Two-dimensional speckle-tracking echocardiography in left ventricular systolic function in patients with systemic lupus erythematosus

OBJECTIVES

To investigate whether two-dimensional speckle-tracking echocardiography (2DSTE) can be considered a criterion for early left ventricular (LV) systolic impairment in patients with systemic lupus erythematosus (SLE) and to further explore the association with each other.

METHODS

We included 38 patients with SLE and assessed the degree of disease activity according to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2000 scoring criteria, together with 38 healthy controls who were matched by sex and age. Routine LV systolic function evaluation parameters were obtained by echocardiography as well as 2DSTE measurement of LV strain parameters to obtain global longitudinal strain (GLS) values, respectively.

RESULTS

(I) On routine LV function parameters such as ejection fractions (EF) and left ventricular end-diastolic internal diameter (LVIDd), the SLE group and the control group did not reflect differences. In contrast, on the LV strain parameter obtained from 2DSTE measurements, the GLS values in all cardiac planes were lower in the SLE group than in the control group and showed statistically significant differences. (II) Correlation analysis showed that there was a correlation between SLEDAI and GLS, especially a meaningful correlation with GLS Avg and GLS A4C, with correlation coefficients of 0.35 and 0.47, respectively.

CONCLUSIONS

The use of 2DSTE can detect early impaired LV systolic function in SLE patients, and GLS is progressively gaining attention as an indicator of subclinical myocardial injury and LV function in SLE patients. The correlation that exists between GLS and SLEDAI might contribute to a better assessment of cardiac involvement in SLE patients. Key Points • Cardiac involvement has become one of the major factors in the poor prognosis of SLE patients, which directly affects the mortality of SLE patients. Traditional echocardiography is difficult to detect early left ventricular function impairment, thus affecting clinicians' judgment and diagnosis. • 2DSTE can recognize subclinical myocardial injury in SLE patients at an early stage, and its derived strain parameters may be used as an indicator to evaluate myocardial involvement and reflect disease activity in SLE patients.

Role of automated functional imaging and myocardial work in assessment of cardiac function in children with obstructive sleep apnea

BACKGROUND

Early identification of abnormal left ventricular function in children with obstructive sleep apnea (OSA) is difficult using conventional echocardiographic indices and commonly used clinical markers of myocardial damage. We sought to investigate the value of automatic function imaging and myocardial work parameters in predicting early cardiac impairment in children having OSA with preserved left heart function and thereby identifying an optimal index for assessment.

PATIENTS AND METHODS

Fifty-two children who presented with symptoms of nocturnal sleep snoring and open-mouth breathing and 34 healthy controls were enrolled in this study. Clinical characteristics and conventional echocardiographic data were collected, and image analysis was performed using two-dimensional speckle-tracking echocardiography to obtain left ventricular global longitudinal strain (GLS), post-systolic index, peak strain dispersion, global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency.

RESULTS

Children with OSA had significantly lower GLS, GWI, and GCW than those without (P < 0.05). Additionally, GWI (β = -32.87, 95% CI: -53.47 to -12.27), and GCW (β = -35.09, 95% CI: -55.35 to -14.84) were found to correlate with the disease severity in the multiple linear regression mode, with worsening values observed as the severity of the disease increased. ROC curve analysis revealed that GCW was the best predictor of myocardial dysfunction, with an AUC of 0.809 (P < 0.001), and the best cutoff point for diagnosing myocardial damage in children with OSA was 1965.5 mmHg%, with a sensitivity of 92.5% and a specificity of 58.7%.

CONCLUSIONS

GLS, GWI, and GCW were identified as predictors of myocardial dysfunction in children with OSA, with GCW being the best predictor.

Global longitudinal strain assessment in contrast-enhanced echocardiography in breast cancer patients: a feasibility study

BACKGROUND

Left ventricular global longitudinal strain (GLS) obtained from two-dimensional speckle-tracking echocardiography (2D-STE) can reflect cancer therapy-related cardiac dysfunction in breast cancer (BC) patients, however, the accuracy and reproducibility of 2D-STE are restricted due to poor image quality.

METHODS

Between January 2019 and October 2021, 160 consecutive BC patients aged ≥ 18 years were recruited. The 160 BC patients (mean age: 48.41 ± 9.93 years, 100% women) underwent both 2D-STE and Contrast-enhanced echocardiography (CEcho), 125 of whom were included in the measurement of GLS. The intraclass correlation coefficient (ICC) was used to determine the intra- and inter-observer reproducibility of 2D-STE and CEcho-STE. Correlation (r) was calculated using Pearson correlation. Statistical significance was set at P < 0.05.

RESULTS

Among 160 BC patients, more segments were recognized by CEcho-STE than by 2D-STE (2,771, 99.53% vs. 2,440, 84.72%). The left ventricular ejection fraction (LVEF) obtained by 2D was lower than CEcho (61.75 ± 6.59% vs. 64.14 ± 5.97%, P < 0.0001). The GLS obtained by 2D-STE was lower than CEcho-STE (-21.74 ± 2.77% vs. -26.79 ± 4.30%, P = 0.001). The ICC of the intraobserver and interobserver agreements in the CEcho-STE group was lower than that in the 2D-STE group. GLS measurements were in good agreement between the 2D-STE and CEcho-STE groups (r = 0.773).

CONCLUSIONS

CEcho can overcome some imaging limitations and recognize more segments than 2D, which may provide an LVEF and GLS closer to the true value. Based on AutoStrain, CEcho-STE may serve as a complementary method for those with poor image quality.

Correlation between Heart rate recovery and Left Atrial phasic functions evaluated by 2D speckle-tracking Echocardiography after Acute Myocardial infarction

BACKGROUND

Heart rate recovery (HRR) in the exercise test is the index of cardiac autonomic system function and sympathovagal balance impaired in patients with myocardial infarction (MI). An instance is left atrial (LA) phasic function, which is impaired in such patients. In this study, we investigated the role of HRR in predicting LA phasic functions in patients with MI.

METHODS

The present study recruited 144 consecutive patients with ST-elevation MI. A symptom-limited exercise test was performed about 5 weeks after MI, with echocardiography conducted just before the exercise test. The patients were divided into abnormal and normal HRR at 60 s (HRR60) and again into abnormal and normal HRR at 120 s (HRR120) after the exercise test. LA phasic functions, evaluated by 2D speckle-tracking echocardiography, were compared between the 2 groups.

RESULTS

Patients with abnormal HRR120 had lower LA strain values and strain rates during the reservoir, conduit, and contraction phases, while those with abnormal HRR60 had lower LA strain values and strain rates during the reservoir and conduit phases. The differences were lost after adjustments for possible confounders, except for LA strain and strain rate during the conduit phase, in patients with abnormal HRR120.

CONCLUSIONS

Abnormal HRR120 in the exercise test can independently predict decreased LA conduit function in patients with ST-elevation MI.

Assessment of left atrial deformation in patients with total anomalous pulmonary venous connection by two-dimensional speckle-tracking echocardiography

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital heart disease of newborns characterized by impaired left ventricle growth and diastolic dysfunction. We hypothesized that the patients with TAPVC reduced blood flow into the left heart prenatally could affect left atrium (LA) not just growth but function. We compared the age-related changes in LA deformation using two-dimensional speckle-tracking echocardiography (2DSTE) in Patients with TAPVC.

METHOD

This single-center, retrospective cohort study was conducted on consecutive isolated TAPVC patients who underwent neonatal surgery between January 1, 2009 and January 1, 2022. The LA datasets in TAPVC patients were analyzed before surgery (n = 28) and follow-ups at 1-2 (n = 24) and 5-7 years of age (n = 13) and compared with those of age-matched healthy controls (January 2009-2022). The LA strain (ε), indicating LA function, was analyzed using QLAB represented by reservoir (εR), conduit (εCD), and contractile (εCT) strains. LA pressure was evaluated by periodic follow-up catheterization after repair.

RESULTS

Compared to the controls, the TAPVC patients had significantly smaller LA maximum volume preoperatively, and with age, the LA maximal volumes reached normal levels, while the LA minimal volumes were larger. All 2DSTE-determined LA strains showed significant reductions at all time points in the TAPVC group compared to those in the control (median εR, εCD, and εCT; before surgery: 17.0% vs. 26.0%, 12.9% vs. 15.9%, and 6.3% vs. 10.4%; follow-up at 1-2 years: 30.0% vs. 45.7%, 23.2% vs. 29.6%, and 6.1% vs. 16.3%; follow-up at 5-7 years: 31.2% vs. 43.1%, 25.0% vs. 31.2%, and 5.2% vs. 10.8%, respectively; p < 0.05). Only εCT did not represented a significant change over time even though after correction of blood flow (median εCT: 6.0% → 5.9%). Patients with pulmonary venous obstruction (PVO) at birth showed significantly decreased εR and εCD and higher LA pressure compared to those without PVO.

CONCLUSION

This study showed that nevertheless maximum volume of LA was recovered within the normal range, reduced LA strains, especially contractile function lasted from birth even after repair in Patients with TAPVC.

Effects of obesity on left atrial phasic functions in patients with chronic ischemic heart disease and preserved left ventricular ejection fraction without recent myocardial infarction: a two-dimensional speckle-tracking echocardiography study

PURPOSE

Left atrial (LA) phasic functions in various subgroups of subjects with obesity are differently impaired, suggesting that obesity may have diverse effects in dissimilar subgroups of subjects with obesity. We aimed to compare the effects of obesity on LA phasic functions in patients suffering from chronic ischemic heart disease with a preserved left ventricular ejection fraction and without a recent myocardial infarction.

METHODS

In our cross-sectional study, 145 consecutive candidates for isolated coronary artery bypass graft (CABG) surgery were divided according to the presence of obesity into 2 groups: obese (36 patients) and nonobese (103 patients), and LA phasic functions were evaluated by two-dimensional speckle-tracking echocardiography (2D STE).

RESULTS

The longitudinal strain rate during the reservoir phase (3.0 ± 0.7 s-1 vs 2.7 ± 0.6 s-1; P = 0.032), longitudinal strain during the contraction phase (19.2 ± 4.7% vs 17.2 ± 4.1%; P = 0.022), and the longitudinal strain rate during the contraction phase (4.4 ± 1.2 s-1 vs 3.9 ± 1.2 s-1; P = 0.036) decreased in the obese group compared with the nonobese group. The other longitudinal 2D STE-derived markers of the LA phasic functions were not different between the 2 groups.

CONCLUSIONS

Among patients suffering from chronic ischemic heart disease with a preserved left ventricular ejection fraction and without a recent myocardial infarction, LA reservoir and contraction functions as measured by 2D STE were impaired in patients with obesity compared with those without it.

Myocardial strain measured via two-dimensional speckle-tracking echocardiography in a family diagnosed with arrhythmogenic left ventricular cardiomyopathy

BACKGROUND

Arrhythmogenic cardiomyopathy is a myocardial disorder characterized by ventricular arrhythmias, right and/or left ventricular involvement, and fibrofatty infiltrations in the myocardium. We report a family diagnosed with arrhythmogenic left ventricular cardiomyopathy (ALVC) and depict their echocardiographic characteristics.

METHODS AND RESULTS

Fifteen family members were divided into three groups based on whether they carried the TMEM43 mutation and had been diagnosed with ALVC. Eight of them had TMEM43 mutations, and four were diagnosed with ALVC according to the Padua criteria. Only the proband experienced sudden cardiac death and had a dilated left ventricle. Left ventricular ejection fraction was reduced in two patients; however, left ventricular global longitudinal strain was depressed in three patients. Low QRS voltages in limb leads were evident in three patients, and five patients had frequent ventricular premature contractions. Late gadolinium enhancement was evident in three patients. Left ventricular layer-specific strain showed that the transmural strain gradient ratio was increased in patients diagnosed with ALVC, and it was elevated in the genotype-positive and phenotype-negative groups compared with healthy individuals.

CONCLUSION

Global left ventricular longitudinal strain better evaluated left ventricular function than left ventricular ejection fraction. The transmural strain gradient ratio was elevated in patients diagnosed with ALVC, suggesting that it was useful for the evaluation of ALVC.

Peak strain dispersion within the left ventricle detected by two-dimensional speckle tracking in patients with uncomplicated systemic lupus erythematosus

Systemic lupus erythematosus (SLE) often leads to various cardiovascular diseases. We aimed to investigate the value of peak strain dispersion (PSD) in evaluating left ventricular dysfunction in patients with uncomplicated SLE. Eighty-seven female SLE patients and fifty-nine healthy female controls were recruited. The SLE patients were divided into inactive disease (SLE disease activity index (SLEDAI) ≤ 4; n = 48) and active disease (SLEDAI ≥ 5; n = 39) subgroups. Traditional echocardiography and two-dimensional speckle-tracking echocardiography were performed using a GE VividE9 ultrasound diagnostic system and an advanced quantitative analysis EchoPAC workstation (version 201), respectively. The global longitudinal strain (GLS) in the SLE with SLEDAI ≤ 4 group was comparable to that in the control group (- 19.89% vs - 20.7%; P = 0.061). However, GLS was obviously damaged in the SLE with SLEDAI ≥ 5 group compared with that in the control group (- 19.07% vs - 20.7%; P < 0.001). PSD impairment was observed in the SLE with SLEDAI ≤ 4 group (33.83 ms vs 31.44 ms; P = 0.012) and SLE with SLEDAI ≥ 5 groups (52.31 ms vs 31.44 ms; P < 0.001), but the largest difference was observed in the active disease group. Linear regression analysis showed that PSD was moderately correlated with the SLEDAI (r = 0.535; P < 0.001) in SLE patients with SLEDAI ≤ 4 and showed the best correlation with the SLEDAI (r = 0.646; P < 0.001) in the SLE patients with SLEDAI ≥ 5. A correlation between GLS and the SLEDAI (r = 0.359; P = 0.025) was found in the active disease group but not in the inactive disease group (r = 0.253; P = 0.082). PSD is more comprehensive and accurate for evaluating left ventricular subclinical dysfunction in SLE patients. In inactive SLE patients, PSD is a more sensitive index to evaluate early systolic dysfunction of the left ventricle. GLS may be a more vulnerable indicator of early left ventricular cardiac dysfunction in active SLE patients. Controlling disease activity may reduce the events of cardiac dysfunction.

Assessment of the ability of the CHA2DS2-VASc scoring system to grade left atrial function by 2D speckle-tracking echocardiography

Background

The CHA₂DS₂-VASc scoring system is correlated with left atrial (LA) reservoir function in patients with atrial fibrillation (AF) rhythm or paroxysmal AF. We assessed the ability of CHA₂DS₂-VASc to grade LA function in patients with sinus rhythm who were candidates for coronary artery bypass grafting (CABG).

Methods

This cross-sectional study recruited 340 consecutive candidates for CABG and categorized them according to their CHA₂DS₂-VASc scores as mild-, moderate-, and high-risk score groups with 34 (10%), 83 (24%), and 223 (66%) patients, respectively. LA function was evaluated via 2D speckle-tracking echocardiography in terms of global longitudinal strain and strain rate during the reservoir, conduit, and contraction phases. In-hospital mortality, postoperative AF, prolonged intensive care unit (ICU) stay, and prolonged mechanical ventilation were assessed.

Results

LA strain and strain rate during the reservoir phase was statistically significantly lower in the high-risk score group than the low- and moderate-risk score groups (27.8 ± 6.9% vs 31.0 ± 5.0% vs 29.8 ± 6.1%, respectively; P = 0.004 and 2.6 ± 0.7 s⁻¹ vs 2.9 ± 0.6 s⁻¹ vs 2.9 ± 0.6 s⁻¹, correspondingly; P = 0.009) and regarding LA strain and strain rate during the conduit phase (9.7 [7.1–12.5]% vs 12.9 [9.4–15.1]% vs 11.5 [9.1–13.8]%, correspondingly; P < 0.001 and 2.1 [1.6–2.7] s⁻¹ vs 2.8 [2.4–3.6] s⁻¹ vs 2.6 [2.2–3.0] s⁻¹, respectively; P < 0.001). In addition, LA strain rate during the conduit phase was lower in the moderate-risk score group than the low-risk score group. After adjustments for possible confounders, these differences remained statistically significant. The risk of postoperative AF and prolonged ICU stay was highest in the high-risk score group (relative risk = 9.67 (1.31–71.43) and 8.05 (1.08–60.16), respectively; P = 0.026 and P = 0.042, respectively).

Conclusions

LA reservoir and conduit functions decreased in the high-risk score group, which was accompanied by an increased risk of postoperative AF and prolonged ICU stay.

Evaluation of the left atrial function by two-dimensional speckle-tracking echocardiography in diabetic patients with obesity

Obesity and diabetes are risk factors for atrial cardiomyopathy and are, thus, deemed public health concerns. However, the effects of obesity on the left atrial (LA) function in patients with diabetes have not been determined yet. We sought to evaluate the effects of obesity on the LA function in patients with type 2 diabetes. Ninety-six consecutive patients with type 2 diabetes without significant coronary artery stenosis in selective coronary angiography were included in this cross-sectional study. Two-dimensional speckle-tracking echocardiography (2DSTE)-derived longitudinal LA myocardial deformation markers were compared between 42 obese and 54 nonobese patients. The longitudinal strain and the longitudinal strain rate of the LA myocardium during the reservoir phase and the contraction phase were reduced in the obese patients with diabetes compared with the nonobese patients with diabetes in the unadjusted analysis. In the adjusted analysis, longitudinal strain and the longitudinal strain rate during the contraction phase and the longitudinal strain rate during the reservoir phase were decreased in the obese patients with diabetes. The reservoir and contraction functions of the LA as evaluated by 2DSTE were decreased in our obese patients with diabetes compared with our nonobese patients with diabetes.

Impaired myocardial deformation and ventricular vascular coupling in obese adolescents with dysglycemia

Background

It is unknown that dysglycemia in obese adolescents has effects on myocardial deformation that are more pronounced when compared to obesity alone. We hypothesized that obesity associated abnormal glucose tolerance (dysglycemia) would have adverse effects on two-dimensional speckle tracking echocardiography derived longitudinal, radial and circumferential strain (LS, RS, CS) compared to age and gender lean controls. We also examined if changes in deformation would be reflected in abnormal ventricular vascular coupling indices (VVI).

Methods

In a prospective cross-sectional design 39 obese adolescents (15.9 ± 1.7 years; 101.5 ± 39 kg; female − 58%) were compared to age and gender matched lean controls (15.7 ± 1.8 yrs, 60 ± 12.8 kg). Based on results from an oral glucose tolerance test (OGTT), obese adolescents were categorized as obese normoglycemic (ONG, n = 25) or obese dysglycemic (ODG, n = 14). Left ventricular (LV) global and average LS, CS, RS and strain rate were measured. LV ejection fraction and mass index were measured and VVI approximated as ratio of arterial elasticity (Ea) and end-systolic elastance (Ees).

Results

Adolescents with ODG had significantly (P = 0.005) impaired global LS (− 20.98% ± 2.8%) compared to controls (− 23.01% ± 2.3%). A similar (P = 0.0027) reduction was observed in average LS for adolescents with ODG (18.87% ± 2.5%) compared to controls (20.49% ± 2%). Global CS was also decreased (P = 0.03) in ODG (− 23.95%) compared to ONG (− 25.80). A similar trend was observed in average CS after multivariate regression for BMI and blood pressure. CS correlated with HbA1c in both groups (P = 0.05). VVI had a negative correlation with both LS (r = − 0.4, P = 0.025) and CS rate (r = − 0.36, P = 0.04).

Conclusions

Myocardial strain and strain rate were significantly altered in obese adolescents. Unfavorable subclinical reductions in global and average CS were more pronounced in adolescents with dysglycemia compared to obese adolescents with normoglycemia and controls. These data indicate progressive worsening of subendocardial function across the spectrum of glucose tolerance. Strain rate was predictive of VVI in obese adolescents, suggesting strain rate may be a sensitive marker for cardiac remodeling in abnormal glucose homeostasis states.

Echocardiographic Assessment for the Detection of Cardiotoxicity Due to Vascular Endothelial Growth Factor Inhibitor Therapy in Metastatic Renal Cell and Colorectal Cancers

BACKGROUND

Cardio-oncology is a recently established discipline that focuses on the management of patients with cancer who are at risk for developing cardiovascular complications as a result of their underlying oncologic treatment. In metastatic colorectal cancer (mCRC) and metastatic renal cell carcinoma (mRCC), vascular endothelial growth factor inhibitor (VEGF-i) therapy is commonly used to improve overall survival. Although these novel anticancer drugs may lead to the development of cardiotoxicity, whether early detection of cardiac dysfunction using serial echocardiography could potentially prevent the development of heart failure in this patient population requires further study. The aim of this study was to investigate the role of two-dimensional speckle-tracking echocardiography in the detection of cardiotoxicity due to VEGF-i therapy in patients with mCRC or mRCC.

METHODS

Patients with mRCC or mCRC were evaluated using serial echocardiography at baseline and 1, 3, and 6 months following VEGF-i treatment.

RESULTS

A total of 40 patients (34 men; mean age, 63 ± 9 years) receiving VEGF-i therapy were prospectively recruited at two academic centers: 26 (65%) were receiving sunitinib, eight (20%) pazopanib, and six (15%) bevacizumab. The following observations were made: (1) 8% of patients developed clinically asymptomatic cancer therapeutics-related cardiac dysfunction; (2) 30% of patients developed clinically significant decreases in global longitudinal strain, a marker for early subclinical cardiac dysfunction; (3) baseline abnormalities in global longitudinal strain may identify a subset of patients at higher risk for developing cancer therapeutics-related cardiac dysfunction; and (4) new or worsening hypertension was the most common adverse cardiovascular event, afflicting nearly one third of the study population.

CONCLUSIONS

Cardiac dysfunction defined by serial changes in myocardial strain assessed using two-dimensional speckle-tracking echocardiography occurs in patients undergoing treatment with VEGF-i for mCRC or mRCC, which may provide an opportunity for preventive interventions.

Prediction of Outcomes in Patients with Chronic Ischemic Cardiomyopathy by Layer-Specific Strain Echocardiography: A Proof of Concept

BACKGROUND

Cardiac magnetic resonance imaging (CMR) has been established as a powerful tool for predicting mortality. However, its application is limited by availability and various contraindications. The aim of this study was to evaluate the predictive value of layer-specific myocardial deformation analysis as assessed by strain echocardiography for cardiac events in patients with chronic ischemic left ventricular dysfunction in comparison with CMR.

METHODS

Three hundred ninety patients (mean age, 63 ± 4 years; 69% men; mean left ventricular ejection fraction [LVEF], 41 ± 7%) with chronic ischemic cardiomyopathy were prospectively enrolled and underwent strain echocardiography and CMR within 3 ± 1 days. LVEF, wall motion score index, and circumferential strain (CS), longitudinal strain, and radial strain for total wall thickness and for three myocardial layers (endocardial, midmyocardial, and epicardial) were determined by echocardiography. The extent of total myocardial scar (TMS) was determined by CMR. Follow-up was obtained for a mean of 4.9 ± 2.2 years. Cardiac events were defined as readmission for worsening of heart failure, ventricular arrhythmias, or death of any cause. The incremental value of LVEF, strain parameters, and TMS to relevant clinical variables was determined in nested Cox models.

RESULTS

There were 133 cardiac events (34%). Baseline clinical data associated with outcomes were age (hazard ratio [HR], 1.27; P = .04), diabetes mellitus (HR, 1.52; P = .001), and renal insufficiency (HR, 1.77; P = .001) by multivariate analysis. The addition of LVEF, global and endocardial strain parameters, and TMS increased the predictive power, but endocardial CS (HR, 1.52; P < .01) caused the greatest increment in model power (χ(2) = 39.2, P < .001). Endocardial CS < -20% was found to be the optimal predictor of prognosis.

CONCLUSIONS

Endocardial CS is a powerful predictor of cardiac events and appears to be a better parameter than LVEF, TMS by CMR, and other strain variables by echocardiography.