Unified adult transthoracic echocardiographic report: an expert consensus document of the Egyptian Working Group of Echocardiography.

BACKGROUND: Physicians face complexity in interpreting the results of echocardiography (ECHO) due to the variability across ECHO laboratories. Many international organizations published reports to reduce the inter-variability in ECHO reporting. However, with the evolution of imaging modalities, significant improvements in ECHO reporting are essential to eliminate any previous discrepancies. The Egyptian Working Group of Echocardiography (EEWG) aimed to prepare a standardized, updated, simple, and comprehensive ECHO reporting in Egypt to offer consistency, guarantee that all the crucial features are fulfilled, and ease practitioners' communication to maximize clinical decision-making. MAIN TEXT: Relevant articles were retrieved and reviewed to explore the current state of TTE reporting practices, existing guidelines, and challenges faced by physicians in interpreting TTE results. Identified gaps and areas for improvement were then employed to establish the outline for the standardization approach. This report addresses crucial components such as demographic data, measurements, and interpretative summaries. It emphasizes left ventricle measurements and systolic function assessment, incorporating advanced techniques like speckle tracking and three-dimensional imaging. The significance of evaluating diastolic function, examining the right ventricle, and assessing valves, pericardium, and aorta are also discussed. CONCLUSION: The current consensus goals to streamline communication among practitioners contribute to a more unified approach to interpreting ECHO results. Our initiative marks a significant step forward in enhancing the standardization and quality of ECHO reporting in Egypt. By introducing this report and encouraging continuous learning, the working group aims to raise the overall reporting quality and facilitate interpretation across diverse echocardiographic settings. This concerted effort improves patient care by ensuring consistency, accuracy, and relevance in interpreting echocardiographic findings.

Boosting protection for patients with non-acute cardiovascular disease: a focus on antithrombotic regimen (a consensus expert opinion from the Egyptian Society of Cardiology working group of thrombosis and prevention).

BACKGROUND: Till the moment of this document writing, no Egyptian consensus is there to guide selection of additional antithrombotic in stable patients with established CVD. Despite use of lifestyle measures and statins, those patients with established CVD still face a considerable burden of residual risk. MAIN BODY: With the evolvement of evidence-based medicine, there have been a lot of recommendations to use additional antithrombotic medications to maximize protection for those patients. Accordingly, the Egyptian Society of Cardiology working group of thrombosis and prevention took the responsibility of providing an expert consensus on the current recommendations for using antithrombotic medications to maximize protection in stable patients with established CVD. For stable patients with established CVD, in addition to proper lifestyle measures and appropriate dose statins, we recommend long-term aspirin therapy. In patients who are unable to take aspirin and in those with a history of gastrointestinal bleeding, clopidogrel is a reasonable alternative. CONCLUSIONS: For some stable atherosclerotic CVD patients who are at high risk of cardiovascular events and at low risk for bleeding, a regimen of rivaroxaban and aspirin might be taken into consideration.

Egyptian practical guidance in lipid management 2020.

BACKGROUND: Numerous epidemiological investigations and randomized clinical studies have determined that dyslipidemia is a major contributor to atherosclerotic cardiovascular disease (ASCVD). Consequently, the management of serum cholesterol and low-density lipoprotein levels has become a central objective in the effort to prevent cardiovascular events. MAIN BODY: Many guidelines were issued by different organizations and societies to define patient risk and establish important recommendations for management strategies. Newer cholesterol-lowering agents (non-statin drugs) are described, and their use is directed primarily to secondary prevention in patients at very high risk of new ASCVD. CONCLUSION: The present guidance summarizes the current methods for risk estimation and outlines the most recent data on lipid management in a simple user-friendly format, to improve physician awareness and help implement guidelines in the daily practice.

Platelet/lymphocyte ratio for prediction of no-reflow phenomenon in ST-elevation myocardial infarction managed with primary percutaneous coronary intervention.

BACKGROUND: Coronary no-reflow phenomenon in ST-segment elevation myocardial infarction (STEMI) is associated with a poor clinical outcome. Although its pathophysiology is not fully understood, a deregulated systemic inflammatory response plays an important role. We aimed to explore the relationship between platelet\lymphocyte ratio (PLR) and no-reflow in patients with acute STEMI who were treated with a primary percutaneous coronary intervention (PPCI). METHODS: A total of 200 patients with STEMI undergoing PPCI were included in the study. Transthoracic echocardiographic examination was performed to assess left ventricular (LV) ejection fraction (EF) and wall motion score index. Blood samples were assayed for platelet and lymphocyte count before PPCI. No-reflow was defined as coronary blood flow thrombolysis in myocardial infarction grade ≤II. RESULTS: No-reflow was observed in 58 (29%) of STEMI patients following PPCI. PLR was significantly higher in hypertensive patients compared to normotensive patients (144.7±91.6 vs. 109.1±47.1, respectively, P<0.001) and in the no-reflow group compared to the normal reflow group (214±93 vs. 101.6±51.3, respectively, P<0.0001). Logistic regression analysis revealed that PLR (ß: 0.485, 95% CI: -0.006-0.001, P<0.002) and LV EF (ß: 0.272, 95% CI: 0.009-0.034, P<0.001) were independent predictors of no-reflow after PPCI. CONCLUSION: Pre-procedural increase in PLR is predictive of the no-reflow phenomenon following PPCI in STEMI patients. RELEVANCE FOR PATIENTS: No reflow phenomenon is an unfavorable complication following PPCI in patients with acute STEMI. High pre-procedural PLR is an independent predictor of reperfusion failure and helps to identify patients who require prophylactic treatment.

Effect of Short-Term L-Thyroxine Therapy on Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy.

OBJECTIVE: Previous experimental studies have provided evidence of notable changes in thyroid hormone signaling that corresponds to alterations in myocardial function in animal models of heart failure (HF). The present study further explores whether oral thyroid hormone treatment can change left ventricular (LV) mechanics and functional status in patients with idiopathic dilated cardiomyopathy (IDCM) or not. METHODS: Sixty IDCM patients who were receiving conventional HF treatment were randomized to oral L-thyroxine (n = 40) or placebo (n = 20) for 3 months. Fifty-two (86.7%) of all IDCM patients were symptomatic, their mean age was 41 ± 12 years, and their ejection fraction was 32% ± 7%. At baseline, the two groups were comparable in clinical and echocardiographic variables. Vector velocity imaging was utilized to assess LV mechanics. Myocardial longitudinal peak systolic strain, systolic strain rate, early and late diastolic strain rate, circumferential strain, LV dyssynchrony, plasma tri-iodothyronine, thyroxine, and thyroid stimulating hormone levels were measured at baseline and 3 months after treatment. RESULTS: All patients receiving L-thyroxine significantly improved in functional status (New York Heart Association class; P < .001) and echocardiographic parameters including end-diastolic diameter (P < .001), end-systolic diameter (P < .001), mitral regurgitation severity reduction (P < .001), and increased ejection fraction (P < .001). Left ventricular mechanics showed marked improvement at segmental and global levels of both longitudinal and circumferential myocardial strain (P < .005) when compared with placebo group. CONCLUSIONS: Short-term L-thyroxine therapy is well tolerated in IDCM patients. It improves cardiac mechanics and functional status, which might support the potential role of synthetic thyroid hormones in HF treatment.

Impact of the left anterior descending artery wrapping around the left ventricular apex on cardiac mechanics in patients with normal coronary angiography.

BACKGROUND: We examined the impact of left anterior descending (LAD) wrapping on left ventricular (LV) mechanics in patients with normal coronary angiography. Seventy-one patients with evidence of normal coronary angiography (LAD wrapping: n = 52, 73%) and LAD non-wrapping (n = 19, 27%) were included in the study. Using 2D-strain imaging, we measured LV longitudinal and circumferential (circ) strain (εsys), systolic strain rate (SRsys), early (SRe) and atrial (SRa) diastolic SR, LV electromechanical dyssynchrony (TTP-SD), and LV twist and torsion in study groups. RESULTS: No significant difference in age, gender, body surface area (BSA), or ejection fraction (EF%) between groups. LAD-wrapping group showed higher deceleration time (DT) (P < 0.0001), global longitudinal εsys % (P < 0.02), circ SRa at the basal segments (P < .02), circ SRsys and SRe, and SRa (P < 0.0001) at the apical segments and apical rotation compared with the non-wrapped group. LV twist was correlated negatively with LV electromechanical dyssynchrony (r = .25, P < 0.03) and positively with longitudinal εsys (r = .47, P < .0001), circ εsys% (r = .55, P < .0001), circ SRsys (r = .23, P < .05), and circ SRe (r = .55, P < .0001). Using multivariate regression analysis, DT: OR 0.932, CI 0.877-0.991, and P < 0.02 and circ at atrial diastole (SRa): OR 0.000, CI .000-.271, and P < 0.03 were independent predictors of LAD wrapping around LV apex. CONCLUSION: Wrapped LAD is associated with better myocardial relaxation and rotational mechanics in patients with normal coronary angiography. This could explain the worse prognosis in such population when LAD occlusion acutely emerges.

Clinical characteristics and in-hospital outcome of heart failure in women: a single center registry from Egyptian cardiac care unit.

BACKGROUND: This study represents figures from a cardiac care unit (CCU) of a university hospital; it describes an example of a tertiary academic center in Egypt and provides an epidemiological view of the female HF patients, their risk profile, and short-term outcome during hospitalization. RESULTS: It is a local single-center cross-sectional observational registry of CCU patients 1 year from July 2015 to July 2016. Patient's data were collected through a special software program. Women with evidence of HF were thoroughly studied. Among the 1006 patients admitted to CCU in 1 year, 345 (34.2%) patients were females and 118 (34.2%) had evidence of HF, whereas 661 (65.7%) were males and 178 (26.9%) of them had HF. Women with HF showed 11.7% prevalence of the total population admitted to CCU. 72.7% were HFrEF and 27.3% were HFpEF. Compared to men, women with HF were older in age, more obese, less symptomatic than men, had higher incidence of associated co-morbidities, less likely to be re-admitted for HF, and less likely to have ACS and PCI. Valvular heart diseases and cardiomyopathies were the commonest etiologies of their HF. Women had more frequent normal ECG, higher EF%, and smaller LA size. There is no difference in medications and CCU procedures. While females had shorter stay, there is no significant difference in hospital mortality compared to male patients. CONCLUSIONS: Despite higher prevalence of HF in females admitted to CCU and different clinical characteristics and etiology of HF, female gender was associated with similar prognosis during hospital course compared to male gender.

Prognostic significance of left ventricular end diastolic pressure using E/E' in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is a prominent feature of hypertrophic cardiomyopathy (HCM). Prediction of LV filling pressure using the ratio between early diastolic transmitral flow and mitral annular velocity (E/e') had proved a good accuracy. AIM OF THIS STUDY: We investigated the value of E/e' to predict cardiovascular (CV) mortality in patients with HCM. METHODS: A total of 243 patients with HCM had E/e' measured in combination with clinical evaluation, conventional echocardiographic measurements, cardiopulmonary exercise evaluation, and Holter monitoring. RESULTS: During a mean follow-up of (3.2 ± 1.2 years), 17 (7%) patients died. Non survivors had significantly higher SBP, DBP, left ventricular outflow tract obstruction (LVOTO) gradient, mitral E, and E/e', but lower e' of mitral annulus and more prevalent restrictive filling pattern. E/e' was directly correlated with age (r = .24, P < .005), left atrial volume index (r = .44, P < .0001), LVMI (r=0.23,P<.005), LVOT gradient (r = .43, P < .0001), NYHA class (r = .19, P < .006), pulmonary artery pressure (r = .24, P < .005), positive family history of HCM (r = .22, P < .005), and inversely related to peak systolic velocity (S) (r = .44, P < .0001). By multivariate analysis, only LVOTO ([RR] 4.11, 95% CI 1.002 to 1.148, P < .04) and E/e' were independent predictors for overall mortality in HCM (relative risk [RR] 5.27, 95% CI 1.002 to 1.024, P < .02). The risk of dying increased with increasing E/e' ratio, being approximately 4 times higher for patients in the highest quartile (HR 3.8 (CI 1.38-5.12, log-rank < 0.002)). CONCLUSIONS: In hypertrophic cardiomyopathy, the E/e' ratio remains a powerful predictor of all-cause mortality, particularly if it is associated with LVOT obstruction.

A comparative study between transthoracic and transesophageal echo modalities in evaluation of left ventricular deformation.

BACKGROUND: 2D strain imaging has been proved as an accurate technique for the assessment of left ventricular (LV) function using transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) has become a standard and essential technique in clinical practice especially when TTE is inconclusive. Adding 2D strain imaging to TEE might be valuable in the evaluation of cardiac performance. The aim of the present study was to compare 2D strain imaging using TTE and TEE in the assessment of left ventricular deformation in patients with cardiovascular diseases. RESULTS: This study was conducted on sixty patients, who were referred for TEE for various clinical indications. All patients were examined with both TTE and TEE 2D strain imaging. Global and regional strain parameters including longitudinal (LS), circumferential (CS), and radial (RS) were examined. Analysis of 2D strain using TTE was time sparing than TEE (16 ± 1 vs 19 ± 2 min, P < 0.001). From 1020 segments explored using TTE, 97% (LS) and 93% (CS and RS) of the segments were fully analyzed versus 90% and 88% using TEE respectively (P < 0.01). TEE longitudinal strain has an excellent agreement with TTE-derived measurements and a modest agreement in circumferential strain but a notable disparity in radial strain values. Both regional and global LS and RS measured by TTE showed higher values (P < 0.01, < 0.03) compared with its corresponding values measured by TEE. Whereas segmental and global values of CS were higher using TTE modes, the difference with the analogous TEE values did not reach statistical significance. LS and CS measured by TTE and TEE showed excellent but similar correlation with LV EF and wall motion score index. CONCLUSION: 2D strain using TTE is user friendly compared to TEE. However, because of the good agreement, TEE 2D strain might represent an appropriate alternative in the evaluation of global LV deformation.

Comparison of vector velocity imaging and three-dimensional speckle tracking echocardiography for assessment of left ventricular longitudinal strain in hypertrophic cardiomyopathy.

Background: Vector velocity imaging (VVI) is a two-dimensional wall motion tracking method that can measure cardiac mechanics in hypertrophic cardiomyopathy (HCM). 3D-speckle tracking echocardiography (3D-STE) has been proven to be superior to conventional measures in assessment of LV function. The aim of this study was to compare the two technologies in the assessment of LV longitudinal strain (LS) in HCM patients. Methods: A total of 50 patients with HCM were investigated using VVI and 3D-STE in same setting. 3D-STE allows obtaining longitudinal, circumferential, radial and area strains (AS). Values of longitudinal strain (LS) and AS by 3D-STE were compared to VVI- derived analyses. Thereafter, VVI-LS values were correlated with LV phenotype. Last, the variability of VVI versus 3DE strain measurements as well as recorded time of analysis was assessed. Results: The absolute value of 3D-STE LS and AS is significantly higher than VVI-LS (P < 0.0001). VVI provided complete longitudinal LV strain information, similar to 3D-STE. There is excellent agreement between the two technologies-derived values, however, a greater number of segments could be analyzed using VVI (94.7%), compared with 3DE (62.1%). Despite VVI being more time consuming, VVI-LS is more correlated to LV mass index, mitral regurgitation severity and functional class when compared with 3D-STE LS and AS. Conclusions: VVI is a feasible modality for assessing LV longitudinal strain. Although VVI agreed well with 3D-STE for most of regional and global LS, a better correlation was found between VVI-LS and HCM phenotype. It is hypothesized that this discrepancy originates from the inferior imaging quality using 3D tracking algorithms.

Relationship of left atrial mechanics to electrical activity on surface electrocardiography in idiopathic dilated cardiomyopathy.

Aim: (1) Assess left atrial (LA) mechanics and electromechanical delay in patients with idiopathic dilated cardiomyopathy (IDCM), and (2) examine the relationship between atrial electromechanical delay and atrial electrical activity [P-wave duration, P-wave dispersion (PWD) and P terminal force (PTF)] on surface ECG. Methods: 73 IDCM patients (age 36  ±  17 years); 63% men,25 age & sex matched healthy subjects were studied. LA atrial electromechanical delay & mechanics (εsys, SRsys, SRe, SRa) were measured with 2D-strain. From 12-lead electrocardiograms, P-wave duration, PWD and PTF calculated. Results: Reservoir, conduit and contractile functions were predominantly reduced compared to control (P < 0.001). Intra-atrial electromechanical delay was 88.9 ± 84.6 in IDCM versus 27.4 ± 16.5 in control (P < 0.0001). In IDCM, PWD (52.89 ± 15), Pmax(98 ± 17.5) and PTF(58.2 ± 36) were significantly increased compared to control (36.20 ± 8.9, 79 ± 9.9, 25.22 ± 8.76) respectively (P < 0.0001). A positive correlation was detected between intra-atrial electromechanical delay and PWD &PTF (r = 0.5, P < 0.0001). By stepwise multiple linear regression analyses, LA reservoir function (LA εsys) [ß = 0.754; CI at 95%:0.356-0.780, P < 0.001] and LA volume [ß = 0.743; CI 95%:0.423-0.75, P < 0.001], and PWD [ß=0.848; CI 95%:0.311-0.644, P < 0.0001], and PTF [ß = 0.927; CI 95%: 0.357-0.722, P < 0.0001] are independent predictors for LA electromechanical delay in IDCM. Conclusion: In addition to altered LA mechanics, atrial electromechanical delay gets longer in IDCM and is correlated with PWD and PTF. Atrial electrical dispersion on surface ECG could be early index of LA dysfunction that deserves further study.

Aortic biomechanics in hypertrophic cardiomyopathy.

BACKGROUND: Ventricular-vascular coupling is an important phenomenon in many cardiovascular diseases. The association between aortic mechanical dysfunction and left ventricular (LV) dysfunction is well characterized in many disease entities, but no data are available on how these changes are related in hypertrophic cardiomyopathy (HCM). AIM OF THE WORK: This study examined whether HCM alone is associated with an impaired aortic mechanical function in patients without cardiovascular risk factors and the relation of these changes, if any, to LV deformation and cardiac phenotype. METHODS: 141 patients with HCM were recruited and compared to 66 age- and sex-matched healthy subjects as control group. Pulse pressure, aortic strain, stiffness and distensibility were calculated from the aortic diameters measured by M-mode echocardiography and blood pressure obtained by sphygmomanometer. Aortic wall systolic and diastolic velocities were measured using pulsed wave Doppler tissue imaging (DTI). Cardiac assessment included geometric parameters and myocardial deformation (strain and strain rate) and mechanical dyssynchrony. RESULTS: The pulsatile change in the aortic diameter, distensibility and aortic wall systolic velocity (AWS') were significantly decreased and aortic stiffness index was increased in HCM compared to control (P < .001) In HCM AWS' was inversely correlated to age(r = - .32, P < .0001), MWT (r = - .22, P < .008), LVMI (r = - .20, P < .02), E/Ea (r = - .16, P < .03) LVOT gradient (r = - 19, P < .02) and severity of mitral regurg (r = - .18, P < .03) but not to the concealed LV deformation abnormalities or mechanical dyssynchrony. On multivariate analysis, the key determinant of aortic stiffness was LV mass index and LVOT obstruction while the role LV dysfunction in aortic stiffness is not evident in this population. CONCLUSION: HCM is associated with abnormal aortic mechanical properties. The severity of cardiac phenotype, not LV deformation, is interrelated to aortic stiffness in patients with HCM. The increased aortic stiffness seems to be promising module that can be added as clinical risk parameter in HCM.

Characterization of Left Atrial Mechanics in Hypertrophic Cardiomyopathy and Essential Hypertension Using Vector Velocity Imaging.

BACKGROUND: Systemic hypertension (HTN) and hypertrophic cardiomyopathy (HCM) may be associated with left atrial (LA) dilation, but whether LA functional abnormalities are characteristic to each disease or not, is unknown. The aim of this study was to characterize LA mechanical changes in patients with HTN and HCM using vector velocity imaging (VVI). METHODS: VVI-derived longitudinal LA function was acquired from apical views in 76 CM patients, 33 hypertension patients and 30 age-matched controls. Peak atrial longitudinal strain (ɛsys ), atrial strain rate during systole (SRsys ), early diastole (SRe ), and late diastole (SRa ) were measured (corresponding to LA reservoir, conduit and contractile functions, respectively). Similar parameters were used to assess left ventricular (LV) function. RESULTS: LV mass and LA volume index were higher in HCM and HTN than in controls. Both LA Reservoir function (LA ɛsys SRsys ) and conduit function (SRe ) were more declined in HCM patients, in comparison to HTN patients and controls (P < 0.0001),whereas conduit function was the only function deteriorated in the HTN group. LA contractile function was preserved among patient groups. In HCM, LV ɛsys and SRa [P < 0.001] are independent predictors for LA ɛsys . While in hypertension, only LVMI is an independent predictor for LA dysfunction (P < 0.01). By receiver operating characteristic analyses, only atrial reservoir function was extrapolative and appeared to be accurate in discriminating HCM from both hypertension and controls, with LA ɛsys ≤ 33% being more sensitive (71.8%) and specific (75%). CONCLUSIONS: Response of LA mechanics to pathologic hypertrophy is entirely different. In HCM LA reservoir and conduit functions are more deteriorated and related to the severity of phenotype, while in hypertension the conduit function is chiefly affected and LA dysfunction is linked to a more advanced disease.

Provocation of left ventricular outflow tract obstruction using nitrate inhalation in hypertrophic cardiomyopathy: Relation to electromechanical delay.

BACKGROUND: Left ventricular outflow tract obstruction (LVOT) is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). It is of major importance that the provocation modalities used are validated against each other. AIM: To define the magnitude of LVOT gradients provocation during both isosorbide dinitrate (ISDN) inhalation and treadmill exercise in non-obstructive HCM and analyze the correlation to the electromechanical delay using speckle tracking. METHODS: We studied 39 HCM pts (64% males, mean age 38 ± 13 years) regional LV longitudinal strain and electromechanical delay (TTP) was analyzed at rest using speckle tracking. LVOT gradient was measured at rest and after ISDN then patients underwent a treadmill exercise echocardiography (EE) and LVOT gradient was measured at peak exercise. RESULTS: The maximum effect of ISDN on LVOT gradient was obtained at 5 minutes, it increased to a significant level in 12 (31%) patients, and in 14 (36%) patients using EE, with 85.6% sensitivity & 100% specificity. Patients with latent obstruction had larger left atrial volume and lower E/A ratio compared to the non-obstructive group (p < 0.01). LVOTG using ISDN was significantly correlated with that using EE (p < 0.0001), resting LVOTG (p < 0.0001), SAM (p < 0.0001), EF% (p < 0.02) and regional electromechanical delay but not related to global LV longitudinal strain. Using multivariate regression, resting LVOTG (p = 0.006) & TTP mid septum (p = 0.01) were found to be independent predictors of latent LVOT obstruction using ISDN. CONCLUSION: There is a comparable diagnostic value of nitrate inhalation to exercise testing in provocation of LVOT obstruction in HCM. Latent obstruction is predominantly dependent on regional electromechanical delay.

Systolic function reserve using two-dimensional strain imaging in hypertrophic cardiomyopathy: comparison with essential hypertension.

BACKGROUND: Although patients with hypertrophic cardiomyopathy (HCM) have normal ejection fractions at rest, the investigators hypothesized that these patients have differentially abnormal systolic function reserves, limiting their exercise capacity compared with patients with hypertension (HTN). METHODS: Forty patients with HCM (mean age, 39.1 ± 12 years), 20 patients with HTN with LVH, and 33 healthy individuals underwent resting and peak exercise echocardiography using two-dimensional strain imaging. Peak longitudinal systolic strain (εsys) and strain rate were measured in apical views. Circumferential εsys and left ventricular (LV) twist were analyzed from short-axis views. LV systolic dyssynchrony was measured from regional longitudinal strain curves as the standard deviation of time to peak strain (time from the beginning of the Q wave on electrocardiography to peak εsys) between 12 segments. The differences between resting and peak exercise values were analyzed, and functional reserve was calculated as the difference divided by the resting value. RESULTS: In patients with HCM, resting values for longitudinal εsys, systolic strain rate, early diastolic strain rate, and atrial diastolic strain rate were significantly lower, while circumferential εsys and twist were higher, compared with patients with HTN and controls (P < .0001). Functional systolic reserve increased during exercise in controls (17 ± 6%), increased to a lesser extent in patients with HTN (10 ± 16%), and was markedly attenuated in patients with HCM (-23 ± 28%) (P < .001). At peak exercise, even with augmented circumferential εsys and twist in patients with HCM (P < .01) compared with those with HTN, both remained lower than in controls (P < .001). LV dyssynchrony was amplified during exercise in patients with HCM compared with those with HTN (P < .001). Within the entire population, exercise capacity was clearly correlated with systolic functional reserve. However when taken separately, it was mainly related to resting LV dyssynchrony and diastolic function in patients with HCM, whereas it was linked to age and LV wall thickness in those with HTN. CONCLUSIONS: Patients with HCM have significantly limited systolic function reserve and more dynamic dyssynchrony with exercise compared with those with HTN. Two-dimensional strain imaging during stress may provide a new and reliable method to identify patients at higher cardiovascular risk.

Right ventricular mechanics in hypertrophic cardiomyopathy using feature tracking.

OBJECTIVES: Right ventricular (RV) mechanics in hypertrophic cardiomyopathy (HCM) are poorly understood. We investigate global and regional deformation of the RV in HCM and its relationship to LV phenotype, using 2D strain vector velocity imaging (VVI). METHODS: 100 HCM patients (42% females, 41 ± 19 years) and 30 control patients were studied using VVI. Longitudinal peak systolic strain (ϵsys), strain rate (SR), time to peak (ϵ) (TTP), displacement of RV free wall (RVFW) and septal wall were analyzed. Similar parameters were quantified in LV septal, lateral, anterior and inferior segments. Intra-V-delay was defined as SD of TTP. Inter-V-delay was estimated from TTP difference between the most delayed LV segment & RVFW. RESULTS: ϵsys and SR of both RV & LV, showed loss of base to apex gradient and significant decline in HCM (p < 0.001). Deformation variables estimated from RVFW were strongly correlated with each other (r = 0.93, p < 0.0001). Both were directly related to LV ϵsys, SRsys, SRe, ejection fraction (EF)%, RVFW displacement (P < 0.001) and inversely related to age, positive family history (p < 0.004, 0.005), RV wall thickness, maximum wall thickness (MWT), intra-V-delay, LA volume (P < 0.0001), LVOT gradient (p < 0.02, 0.005) respectively. ROC curves were constructed to explore the cut-off point that discriminates RV dysfunction. Global and RVFW ϵsys: - 19.5% shows 77, 70% sensitivity & 97% specificity, SRsys: - 1.3s(- 1) shows 82, 70% sensitivity & 30% specificity. Multivariate analyses revealed that RVFW displacement (ß = - 0.9, p < 0.0001) and global LV SRsys (ß = 5.9, p < 0.0001) are independent predictors of global RV deformation. CONCLUSIONS: Impairment of RV deformation is evident in HCM using feature tracking. It is independently influenced by LV mechanics and correlated to the severity of LV phenotype. RVFW deformation analysis and global RV assessment are comparable.

Relationship of mechanical dyssynchrony to QT interval prolongation in hypertrophic cardiomyopathy.

AIMS: Hypertrophic cardiomyopathy (HCM) is usually associated with electrocardiographic (ECG) abnormalities. QT interval and its dispersion can be clinical markers of electrophysiological instability and ventricular arrhythmias. We aimed to clarify the relation of QT variables to mechanical dyssynchrony and myocardial function in HCM. METHODS AND RESULTS: The study population comprised 82 HCM patients, 28 healthy subjects as control. We assessed regional deformation indexes using vector velocity imaging in 12 myocardial segments. Peak systolic strain (ε(sys)), strain rate (SR(sys)), and post-systolic strain (PSS) were measured. Contraction time (CT) was measured from regional strain curves for each segment, as the time from the beginning of the Q-wave to the time-to-peak ε(sys) (TPS), mechanical dyssynchrony was estimated as TPS-SD. From 12-lead surface ECG, QT interval, QT dispersion, and its corrected values were measured. According to QT(c) (QT(c) ≥ 440 or <440 ms), patients were categorized into two groups: long QT and normal QT HCM. In the long QT group, QT(cd) and CT in all left ventricular (LV) segments were significantly prolonged; ε(sys) and SR(sys) were markedly attenuated compared with the other two groups (P<0.001). LV dyssynchrony was significantly greater (P<0.001) and PSS was more frequent in long QT HCM compared with the other two groups (P<0.001). TPS-SD was correlated positively with QT(c) (r=0.38, P<0.01) and QT(cd) (r=0.45, P<0.001). QT(c) ≥ 440 ms identified LV mechanical dyssynchrony with 70% sensitivity, 100% specificity, and positive predictive value. CONCLUSION: QT interval prolongation on surface ECG shows significant association with mechanical dyssynchrony and LV dysfunction in HCM. This may add pathophysiological insight into understanding ECG changes in such myocardial disease.