ventricular hypertrophy and altered proinflammatory status in adult offspring only after a high-fat diet. A diabetic pregnancy itself was not sufficient to impair myocardial function and gene expression in male offspring later in life. This suggests that a postnatal high-fat diet is important for the development of cardiac dysfunction in rat offspring after diabetic pregnancy. Our data provide evidence that a diabetic pregnancy is a novel cardiac risk factor that becomes relevant when other challenges, such as a high-fat diet, are present.

Speckle tracking derived strain in neonates: planes, layers and drift

The aims of this study was to assess the effect of using a four chamber versus a three plane model on speckle tracking derived global longitudinal strain, the effects of drift compensation, the effect of assessing strain in different layers and finally the interplay between these aspects for the assessment of strain in neonates. Speckle tracking derived longitudinal strain was obtained from 22 healthy neonates. ANOVA, Bland-Altman analyses, coefficients of variation and assessment of intraclass correlation coefficients were conducted to assess the effect of the abovementioned aspects as well as assess both inter-observer and intra-observer variability. Neither the use of the three plane model versus the four chamber model nor the use of drift compensation had a substantial effect on global longitudinal strain (less than 1%, depending on which layer was being assessed). A gradient was seen with increasing strain from the epicardial to endocardial layers, similar to what is seen in older subjects. Finally, drift compensation introduced more discrepancy in segmental strain values compared to global longitudinal strain. Global longitudinal strain in healthy neonates remains reasonably consistent regardless of whether the three plane or four chamber model is used and whether drift compensation is applied. Its value increases when one moves from the endocardial to the epicardial layer. Finally, drift compensation introduces more discrepancy for regional measures of longitudinal strain compared to global longitudinal strain.

Does gender bias affect outcomes in mitral valve surgery for degenerative mitral regurgitation?

OBJECTIVES

This study was conducted to determine if gender bias explains the worse outcomes in women than in men who undergo mitral valve surgery for degenerative mitral regurgitation.

METHODS

Patients who underwent mitral valve surgery for degenerative mitral regurgitation with or without concomitant ablation surgery for atrial fibrillation were identified from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and were defined according to the Society of Thoracic Surgery National Adult Cardiac Surgery Database. Of the 1004 patients (33% female, mean age 62.1 ± 12.4 years; 67% male, mean age 60.1 ± 12.4 years) who met this criteria, propensity score matching was utilized to compare sex-related differences.

RESULTS

Propensity score matching of 540 patients (270 females, mean age 61.0 ± 12.2; 270 males, mean age 60.9 ± 12.3) demonstrated that 98% of mitral valve surgery performed in both groups was mitral valve repair and 2% was mitral valve replacement. Preoperative CHA2DS2-VASc scores were higher in women and fewer women were discharged directly to their homes. Before surgery, women had smaller left heart chambers, lower cardiac outputs, higher diastolic filling pressures and higher volume responsiveness than men. However, preoperative left ventricular and right ventricular strain values, which are normally higher in women, were similar in the 2 groups, indicating worse global strain in women prior to surgery.

CONCLUSIONS

The worse outcomes reported in women compared to men undergoing surgery for degenerative mitral regurgitation are misleading and not based on gender bias except in terms of referral patterns. Men and women who present with the same type and degree of mitral valve disease and similar comorbidities receive the same types of surgical procedures and experience similar postoperative outcomes. Speckle-tracking echocardiography to assess global longitudinal strain of the left and right ventricles should be utilized to monitor for myocardial dysfunction related to chronic mitral regurgitation.

Left Ventricular Strain: A Reliable Predictor of Short-Term Outcomes in Patients with Anterior Wall Myocardial Infarction without Heart Failure

Background:

Left ventricular ejection fraction (LVEF) is a key determinant in decision-making after acute myocardial infarction (MI). Little is known of its relationship with left ventricular Strain and N-Terminal fragment of pro-B-type Natriuretic Peptide (NT-pro-BNP) following acute anterior wall MI (AWMI).

Materials and Methods:

We conducted a prospective cohort study of patients with a diagnosis of acute AWMI and the absence of overt heart failure (HF). Assessment of LVEF, strain parameters on echocardiography was done, and NT-pro-BNP levels were obtained. Follow-up for adverse cardiac events was done for 30 days postdischarge. Correlation of LVEF and NT-pro-BNP with various strain parameters were ascertained.

Results:

Of the total of 50 patients of AWMI enrolled, the mean LVEF in the study was 43.46 ± 3.72%.Eleven patients (22%) had adverse events at 30 days of follow-up. Patients with adverse events had significantly higher overall peak systolic longitudinal strain (PSLS), lower mid-region peak systolic longitudinal velocity (PSLV), and basal region PSLV. A significant negative correlation was observed between LVEF and mean Peak PSLS of combined apical plus mid regions of the left ventricle (r = −0.700). Log10-NT-pro BNP also showed a strong negative correlation with overall PSLV (r = −0.792) as well as regional PSLV values of combined apical plus mid (r = −0.763) and basal segments (r = −0.748).

Conclusions:

In patients with AWMI without HF, PSLS and PSLV are good predictors of adverse outcomes at 30-day follow-up. Furthermore, NT-pro BNP can also be an indirect predictor of strain parameters on echocardiography.

Left ventricular remodeling and dysfunction in primary aldosteronism

Primary aldosteronism (PA) is a common cause of secondary hypertension and is associated with worse cardiovascular outcomes. The elevated aldosterone in PA leads to left ventricular (LV) remodeling and dysfunction. In recent decades, clinical studies have demonstrated worse LV remodeling including increased LV mass and cardiac fibrosis in patients with PA compared to patients with essential hypertension. Several mechanisms may explain the process of aldosterone-induced LV remodeling, including directly profibrotic and hypertrophic effects of aldosterone on myocardium, increased reactive oxygen species and profibrotic molecules, dysregulation of extracellular matrix metabolism, endothelium dysfunction and circulatory macrophages activation. LV remodeling causes LV diastolic and systolic dysfunction, which may consequently lead to clinical complications such as heart failure, atrial fibrillation, ischemic heart disease, and other vascular events. Adequate treatment with adrenalectomy or medical therapy can improve LV remodeling and dysfunction in PA patients. In this review, we discuss the mechanisms of aldosterone-induced LV remodeling and provide an up-to-date review of clinical research about LV remodeling-related heart structural changes, cardiac dysfunction, and their clinical impacts on patients with PA.

Evaluation of left atrial and ventricular myocardial functions by three-dimensional speckle tracking echocardiography in patients with euthyroid Hashimoto's thyroiditis

Hashimoto's Thyroiditis (HsT) is one of the most frequently occurring autoimmune diseases, characterized by lymphocytic infiltration, destruction and fibrosis of thyroid tissue and the presence of antibodies to thyroid peroxidase and thyroglobulin. The effects of euthyroid Hashimoto's thyroiditis (eHsT) on cardiovascular system are unclear. We aimed to identify if any deteriorations in LA and LV myocardial functions in patients with eHsT by 3D-STE in the current study. Fifty eight patients with eHsT and 60 age- and gender-matched controls were enrolled into the study. All participants underwent laboratory analyses which included thyroid hormones and thyroid autoantibody levels; and conventional 2D echocardiographic and 3D-STE analyses were performed. The mean age of the study patients was 34.5 ± 9 years, and 68.6% were female. Left ventricular global longitudinal strain (LV-GLS) was significantly depressed in the eHsT (+) group than in the control group (- 15.3 ± 3.6 vs. - 22.8 ± 3.8, p < 0.001). The LV-GLS was found to be disrupted linearly as thyroid autoantibodies increased (r = 0.684 for anti-TPO-ab and LV-GLS; r = 0.649 for anti-Tg-ab and LV-GLS). The present study demonstrated that 3D-STE is useful in the early detection of LV myocardial dysfunction in patients with eHsT. We found that eHsT had a negative effect on LV myocardial dynamics. According to these findings, these myocardial alterations that are present early in the disease process may be considered as a reason to start medical treatment earlier, even at the euthyroid stage to prevent LV myocardial impairment.

Early Left Ventricular Systolic Dysfunction Detected by Two-Dimensional Speckle-Tracking Echocardiography in Young Patients with Congenital Generalized Lipodystrophy

PURPOSE

Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive disorder characterized by the absence of functional adipocytes resulting in ectopic lipid storage, metabolic disorders and early cardiovascular disease. Two-dimensional speckle-tracking (2D-STE) allows the detection of early abnormalities in myocardial function. We aimed to evaluate myocardial deformation in a large sample of CGL patients using 2D-STE.

PATIENTS AND METHODS

A cross-sectional study of 22 patients with CGL and 22 healthy subjects, matched for sex and age, was conducted from 2013 to 2018. All participants had undergone standard conventional echocardiography (ECHO) and 2D-STE. Determination of blood glucose, lipids, insulin, and leptin were performed in all CGL patients.

RESULTS

In the CGL group the mean age was 14.6±10.7 years where 68.2% (n=15) were younger than 18 years old. All the patients had hypoleptinemia, 95.4% (21/22) low HDL-c, 86.4% (19/22) hypertriglyceridemia, 68.2% (15/22) diabetes, 50% (11/22) hepatic steatosis, 41% (9/22) insulin resistance, 41% (9/22) hypercholesterolemia, and 18.2% (4/22) hypertension. ECHO showed that 36.6% (8/22) of CGL patients presented diastolic dysfunction, 31.8% (7/22) left ventricular hypertrophy (LVH), 27.3% (6/22) increased left atrial volume index (LAVI), and 18.2% (4/22) increased left ventricular systolic diameter (LVDS) but normal ejection fraction (EF), whether using 2D-STE, 68.2% (15/22) of CGL patients showed abnormal global longitudinal strain (GLS) (p<0.01), and in almost LV segments. Positive association between abnormal GLS and A1c (r=0.57, p=0.005), glucose (r=0.5, p=0.018) and basal insulin (r= 0.69, p= 0.024), and negative association with leptin (r = -0.51, p = 0.005) were found in these patients.

CONCLUSION

The 2D-STE revealed precocious left ventricular systolic dysfunction in a young CGL population with normal systolic function by ECHO. Early exposure to common metabolic abnormalities as insulin resistance, hyperglycemia, and hypoleptinemia must be involved in myocardial damage in these patients.

Subclinical Myocardial Dysfunction Demonstrated by Speckle Tracking Echocardiography in Children with Euthyroid Hashimoto’s Thyroiditis

Objective

Thyroid hormones have an important role in the regulation of the cardiovascular system. The aim of this study was to investigate the presence of subclinical myocardial dysfunction in children with euthyroid Hashimoto’s thyroiditis (eHT) without evident heart disease using tissue doppler imaging (TDI) and speckle tracking echocardiography (STE) methods.

Methods

TDI and STE were peformed in 50 children with eHT and in 35 healthy children. To assess myocardial velocities and time intervals, including peak systolic velocity (Sm), peak early diastolic velocity (Em), peak late diastolic velocity (Am), isovolumetric contraction time (IVCT), isovolumetric relaxation time (IVRT) and ejection time (ET), TDI was performed at the base of the interventricular septum (IVS) and in the left and right ventricles (LV and RV, respectively). Analysis of myocardial deformation by STE including strain (S) and strain rate (SR) was performed globally in two planes, longitudinal (L) and mid-circumferential (C) in LV [LV global longitudinal strain (LVGLS), LV global longitudinal strain rate (LVGLSR), LV global circumferential strain (LVGCS), LV global circumferential strain rate (LVGCSR)] and RV [(RV global longitudinal strain (RVGLS), RV global longitudinal strain rate (RVGLSR)].

Results

Among TDI parameters, ET at LV and IVS were significantly lower, IVRT and myocardial performance index at LV and IVS were significantly higher in the eHT group compared to controls (p=0.001). There were no significant differences in Sm, Em, Am and IVCT values between patients and controls. LVGLS, LVGLSR, LVGCS and LVGCSR values were significantly lower in patients than controls (p=0.01). There was a negative correlation between thyroid antibody levels and LV global longitudinal and circumferential strain and strain rate values (TPO-Ab and Tg-Ab between LVGLS, LVGLSR, LVGCS and LVGCSR; r=-411, p<0.001; r=-541, p<0.001; r=-430, p<.0.001; r=-502, r<0.01 and r=-397, p<0.001; r=-473, p<0.001; r=-519, p<0.001; r=-421, p<0.00, respectively).

Conclusion

The results show that myocardial function in children with eHT is impaired in the absence of any clinical symptoms and that conventional echocardiography is inadequate to determine these changes.

Aldosterone induces left ventricular subclinical systolic dysfunction: a strain imaging study

BACKGROUND

Primary aldosteronism is associated with a higher incidence of left ventricular (LV) hypertrophy and diastolic dysfunction than essential hypertension. However, systolic function via endocardial measurements is similar between patients with primary aldosteronism and essential hypertension. Speckle-tracking echocardiography is a sensitive tool which can detect subclinical impairments in systolic function. The aim of this study was to investigate aldosterone-induced subclinical impairments in systolic function.

METHODS

We prospectively enrolled patients with primary aldosteronism and essential hypertension and analyzed their clinical data, biochemical data, and echocardiographic parameters, including myocardial strain [global longitudinal strain (GLS)].

RESULTS

Thirty-six patients with primary aldosteronism and 31 patients with essential hypertension were enrolled for analysis. The patients with primary aldosteronism had significantly lower serum potassium levels, lower plasma renin activity, higher aldosterone-to-renin ratio (ARR), and higher 24-h urinary aldosterone levels than patients with essential hypertension. With regards to echocardiographic parameters, the patients with primary aldosteronism had a thicker ventricular wall and higher LV mass index than those with essential hypertension. Most importantly, we found significant degradation of GLS in the patients with primary aldosteronism compared with those with essential hypertension (-17.84 ± 2.36 vs. -20.13 ± 2.32, P < 0.001). In correlation analysis, GLS was significantly correlated with serum potassium level, LV mass index, log-transformed plasma renin activity, log-transformed ARR, and log-transformed 24-h urinary aldosterone levels (all P < 0.05). Multivariate linear regression analysis further identified log-transformed ARR (β = 0.771, 95% confidence interval: 0.011-1.530, P = 0.047), and log-transformed 24-h urinary aldosterone level (β = 1.765, 95% confidence interval: 0.01-3.529, P = 0.050) as independent factors correlated with GLS.

CONCLUSION

Patients with primary aldosteronism have a lower magnitude of GLS than patients with essential hypertension, suggesting that aldosterone induces a subclinical decline in LV systolic function.

Use of speckle-tracking echocardiography-derived strain and systolic strain rate measurements to predict rejection in transplant hearts with preserved ejection fraction

BACKGROUND

Noninvasive diagnosis of allograft rejection in heart transplant recipients is challenging. The utility of 2-dimensional speckle-tracking echocardiography (2D-STE) to predict severe rejection in heart transplant recipients with preserved left ventricular ejection fraction (LVEF) was evaluated.

METHODS

Adult heart transplant patients with preserved LVEF (> 55%) and severe rejection by biopsy (Rejection Grade ≥ 2R) or no rejection between 1997 and 2011 at the Mayo Clinic in Rochester, Minnesota were evaluated. Transthoracic echocardiography was performed within 1 month of the biopsy. LV global longitudinal and circumferential strain and strain rates (GLS, GLSR, GCS, and GCSR) were analyzed retrospectively.

RESULTS

Of 65 patients included, 25 had severe rejection and 40 were normal transplant controls without rejection. Both groups had more men than women (64 and 75%, respectively). Baseline clinical variables were similar between the groups. Both groups had normal LVEF (64.3% vs 64.5%; P = .87). All non-strain echocardiographic variables were similar between the 2 groups. Strain analysis showed significantly increased early diastolic longitudinal strain rate (P = .02) and decreased GCS (P < .001) and GCSR (P = .02) for the rejection group compared with the control group. The area under the receiver operating characteristic curve for GCS was 0.77. With a GCS cutoff of - 17.60%, the sensitivity and specificity of GCS to detect severe acute rejection were 81.8 and 68.4%, respectively.

CONCLUSIONS

2D-STE may be useful in detecting severe transplant rejection in heart transplant patients with normal LVEF.

Association between asymmetric dimethylarginine serum levels and left ventricular longitudinal deformation in patients with normal ejection fractions: a two-dimensional speckle-tracking echocardiography examination

OBJECTIVES

Nitric oxide is an endogenous substance that preserves the myocardial function in patients with heart failure. Asymmetric dimethylarginine (ADMA) is a competitive inhibitor of endogenous nitric oxide synthase. We sought to explore the association between the left ventricular (LV) function as assessed with two-dimensional echocardiography and the serum level of ADMA in nondiabetic patients without significant coronary artery disease.

PATIENTS AND METHODS

Eighty-seven consecutive patients with normal LV ejection fractions were included in this cross-sectional study. The ADMA serum level was measured, and the longitudinal deformation indices of the LV myocardium were evaluated using two-dimensional speckle-tracking echocardiography (2DSTE).

RESULTS

The systolic strain, the systolic strain rate, and the early and late diastolic strain rates as evaluated with 2DSTE were not statistically significantly different between the patients with normal ADMA serum levels and those with increased ADMA serum levels. The two study groups were also not significantly different in terms of the systolic and diastolic myocardial velocities obtained with tissue Doppler.

CONCLUSION

Our findings showed no statistically significant correlations between the serum ADMA level and the 2DSTE-derived indices of the longitudinal deformation of the LV myocardium in our nondiabetic patients without significant coronary artery stenosis and with normal LV ejection fractions.

Use of the Speckle tracking method for determining global parameters of heart contractility in healthy individuals

The speckle tracking method allows one to quantify the temporal and spatial characteristics of myocardial contraction. Importantly, it does not depend on a scanning angle and allows one to record the movement of speckles in 2D mode in any direction, unlike tissue Doppler imaging. This examination is non-invasive, safe for patients, and economically more beneficial in comparison with other modern methods of assessing heart contractility: MRI and scintigraphy. Diagnostic thresholds are suggested for obtaining peak values of all types of global strains and strain rates by sampling a healthy group, which can reveal early signs of left ventricle contractility failure. Correlation relationships of deformation parameters between themselves and with left ventricular hemodynamic indices, as well as anthropometric parameters in healthy subjects highlight the features of heart contraction biomechanics. However, currently this method is scarcely studied because no generally accepted normal range of strain values exists.

•

It is necessary to have sufficient qualification and skills in dealing with the XStrain™ Esaote software to obtain optimal values ​​of myocardial deformation.

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The study results expand the database of this software for users and determine the normal range of the left ventricular contractility parameters.

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The revealed interrelationships of strain values ​​in healthy individuals are relevant for understanding how the contractility mechanisms are altered in patients, and open up the prospect of studying the heart’s compensatory possibilities.

Myocardial strain/stress changes identified by echocardiography may reveal early sepsis-induced myocardial dysfunction

Objective

To perform early assessment of sepsis-induced myocardial dysfunction (SIMD) using strain/stress echocardiography.

Methods

A canine model of SIMD was established using intravenous injection of lipopolysaccharide (LPS, 2 mg/kg). Thirteen dogs were included, comprising an LPS-treated SIMD group (n = 7) and saline control group (n = 6). SIMD was assessed at various time-points using cardiac measurements including haemodynamics and echocardiography.

Results

Systolic and radial ventricular wall stress and circular ventricular wall stress (WSsc) were significantly lower in the sepsis group versus the control group at all time-points. Logistic regression analysis revealed an inverse correlation between stress rate of the front-posterior and bottom wall and left ventricle systolic wall strength. In contrast, a positive correlation was found between the mean velocity of circumferential fibre shortening (mVCF) or heart rate-adjusted mVCF (RVCF) and WSsc. Using regression equations, predicted values for mVCF and RVCF in animals with sepsis were significantly higher than measured values at 4- 5- and 6-h time-points.

Conclusions

These findings will further the understanding of pathophysiological alterations in SIMD at the early stage of sepsis, and suggest that strain rate may reflect the nature of myocardial contractility.

Evaluation of left ventricular strain in patients with dilated cardiomyopathy

Objective Dilated cardiomyopathy (DCM) can cause structural and functional changes in the left ventricle (LV). In this study, we evaluated whether cardiac magnetic resonance tissue-tracking (MR-TT) can be applied to the detection of LV abnormalities in patients with DCM. Methods We used MR-TT to analyze the global peak radial strain (GPRS), global peak circumferential strain (GPCS), and global peak longitudinal strain (GPLS) in every segment of the LV in 23 patients with DCM and 25 controls. The LV ejection fraction was also measured as a function indicator. Results Compared with the controls, the GPRS, GPCS, and GPLS were significantly reduced in patients with DCM, indicating global LV function impairment in all directions. We also identified a significant linear correlation between the GPRS, GPCS, and GPLS and the LV ejection fraction, indicating that LV function relies on coordinated wall motion from all directions. Moreover, we found that patients with DCM had a significantly reduced magnitude of the PRS, PCS, and PLS in most segments at different levels, indicating impaired myocardial function in most LV regions. Conclusions Our results demonstrate that LV myocardial strain in patients with DCM can be sensitively detected by MR-TT (not only the global LV function changes but also the segmental strain), which can help to identify the injured segment at an early stage and guide clinical treatment.

Cardiac Imaging in Heart Failure with Comorbidities

Imaging modalities stand at the frontiers for progress in congestive heart failure (CHF) screening, risk stratification and monitoring. Advancements in echocardiography (ECHO) and Magnetic Resonance Imaging (MRI) have allowed for improved tissue characterizations, cardiac motion analysis, and cardiac performance analysis under stress. Common cardiac comorbidities such as hypertension, metabolic syndromes and chronic renal failure contribute to cardiac remodeling, sharing similar pathophysiological mechanisms starting with interstitial changes, structural changes and finally clinical CHF. These imaging techniques can potentially detect changes earlier. Such information could have clinical benefits for screening, planning preventive therapies and risk stratifying patients. Imaging reports have often focused on traditional measures without factoring these novel parameters. This review is aimed at providing a synopsis on how we can use this information to assess and monitor improvements for CHF with comorbidities.

The detection of viable myocardium by low-dose dobutamine stress speckle tracking echocardiography in patients with old myocardial infarction

PURPOSE

To explore the significance and value of speckle-tracking echocardiography (STE) associated with low-dose dobutamine stress echocardiography (LDDSE) for the detection of viable myocardium (VM) in patients with old myocardial infarction (OMI).

METHODS

We performed STE with LDDSE in 33 hospitalized patients with OMI and left ventricular systolic dysfunction. QLAB software was used to analyze strain (S) and strain rate (Sr). Percutaneous coronary intervention (PCI) was subsequently performed. The movement of each wall segment was observed by routine echocardiography before and after 1, 3, and 6 months of PCI, and improvement was regarded as the gold standard for diagnosing VM.

RESULTS

Compared with semi-quantitative wall-motion analysis combined with LDDSE, the sensitivity, specificity, and accuracy of c-STE (combining the three directions of S and Sr) at LDDSE were 91.6%, 79.5%, and 87.5%, respectively (p < 0.02). Among the deformation parameters, longitudinal strain (LS) and longitudinal strain rate (LSr) had the highest sensitivity, specificity, and accuracy. Upon combining LS and LSr at LDDSE to parallel tests, the sensitivity, specificity, and accuracy were 91.7%, 90%, and 90.6%, respectively. Compared with baseline, LVEF after PCI increased from 43.3% ± 2.6% to 47.3% ± 2.9% (p < 0.001).

CONCLUSIONS

Global strain at LDDSE is superior to semi-quantitative wall-motion analysis with LDDSE for the assessment of VM. When the multivariable analysis and the parallel tests are combined, LS combined with LSr can be considered an independent predictor of VM. LVEF is improved after PCI in patients with VM and OMI. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:545-554, 2016.

Evaluation of myocardial viability in old myocardial infarcted patients with CHF: delayed enhancement MRI vs. low-dose dobutamine stress speckle tracking echocardiography

The aim of this study was to explore the significance of delayed enhancement magnetic resonance imaging (DE-MRI) combined with two-dimensional speckle tracking echocardiography (STE) and low dose dobutamine stress echocardiography (LDDSE) to assess viable myocardium (VM) in the patients with old myocardial infarction (OMI) associated with congestive heart failure (CHF). Thirty five hospitalized OMI patients with regional wall motion abnormalities and left ventricular ejection fraction (LVEF) < 50% were recruited based on routine echocardiography. The results showed that DE-MRI facilitated the detection of VM, with a sensitivity, specificity and accuracy of 92.41%, 89.19% and 91.32%, respectively. In a parallel test of the two main parameters in STE, the sensitivity, specificity, and accuracy were improved from baseline to LDDSE (71.72% vs. 91.72%, 70.27% vs. 85.14%, and 71.23% vs. 89.50%, P < 0.05). A parallel test involving STE with LDDSE showed high sensitivity for VM. However its specificity and accuracy were lower than DE-MRI, even when combined with LDDSE. Therefore, combining these two methods, improves the sensitivity, specificity and accuracy for assessment of VM. The combination approach is the best option for the evaluation of VM using serial test. It provides further treatment options and prognosis of patients with OMI. LVEF is improved significantly after PCI in OMI patients with VM and CHF.

Optimization-Based Speckle Tracking Algorithm for Left Ventricle Strain Estimation: A Feasibility Study

Speckle tracking echocardiography (STE) is a widespread method for calculating myocardial strains and estimating left ventricle function. Since echocardiographic clips are corrupted by speckle decorrelation noise, resulting in irregular, nonphysiological tissue displacement fields, smoothing is performed on the displacement data, affecting the strain results. Thus, strain results may depend on the specific implementations of 2-D STE, as well as other systems' characteristics of the various vendors. A novel algorithm (called K-SAD) is introduced, which integrates the physiological constraint of smoothness of the displacement field into an optimization process. Simulated B-mode clips, modeling healthy and abnormal cases, were processed by K-SAD. Peak global and subendocardial longitudinal strains, as well as regional strains, were calculated. In addition, 410 healthy subjects were also processed. The results of K-SAD are compared with those of one of the leading commercial product. K-SAD provides global mid-wall strain values, as well as subendocardial and regional strain values, all in good agreement with the ground-truth-simulated phantom data. K-SAD peak global longitudinal systolic strain values for 410 healthy subjects are quite similar for the different regions: - 17.02 ± 4.02%, - 19.00 ± 3.45%, and - 19.72 ± 5.06% at the basal, mid, and apical regions, respectively. Improved performance under noisy conditions was demonstrated by comparing a subgroup of 40 subjects with the best image quality with the remaining 370 cohort: K-SAD provides statistically similar global and regional results for the two cohorts. Our study indicates that the sensitivity of strain values to speckle noise, caused by the post block-matching weighted smoothing, can be significantly reduced and accuracy enhanced by employing an integrated one-stage, physiologically constrained optimization process.

Effects on heart function of neoadjuvant chemotherapy and chemoradiotherapy in patients with cancer in the esophagus or gastroesophageal junction - a prospective cohort pilot study within a randomized clinical trial

BACKGROUND

Neoadjuvant therapy for cancer of the esophagus or gastroesophageal (GE)-junction is well established. The pros and cons of chemoradiotherapy and chemotherapy are debated. Chemoradiotherapy might impair cardiac function eliciting postoperative morbidity. The aim of this pilot study was to describe acute changes in left ventricular function following chemoradiotherapy or chemotherapy.

METHODS

Patients with esophageal and (GE)-junction cancer enrolled at our center into a multicenter trial comparing neoadjuvant chemoradiotherapy and chemotherapy were eligible. Patients were randomized to receive cisplatin and 5-fluorouracil with or without the addition of 40 Gy radiotherapy prior to surgery. Left ventricular function was evaluated using echocardiography and plasma N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) before and after neoadjuvant treatment. The primary outcome measure was left ventricular global strain (GS). Clinical effects were assessed using repeated exercise tests. Linear mixed models were used to analyze the effects of treatment group, and the interaction between groups.

RESULTS

40 patients participated (chemoradiotherapy, n=17; chemotherapy, n=23). In the chemoradiotherapy group there was no change in left ventricular global strain but mitral annular plane systolic excursion (MAPSE) of the ventricular septum, early diastolic filling velocity (E-velocity), and the ratio of early to late ventricular filling velocities (E/A ratio) decreased significantly (p=0.02, p=0.01, and p=0.03, respectively). No changes were observed in the chemotherapy group. There was a trend towards an interaction effect for MAPSE sept and E (p=0.09 and p=0.09). NT-proBNP increased following chemoradiotherapy (p=0.05) but not after chemotherapy (p>0.99), and there was a trend towards an interaction effect (p=0.07). Working capacity decreased following neoadjuvant treatment (chemoradiotherapy p = 0.001, chemotherapy p=0.03) and was more pronounced after chemoradiotherapy with a trend towards an interaction effect (p=0.10).

CONCLUSIONS

Neoadjuvant chemoradiotherapy but not chemotherapy before surgery for cancer of the esophagus or GE-junction seems to induce an acute negative effect on both systolic and diastolic left ventricular function. Future studies on neoadjuvant treatment for esophageal cancer are suggested to add measurements of cardiac function.

TRIAL REGISTRATION

Clinical Trials.gov NCT01362127 .

Evaluation of cardiac function by two-dimensional speckle tracking echocardiography in ulcerative colitis patients

PURPOSE

Although ulcerative colitis (UC) shows obvious similarities with other autoimmune diseases, cardiac consequences have not adequately introduced. The aim of our study was to evaluate left ventricular (LV) function in UC patients by using novel echocardiographic parameters.

RESULTS

Forty-five UC patients (mean age 37, 18 female) and 90 age- and sex-matched healthy volunteers (mean age 40, 38 female) included in the study. The mean disease activity score according to partial Mayo score was 2.16 ± 2.13. Mean global longitudinal strain (GLS) and global longitudinal strain rate (GLSR) measurements were significantly lower (-21.16 ± 2.71 vs. -23.36 ± 3.34; p < 0.001 and -1.33 ± 0.24 vs. -1.43 ± 0.24; p = 0.037, respectively), whereas global circumferential (-22.67 ± 3.66 vs. -23.37 ± 3.99; p = 0.140) and global radial strain (43.07 ± 8.58 vs. 44.12 ± 9.32; p = 0.545) measurements of the LV were similar in patients with UC compared with controls. The correlation coefficient (r) between GLS and partial Mayo score was -0.578 (p < 0.001).

CONCLUSION

Our study suggests that systolic cardiac deformation values are impaired in UC patients. Reduced GLS and GLSR might be an early indicator of cardiac involvement in this population.

Left ventricular strain and strain rates are decreased in children with normal fractional shortening after exposure to anthracycline chemotherapy

BACKGROUND

Anthracycline chemotherapeutic agents carry the well-recognised risk of cardiotoxicity. Previous methods to evaluate cardiac function are useful, but have significant limitations. We sought to determine the left ventricular strain and strain rate of paediatric cancer patients with normal fractional shortening treated with anthracyclines using the latest ultrasound feature-tracking technology.

PATIENTS AND METHODS

Echocardiograms on cancer patients before anthracycline exposure and following completion of treatment were retrospectively analysed using Velocity Vector Imaging software in the circumferential and longitudinal planes. The same analysis was performed on matched controls. Only patients with a fractional shortening ≥28% were included.

RESULTS

In all, 71 patients were identified with an age at diagnosis of 10.5 ± 4.7 years. The time from diagnosis to follow-up was 3.9 ± 4.0 years and the cumulative anthracycline dose was 356 ± 106 mg/m². Following anthracycline exposure, paediatric cancer patients had a higher heart rate and a lower longitudinal strain, longitudinal diastolic strain rate, circumferential strain, and circumferential systolic and diastolic strain rate when compared with controls. Diastolic strain rate showed the greatest percent difference following anthracycline exposure versus controls.

CONCLUSION

Despite having a normal fractional shortening, children exposed to anthracyclines have subclinical derangement of their left ventricular deformation as measured by decreases in strain and strain rate in both the circumferential and longitudinal axis. In particular, there was a profound decrease in diastolic strain rate following anthracycline exposure compared with controls. Whether the decline of strain or strain rate can predict future risk of developing cardiomyopathy requires further investigation.

Left ventricular rotation and right-left ventricular interaction in congenital heart disease: the acute effects of interventional closure of patent arterial ducts and atrial septal defects

BACKGROUND

Left ventricular rotation is physiologically affected by acute changes in preload. We investigated the acute effect of preload changes in chronically underloaded and overloaded left ventricles in children with shunt lesions.

METHODS

A total of 15 patients with atrial septal defects (Group A: 7.4 ± 4.7 years, 11 females) and 14 patients with patent arterial ducts (Group B: 2.7 ± 3.1 years, 10 females) were investigated using 2D speckle-tracking echocardiography before and after interventional catheterisation. The rotational parameters of the patient group were compared with those of 29 matched healthy children (Group C).

RESULTS

Maximal torsion (A: 2.45 ± 0.9°/cm versus C: 1.8 ± 0.8°/cm, p < 0.05), apical peak systolic rotation (A: 12.6 ± 5.7° versus C: 8.7 ± 3.5°, p < 0.05), and the peak diastolic torsion rate (A: -147 ± 48°/second versus C: -110 ± 31°/second, p < 0.05) were elevated in Group A and dropped immediately to normal values after intervention (maximal torsion 1.5 ± 1.1°/cm, p < 0.05, apical peak systolic rotation 7.2 ± 4.1°, p < 0.05, and peak diastolic torsion rate -106 ± 35°/second, p < 0.05). Patients in Group B had decreased maximal torsion (B: 1.8 ± 1.1°/cm versus C: 3.8 ± 1.4°/cm, p < 0.05) and apical peak systolic rotation (B: 8.3 ± 6.1° versus C: 13.9 ± 4.3°, p < 0.05). Defect closure was followed by an increase in maximal torsion (B: 2.7 ± 1.4°/cm, p < 0.05) and the peak diastolic torsion rate (B: -133 ± 66°/second versus -176 ± 84°/second, p < 0.05).

CONCLUSIONS

Patients with chronically underloaded left ventricles compensate with an enhanced apical peak systolic rotation, maximal torsion, and quicker diastolic untwisting to facilitate diastolic filling. In patients with left ventricular dilatation by volume overload, the peak systolic apical rotation and the maximal torsion are decreased. After normalisation of the preload, they immediately return to normal and diastolic untwisting rebounds. These mechanisms are important for understanding the remodelling processes.

Right ventricular longitudinal deformation parameters and exercise capacity : prognosis of patients with chronic thromboembolic pulmonary hypertension

OBJECTIVE

Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease characterized by increased pulmonary vascular resistance resulting in pulmonary hypertension and right heart failure. The six-minute walk test (6MWT) distance is associated with the prognosis of CTEPH patients. Speckle tracking echocardiography (STE) is a reliable method for determining ventricular function. The aim of this study was to assess and compare the right ventricular (RV) function of CTEPH patients according to their 6MWT distances.

METHODS

Forty-nine consecutive CTEPH patients (mean age, 50 ± 16 years; 22 male) who were referred to our center for pulmonary thromboendarterectomy (PTE) were included in the study. All patients underwent the 6MWT and right heart catheterization (RHC). Standard echocardiography and STE were performed on all patients before PTE. Patients were divided into two groups based on their 6MWT distance being less or more than 300 m.

RESULTS

Patients with a shorter 6MWT distance had a significantly larger RV, while they had a significantly lower RV fractional area change and higher myocardial performance index suggesting impaired RV function. Both RV basal-lateral strain and strain rate measures were significantly lower in patients with shorter 6MWT distances than those with longer 6MWT distances. Similarly, they had lower RV basal-septal, mid-lateral, and global strain measures. 6MWT distances were correlated with RV basal-lateral and mid-lateral strain measures (r = 0.349, p = 0.025 and r = 0.415, p = 0.008, respectively).

CONCLUSION

Our data suggest that RV myocardial deformation parameters are associated with 6MWT distances. Determination of RV dysfunction by STE may be helpful in identifying patients with a poor prognosis.

Accuracy of real-time single- and multi-beat 3-d speckle tracking echocardiography in vitro

With little data published on the accuracy of cardiac 3-D strain measurements, we investigated the agreement between 3-D echocardiography and sonomicrometry in an in vitro model with a polyvinyl alcohol phantom. A cardiac scanner with a 3-D probe was used to acquire recordings at 15 different stroke volumes at a heart rate of 60 beats/min, and eight different stroke volumes at a heart rate of 120 beats/min. Sonomicrometry was used as a reference, monitoring longitudinal, circumferential and radial lengths. Both single- and multi-beat acquisitions were recorded. Strain values were compared with sonomicrometer strain using linear correlation coefficients and Bland-Altman analysis. Multi-beat acquisition showed good agreement, whereas real-time images showed less agreement. The best correlation was obtained for a heart rate 60 of beats/min at a volume rate 36.6 volumes/s.

Global and segmental myocardial deformation by 2D speckle tracking compared to visual assessment

AIM

To examine the feasibility and reliability of measuring global and segmental longitudinal strain (LS) compared to visual assessment of wall motion (WM).

METHODS

Assessment of segmental (17 left ventricular segments) LS using automatic function imaging (AFI) in 55 patients (60.0 ± 8.7 years, 73% male) divided into 2 groups: group I included 35 patients with WM abnormalities and/or impaired ejection fraction and group II included 20 patients with normal WM and ejection fraction. Visual analysis of WM abnormalities was performed using 2-dimensional echocardiography (2DE) and WM score was calculated. Both modalities were analyzed by one expert reader at 2 different sessions.

RESULTS

Analysis of 935 left ventricular segments was completed in 94.1% and 96.3% by visual assessment and AFI, respectively. There was a strong positive linear relationship between the WM score and global LS in all patients. Intra-observer agreement for calculation of WM score was excellent for group I patients (kappa: 0.97) and very good for group II patients (kappa: 0.92). Intra-observer agreement for AFI showed excellent agreement with very small mean difference in both group I and II (-0.0 ± 2.3 and -0.0 ± 1.9, respectively).

CONCLUSION

The interpretation of global and segmental LS using AFI is a more feasible and reliable technique for the quantification of myocardial deformation than visual assessment of WM scores.

Myocardial infarct size and area at risk assessment in mice

Mouse models of myocardial ischemia and infarction are important in cardiovascular research. Reliable and reproducible assessment of the area at risk (AAR) and infarct size (IS) in mice is vital for deciphering mechanisms behind these common diseases, and for developing and evaluating treatment strategies. The present review will briefly describe and discuss the most common methods for determining the AAR and IS in mouse models of cardiovascular disease. Several methods exist for ex vivo assessment of IS. Conventional histological stains target the fibrous scar and require several days to pass from the time of infarct induction until the animal is euthanized, whereas triphenyltetrazolium-based techniques stain the viable tissue surrounding the infarct and can be performed on tissue harvested within a few hours after infarction. The AAR is usually stained by injecting a dye into the circulation. This dye subsequently distributes to perfused tissue but leaves the AAR unstained. In vivo assessment enables serial measurements of the IS and/or AAR and is sometimes preferable to ex vivo techniques. Echocardiography is usually the method of choice but magnetic resonance imaging-based techniques are also used. The aim of the present review was to provide basic researchers with an introduction to the various techniques used to assess and quantify the IS and AAR in experimental mouse models of myocardial ischemia-reperfusion and infarction.

Role of cardiovascular imaging in systemic autoimmune diseases

Systemic autoimmune diseases are characterized by an excess of cardiovascular (CV) morbidity and mortality compared to the general population, mainly due to chronic inflammation that promotes the development of endothelial dysfunction and enhanced atherosclerosis. Early diagnosis of silent CV involvement is mandatory to improve the long term prognosis of these patients and CV imaging provides valuable information as a reliable diagnostic tool. Transthoracic echocardiography, with several applications (e.g. coronary flow reserve evaluation, tissue Doppler imaging, speckle tracking and the transesophageal approach), represents a first line evaluation, in association with biomarkers of endothelial dysfunction, such as asymmetric dimethylarginine. Nuclear medicine provides useful information on myocardial perfusion. The aim of this editorial is to provide a brief but complete review of the diagnostic tools available for screening and follow up of CV involvement in systemic autoimmune diseases.