Complex evaluation of left atrial dysfunction in patients with type 1 diabetes mellitus by three-dimensional speckle tracking echocardiography: results from the MAGYAR-Path Study

Lower left atrial function in young individuals with type 1 diabetes mellitus compared to healthy controls: an echocardiographic study

In adulthood, individuals with type 1 diabetes mellitus may develop a condition of heart failure with preserved ejection fraction. However, subclinical changes to the heart in diabetes are likely to occur prior to the clinical presentation. This cross-sectional study aimed to compare left atrial function by echocardiography between 43 individuals with type 1 diabetes and 43 healthy controls, aged 10-30 years. All participants underwent echocardiography and 2D speckle tracking measurements for left atrial phase function parameters. Physical capacity was assessed by exercise test on a bicycle. Results showed that participants with type 1 diabetes had significantly lower left atrial function parameters than healthy controls (p < 0.05). There was a significant negative correlation between HbA1c means and reservoir and conduit strain (p < 0.05) and individuals with BMI < 30 showed a lower left atrial stiffness (p < 0.05). Individuals with type 1 diabetes and a higher physical capacity did not differ from their healthy peers. Results indicate that lower HbA1c levels, BMI < 30 and a higher physical capacity are favourable in terms of left atrial function in children and young adults with type 1 diabetes mellitus. Left atrial strain by echocardiography might become a new important tool in assessing heart function in T1DM.

Quality of glycemic control has significant impact on myocardial mechanics in type 1 diabetes mellitus

The potential associations between disease duration, glycemic control, and the echocardiographic markers of the myocardial mechanics were investigated in asymptomatic T1DM patients. Seventy T1DM patients (38.2 ± 11.7 years, 46 female) and 30 healthy volunteers were investigated. Besides the conventional and tissue Doppler measurements, left ventricular global longitudinal (GLS) and circumferential (GCS) strain as well as left and right atrial strain parameters were measured with 2D speckle tracking technique. Median HbA_1c level was 7.4 (1.8)%. Even when added age and hypertension to the model, current HbA1c level remained independent predictor of left ventricular GLS (p = 0.002), GCS (p < 0.001), mitral e' (p = 0.018), tricuspid e' (p = 0.018) and left (p = 0.039) and right atrial conduit strain (p = 0.047) in multiple linear regression models. Correlations between disease duration and the echocardiographic variables lost their significance in multiple models. In patients with a combination of HbA_1c ≤ 7.4% and no hypertension, echocardiographic findings did not differ from those in healthy volunteers. Patients with HbA_1c > 7.4% and no hypertension and especially patients with coexisting hypertension and HbA_1c > 7.4%, exhibited significantly impaired myocardial mechanics. Quality of glycemic control has a significant impact on myocardial mechanics in T1DM patients. Regarding disease duration this relationship was not proved.

Left Atrial Volumetric and Functional Properties in Hemophilia - Insights from a Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Path Study

Introduction

Hemophilia is an inherited disorder due to deficiencies in factor VIII (type A) and factor IX (type B). Abnormalities in myocardial mechanics could be theorized due to hemophilia-associated hypocoagubility and related quantitative and qualitative changes of the blood. The present study aimed a detailed assessment of left atrial (LA) volumetric and functional properties in patients with hemophilia using three-dimensional speckle-tracking echocardiography (3DSTE).

Materials and Methods

The study consisted of 12 subjects with hemophilia type A and 2 cases with hemophilia type B (mean age: 40.8 ± 19.1 years, all males). Results of hemophilia patients were compared to that of 23 age-, gender- and risk factor-matched controls (42.4 ± 9.0 years, all males). Routine two-dimensional Doppler echocardiography and 3DSTE were performed in all subjects.

Results

LA volumes respecting cardiac cycle did not differ between controls and hemophilia patients. From LA volume-based functional properties, LA stroke volumes were similar between the groups examined in all phases of LA function. While total atrial emptying fraction featuring LA reservoir function was reduced in patients with hemophilia compared to that of controls, passive and active atrial emptying fraction characterizing LA conduit and booster pump functions were similar between the groups. From LA strains, peak mean segmental circumferential and longitudinal LA strains were impaired in patients with hemophilia, other peak LA strains were similar between the groups. LA strains at atrial contraction did not differ between groups of hemophilia patients and controls.

Conclusions

Hemophilia is not associated with LA volumetric changes, but mild LA functional abnormalities are present.

Cardiac Imaging for the Assessment of Left Atrial Mechanics Across Heart Failure Stages

The left atrium (LA) is emerging as a key element in the pathophysiology of several cardiac diseases due to having an active role in contrasting heart failure (HF) progression. Its morphological and functional remodeling occurs progressively according to pressure or volume overload generated by the underlying disease, and its ability of adaptation contributes to avoid pulmonary circulation congestion and to postpone HF symptoms. Moreover, early signs of LA dysfunction can anticipate and predict the clinical course of HF diseases before the symptom onset which, particularly, also applies to patients with increased risk of HF with still normal cardiac structure (stage A HF). The study of LA mechanics (chamber morphology and function) is moving from a research interest to a clinical application thanks to a great clinical, prognostic, and pathophysiological significance. This process is promoted by the technological progress of cardiac imaging which increases the availability of easy-to-use tools for clinicians and HF specialists. Two-dimensional (2D) speckle tracking echocardiography and feature tracking cardiac magnetic resonance are becoming essential for daily practice. In this context, a deep understanding of LA mechanics, its prognostic significance, and the available approaches are essential to improve clinical practice. The present review will focus on LA mechanics, discussing atrial physiology and pathophysiology of main cardiac diseases across the HF stages with specific attention to the prognostic significance. Imaging techniques for LA mechanics assessment will be discussed with an overlook on the dynamic (under stress) evaluation of the chamber.

Left atrial function in diabetes: does it help?

Left atrial (LA) structural, functional and mechanical changes have important role in development of diabetic cardiomyopathy and it was discovered that LA remodeling has important prognostic role in the patients with diabetes (DM). Previously the focus of echocardiographic studies in DM population was on the left ventricular structure and function, but the atrioventricular coupling was proved to be one of the main predictors of cardiovascular morbidity and mortality in DM patients. Each phase of LA cycle has determinant role in the atrioventricular coupling and therefore the accurate assessment of LA phasic function gained importance over last decade. The failure of any of the three LA phasic functions (reservoir, conduit or contractile) leads potentially to LA dilatation, left ventricular diastolic dysfunction, atrial fibrillation and ultimately development of heart failure with preserved (or even reduced) ejection fraction. Even though LA phasic function has not been extensively studied in DM population, it is reasonable to hypothesize that LA dysfunction is very frequent in these patients, considering the high prevalence of atrial fibrillation and heart failure in these individuals. In research and clinical purposes two techniques have been used for determination of LA phasic function: volumetric and strain. Although these methods fundamentally differ, with their own advantages and limitations, they also provide comparable results that can direct our therapeutic approach in DM patients. Namely, not only that LA function represents an independent predictor of cardiovascular outcome in DM patients, but also it has been also associated with parameters of glycemic control. This review summarized the current knowledge regarding LA phasic function in DM patients.

Contribution of Modern Echocardiographic Techniques in the Detection of Subclinical Heart Dysfunction in Young Adults with Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease affects about 30% of the population and it has a growing tendecy with the increasing incidence of obesity. Currently, a large amount of clinical evidence has shown that cardiovascular disease represents the main cause of mortality in patients suffering from non-alcoholic fatty liver disease.

OBJECTIVE

In this study we investigated the structural and functional changes of the left ventricle in young adults with hepatic steatosis using modern echocardiographic techniques.

METHODS

By using tissue Doppler imaging and also Speckle tracking echocardiography the left ventricle systolic function was assessed.

RESULTS

All patients included in the study had a normal left ventricular ejection fraction but, when the longitudinal function of the left ventricle was assessed using the tissue Doppler technique (maximum systolic velocity S) statistically significant differences were found in both the group of patients with non-alcoholic fatty liver as well as in the group of patients associated with diabetes. Using speckle tracking echocardiography, we found a statistically significant decrease of the global longitudinal strain in the endocardium, in the group of patients with non-alcoholic liver disease but also in the group of those with diabetes. The overall longitudinal strain at the myocardium was significantly reduced only in the group of patients with non-alcoholic fatty liver disease and diabetes, while the overall longitudinal strain at the epicardium showed no changes in any of the groups studied. Also, no changes were observed at the circumferential strain.

CONCLUSION

Non-alcoholic fatty liver disease, diagnosed in asymptomatic young adults may be a risk factor for remodeling the left ventricle over time, being associated with subclinical myocardial dysfunction, regardless of the presence of other cardiovascular risk factors.

Normal reference values of three-dimensional speckle-tracking echocardiography-derived left atrial strain parameters (results from the MAGYAR-Healthy Study)

Left atrial (LA) size and function have been demonstrated to be important imaging biomarkers with powerful potential in predicting clinical outcome in several disorders. The angle-independent three-dimensional (3D) speckle-tracking echocardiography (3DSTE) has a capability for quantitative assessment of LA volumes and strains in 3D space at the same time from the same 3D acquired datasets. Therefore, the objective of the present study was to define normal values of 3DSTE-derived LA strains in healthy subjects. It was also examined whether there is any age- and gender-dependency of these parameters. The present study comprised 309 healthy volunteers, from which 87 were excluded due to inadequate image quality. The remaining group consisted of 222 subjects (mean age: 36.3 ± 13.7 years, 112 males). Complete two-dimensional echocardiography and 3DSTE have been performed in all cases. Peak circumferential strain (CS) increased with age with a decline > 50 years in females, in males CS remained almost unchanged. While peak longitudinal strain (LS) increased with age with unchanged parameters > 50 years, parallel increase in peak area strain (AS) with age could be demonstrated in both genders with a decline in females > 50 years. While CS and AS at atrial contraction increased with age in females, parallel decrease could be demonstrated in males. LS at atrial contraction increased with age especially in females. Normal values of 3DSTE-derived LA peak strains and strains at atrial contraction are demonstrated together with their age- and gender-dependency.

Left Atrial Deformation Analysis in Patients with Corrected Tetralogy of Fallot by 3D Speckle-Tracking Echocardiography (from the MAGYAR-Path Study)

Background

Three-dimensional (3D) echocardiography coupled with speckle-tracking echocardiographic (STE) capability is a novel methodology which has been demontrated to be useful for the assessment of left atrial (LA) volumes and functional properties. There is increased scientific interest on myocardial deformation analysis in adult patients with corrected tetralogy of Fallot (cTOF).

Objectives

To compare LA volumes, volume-based functional properties and strain parameters between cTOF patients and age- and gender-matched healthy controls.

Methods

The study population consisted of 19 consecutive adult patients with cTOF in sinus rhythm nursing at the University of Szeged, Hungary (mean age: 37.9 ± 11.3 years, 8 men, who had repair at the age of 4.1 ± 2.5 years). They all had undergone standard transthoracic two-dimensional Doppler echocardiographic study extended with 3DSTE. Their results were compared to 23 age- and gender-matched healthy controls (mean age: 39.2 ± 10.6 years, 14 men).

Results

Increased LA volumes and reduced LA emptying fractions respecting cardiac cycle could be demonstrated in cTOF patients compared to controls. LA stroke volumes featuring all LA functions showed no differences between the 2 groups examined. LA global and mean segmental uni- and multidirectional peak strains featuring LA reservoir function were found to be diminished in adult patients with cTOF as compared to controls. Similarly to peak strains reduced global and mean segmental LA strains at atrial contraction characterizing atrial booster pump function could be demonstrated in cTOF patients as compared to controls.

Conclusions

Significant deterioration of all LA functions could be demonstrated in adult patients with cTOF late after repair.