Long-term outcomes prediction in diabetic heart failure with preserved ejection fraction by cardiac MRI.

OBJECTIVES: We aimed to explore imaging features including tissue characterization and myocardial deformation in diabetic heart failure with preserved ejection fraction (HFpEF) patients by magnetic resonance imaging (MRI) and investigate its prognostic value for adverse outcomes. MATERIALS AND METHODS: Patients with HFpEF who underwent cardiac MRI between January 2010 and December 2016 were enrolled. Feature-tracking (FT) analysis and myocardial fibrosis were assessed by cardiac MRI. Cox proportional regression analysis was performed to determine the association between MRI variables and primary outcomes. Primary outcomes were all-cause death or heart failure hospitalization during the follow-up period. RESULTS: Of the 335 enrolled patients with HFpEF, 191 had diabetes mellitus (DM) (mean age: 58.7 years ± 10.8; 137 men). During a median follow-up of 10.2 years, 91 diabetic HFpEF and 56 non-diabetic HFpEF patients experienced primary outcomes. DM was a significant predictor of worse prognosis in HFpEF. In diabetic HFpEF, the addition of conventional imaging variables (left ventricular ejection fraction, left atrial volume index, extent of late gadolinium enhancement (LGE)) and global longitudinal strain (GLS) resulted in a significant increase in the area under the receiver operating characteristic curve (from 0.693 to 0.760, p < 0.05). After adjustment for multiple clinical and imaging variables, each 1% worsening in GLS was associated with a 9.8% increased risk of adverse events (p = 0.004). CONCLUSIONS: Diabetic HFpEF is characterized by more severely impaired strains and myocardial fibrosis, which is identified as a high-risk HFpEF phenotype. In diabetic HFpEF, comprehensive cardiac MRI provides incremental value in predicting prognosis. Particularly, MRI-FT measurement of GLS is an independent predictor of adverse outcome in diabetic HFpEF. CLINICAL RELEVANCE STATEMENT: Our findings suggested that MRI-derived variables, especially global longitudinal strain, played a crucial role in risk stratification and predicting worse prognosis in diabetic heart failure with preserved ejection fraction, which could assist in identifying high-risk patients and guiding therapeutic decision-making. KEY POINTS: • Limited data are available on the cardiac MRI features of diabetic heart failure with preserved ejection fraction, including myocardial deformation and tissue characterization, as well as their incremental prognostic value. • Diabetic heart failure with preserved ejection fraction patients was characterized by more impaired strains and myocardial fibrosis. Comprehensive MRI, including tissue characterization and global longitudinal strain, provided incremental value for risk prediction. • MRI served as a valuable tool for identifying high-risk patients and guiding clinical management in diabetic heart failure with preserved ejection fraction.

Cardiac MRI Risk Stratification for Dilated Cardiomyopathy with Left Ventricular Ejection Fraction of 35% or Higher.

Background Studies over the past 15 years have demonstrated that a considerable number of patients with dilated cardiomyopathy (DCM) who died from sudden cardiac death (SCD) had a left ventricular (LV) ejection fraction (LVEF) of 35% or higher. Purpose To identify clinical and cardiac MRI risk factors for adverse events in patients with DCM and LVEF of 35% or higher. Materials and Methods In this retrospective study, consecutive patients with DCM and LVEF of 35% or higher who underwent cardiac MRI between January 2010 and December 2017 were included. The primary end point was a composite of SCD or aborted SCD. The secondary end point was a composite of all-cause mortality, heart transplant, or hospitalization for heart failure. The risk factors for the primary and secondary end points were identified with multivariable Cox analysis. Results A total of 466 patients with DCM and LVEF of 35% or higher (mean age, 44 years ± 14 [SD]; 358 men) were included. During a mean follow-up of 79 months ± 30 (SD) (range, 7-143 months), 40 patients reached the primary end point and 61 reached the secondary end point. In the adjusted analysis, age (hazard ratio [HR], 1.03 per year [95% CI: 1.00, 1.05]; P = .04), family history of SCD (HR, 3.4 [95% CI: 1.3, 8.8]; P = .01), New York Heart Association (NYHA) class III or IV (HR vs NYHA class I or II, 2.1 [95% CI: 1.1, 3.9]; P = .02), and myocardial scar at late gadolinium enhancement (LGE) MRI greater than or equal to 7.1% of the LV mass (HR, 4.4 [95% CI: 2.4, 8.3]; P < .001) were associated with SCD or aborted SCD. For the composite secondary end point, LGE greater than or equal to 7.1% of the LV mass (HR vs LGE <7.1%, 2.0 [95% CI: 1.2, 3.4]; P = .01), left atrial maximum volume index, and reduced global longitudinal strain were independent predictors. Conclusion For patients with dilated cardiomyopathy and left ventricular (LV) ejection fraction of 35% or higher, cardiac MRI-defined myocardial scar greater than or equal to 7.1% of the LV mass was associated with sudden cardiac death (SCD) or aborted SCD. © RSNA, 2022 Online supplemental material is available for this article.

Ventricular-atrial coupling in subjects with normal, preserved, and reduced left ventricular ejection fraction: insights from cardiac magnetic resonance imaging.

OBJECTIVES: To assess the correlation between LA and LV strain measurements in different clinical scenarios and evaluate to what extent LA deformation contributes to the prognosis of patients. METHODS: A total of 297 consecutive participants including 75 healthy individuals, 75 hypertrophic cardiomyopathy (HCM) patients, 74 idiopathic dilated cardiomyopathy (DCM), and 73 chronic myocardial infarction (MI) patients were retrospectively enrolled in this study. The associations of LA-LV coupling with clinical status were statistically analyzed by correlation, multiple linear regression, and logistic regression. Survival estimates were calculated by receiver operating characteristic analyses and Cox regression analyses. RESULTS: Overall, moderate correlations were found between LA and LV strain in every phase of the cardiac cycle (r: -0.598 to -0.580, all p < 0.001). The slope of the regression line of the individual strain-strain curve had a significant difference among 4 groups (-1.4 ± 0.3 in controls, -1.1 ± 0.6 in HCM, -1.8 ± 0.8 in idiopathic DCM, -2.4 ± 1.1 in chronic MI, all p < 0.05). During a median follow-up of 4.7 years, the total LA emptying fraction was independently associated with primary (hazard ratio: 0.968, 95% CI: 0.951-0.985) and secondary endpoints (hazard ratio: 0.957, 95% CI: 0.930-0.985) with an area under the curve (AUC) of 0.720 respectively, 0.806, which was significantly higher than the AUC of LV parameters. CONCLUSIONS: The coupled correlations between the left atria and ventricle in every phase and the individual strain-strain curve vary with etiology. LA deformation in late diastole provides prior and incremental information on cardiac dysfunction based on LV metrics. The total LA emptying fraction was an independent indicator for clinical outcome superior to that of LV typical predictors. CLINICAL RELEVANCE STATEMENT: Left ventricular-atrial coupling is not only valuable for comprehending the pathophysiological mechanisms of cardiovascular diseases caused by different etiologies but also holds significant importance for the prevention of adverse cardiovascular events and targeted treatment. KEY POINTS: • In HCM patients with preserved LVEF, LA deformation is a sensitive indicator for cardiac dysfunction prior to LV parameters with a reduced LA/LV strain ratio. • In patients with reduced LVEF, LV deformation impairment is more consequential than that of the LA with an increased LA/LV strain ratio. Furthermore, impaired LA active strain indicates potential atrial myopathy. • Among LA and LV parameters, the total LA emptying fraction is the best predictor for guiding clinical management and follow-up in patients with different statuses of LVEF.

A novel cardiac magnetic resonance-based personalized risk stratification model in dilated cardiomyopathy: a prospective study.

OBJECTIVES: To explore individual weight of cardiac magnetic resonance (CMR) metrics to predict mid-term outcomes in patients with dilated cardiomyopathy (DCM), and develop a risk algorithm for mid-term outcome based on CMR biomarkers. MATERIALS AND METHODS: Patients with DCM who underwent CMR imaging were prospectively enrolled in this study. The primary endpoint was a composite of heart failure (HF) death, sudden cardiac death (SCD), aborted SCD, and heart transplantation. RESULTS: A total of 407 patients (age 48.1 ± 13.8 years, 331 men) were included in the final analysis. During a median follow-up of 21.7 months, 63 patients reached the primary endpoint. NYHA class III/IV (HR = 2.347 [1.073-5.133], p = 0.033), left ventricular ejection fraction (HR = 0.940 [0.909-0.973], p < 0.001), late gadolinium enhancement (LGE) > 0.9% and ≤ 6.6% (HR = 3.559 [1.020-12.412], p = 0.046), LGE > 6.6% (HR = 6.028 [1.814-20.038], p = 0.003), and mean extracellular volume (ECV) fraction ≥ 32.8% (HR = 5.922 [2.566-13.665], p < 0.001) had a significant prognostic association with the primary endpoints (C-statistic: 0.853 [0.810-0.896]). Competing risk regression analyses showed that patients with mean ECV fraction ≥ 32.8%, LGE ≥ 5.9%, global circumferential strain ≥ - 5.6%, or global longitudinal strain ≥ - 7.3% had significantly shorter event-free survival due to HF death and heart transplantation. Patients with mean ECV fraction ≥ 32.8% and LGE ≥ 5.9% had significantly shorter event-free survival due to SCD or aborted SCD. CONCLUSION: ECV fraction may be the best independently risk factor for the mid-term outcomes in patients with DCM, surpassing LVEF and LGE. LGE has a better prognostic value than other CMR metrics for SCD and aborted SCD. The risk stratification model we developed may be a promising non-invasive tool for decision-making and prognosis. CLINICAL RELEVANCE STATEMENT: "One-stop" assessment of cardiac function and myocardial characterization using cardiac magnetic resonance might improve risk stratification of patients with DCM. In this prospective study, we propose a novel risk algorithm in DCM including NYHA functional class, LVEF, LGE, and ECV. KEY POINTS: • The present study explores individual weight of CMR metrics for predicting mid-term outcomes in dilated cardiomyopathy. • We have developed a novel risk algorithm for dilated cardiomyopathy that includes cardiac functional class, ejection fraction, late gadolinium enhancement, and extracellular volume fraction. • Personalized risk model derived by CMR contributes to clinical assessment and individual decision-making.

Left atrial reservoir strain measurements derived from intracardiac echocardiography in patients with atrial fibrillation: comparison with transthoracic echocardiography.

BACKGROUND: Intracardiac echocardiography (ICE) provides accurate left atrial (LA) anatomical information in the procedure of atrial fibrillation (AF) ablation but lacks LA functional assessment. LA reservoir strain (LASr) is an excellent marker of LA reservoir function. This study aimed to assess the agreement between LASr derived from ICE and transthoracic echocardiography (TTE) in AF patients and analyze the reproducibility of LASr assessed by ICE combined with speckle tracking imaging. METHODS: This study prospectively enrolled 110 patients with a clinical diagnosis of AF who were ready for AF ablation, including 71 patients with paroxysmal AF and 39 with persistent AF. TTE and ICE examinations were performed on each individual before AF ablation. LASr measurements derived from ICE and TTE images were using dedicated LA-tracking software. Pearson correlation coefficients (r) and Bland-Altman plots were used to evaluate the agreement of LASr between the two modalities. Intraclass correlation coefficients (ICCs) were used to assess intra- and inter-observer reproducibility. RESULTS: The agreement between LASr obtained from ICE and TTE, especially between LASrLPV (LASr derived from LA left pulmonary vein view of ICE) and LASrTTE (LASr derived from TTE) were good in both paroxysmal and persistent AF patients [r = 0.890 (P < 0.001) for overall population; r = 0.815 (P < 0.001) and Bias ± LOA: -0.3 ± 9.9% for paroxysmal AF; r = 0.775 (P < 0.001) and Bias ± LOA: -2.6 ± 3.9% for persistent AF, respectively]. But the values of LASr derived from ICE were slightly lower than those of TTE, especially in patients with persistent AF. The ICCs for LASr derived from ICE were excellent (all ICCs > 0.90). CONCLUSIONS: In patients with AF, LASr derived from ICE demonstrated excellent reproducibility and showed good agreement with LASr obtained from TTE. Obtaining LASr from ICE images may be a supplementary method to evaluate LA reservoir function in AF patients and expands the potential of ICE in the field of cardiac function assessment.

Changes and predictors of secondary mild mitral regurgitation after coronary artery bypass grafting.

BACKGROUND: Secondary mitral regurgitation (SMR) has been related to left ventricular (LV) remodeling and geometric deformation of the mitral apparatus after myocardial infarction (MI), and proved to be associated with adverse cardiac events. We assessed the proportion of mild SMR before and after isolated coronary artery bypass grafting (CABG) surgery, and further study to evaluate dynamic changes of MR and the determinants of such process on 1 year follow-up. METHODS: From 2019 to 2021, cohort study of 171 consecutive hospitalized patients who underwent selective isolated CABG surgery were included and divided into the control group and mild MR group according to whether mild MR occurred at baseline. Univariate analysis and multivariate logistic regression analysis were used to test the associations of changes in MR after CABG, and p < 0.05 was considered significant. RESULTS: The mean age of the cohort was 61.31 ± 8.71 years and 78.95% were male at baseline, divided into the control group (74.85%) and mild MR group (25.15%), respectively. The LV volumetric and size parameters were higher in the mild MR group, with decline in LV and left atrial (LA) strain measurements. About half participants with mild MR at baseline persisted in that category and the rest reverted to none MR on follow-up, while preoperative left main coronary artery occlusion may impede the improvement (p < 0.05). The control group at baseline tended to maintain none MR and one-eighth progressed to mild MR on follow-up, moreover older age and lower LVEF emerged as key correlation of this development. LA volume index (LAVi) was associated with an increased risk of developing mild MR (p < 0.05). CONCLUSIONS: Patients with secondary mild MR had LA dysfunction and CABG surgery promoted regression of MR. LAV has an incremental role for early detection of change in MR over time after surgery.

Left atrial dysfunction may precede left atrial enlargement and abnormal left ventricular longitudinal function: a cardiac MR feature tracking study.

BACKGROUND: The role of the dysfunction of left atrium in the occurrence and development of cardiovascular disease has been gradually recognized. We aim to compare the impact on left atrial (LA) function between patients with hypertrophic cardiomyopathy (HCM) and hypertension (HTN) without LA enlargement using cardiovascular magnetic resonance feature tracking (CMR-FT), and if possible, explore the capability of LA function for providing clinical implication and predicting clinical adverse events in the early stage of cardiovascular disease. METHODS: Consecutive 60 HCM patients and 60 HTN patients with normal LA size among 1413 patients who underwent CMR were retrospectively analyzed as well as 60 controls. Left atrial and ventricular functions were quantified by volumetric and CMR-FT derived strain analysis from long and short left ventricular view cines. The primary endpoint was a composite of all-cause death, stroke, new-onset or worsening heart failure to hospitalization, and paroxysmal or persistent atrial fibrillation. RESULTS: Compared to the controls, both HTN and HCM participants had impaired LA reservoir function (εs) and conduit function (εe) with the different stage of LA booster pump dysfunction (εa). LA strain was more sensitive than LV longitudinal strain (GLS) for evaluate primary endpoint (εs: 33.9% ± 7.5 vs. 41.2% ± 14.3, p = 0.02; εe: 13.6% ± 6.2 vs. 17.4% ± 10.4, p = 0.03; εa: 20.2% ± 6.0 vs. 23.7% ± 8.8, p = 0.07; GLS: -19.4% ± 6.4 vs. -20.0% ± 6.8, p = 0.70, respectively). After a mean follow-up of 6.8 years, 23 patients reached primary endpoint. Cox regression analyses indicated impaired LA reservoir and booster pump strain were associated with clinical outcomes in patients at the early stage of HTN and HCM (p < 0.05). CONCLUSIONS: CMR-FT-derived strain is a potential and robust tool in demonstrating impaired LA mechanics, quantifying LA dynamics and underlining the impacts on LA-LV coupling in patients with HTN and HCM without LA enlargement. The corresponding LA dysfunction is a promising metric to assess clinical implication and predict prognosis at the early stage, superior to GLS.

Early Diastolic Longitudinal Strain Rate at MRI and Outcomes in Heart Failure with Preserved Ejection Fraction.

Background Assessment of subclinical myocardial dysfunction by using feature tracking has shown promise in prognosis evaluation of heart failure with preserved ejection fraction (HFpEF). Global early diastolic longitudinal strain rate (eGLSR) can identify earlier diastolic dysfunction; however, limited data are available on its prognostic value in HFpEF. Purpose To evaluate the association between left ventricular (LV) eGLSR and primary composite outcomes (all-cause death or heart failure hospitalization) in patients with HFpEF. Materials and Methods In this retrospective study, consecutive patients with HFpEF (included from January 2010 to March 2013) underwent cardiovascular MRI. The correlation between eGLSR and variables was assessed by using linear regression. The association between eGLSR (obtained with use of feature tracking) and outcomes was analyzed by using Cox proportional regression. Results A total of 186 patients with HFpEF (mean age ± standard deviation, 59 years ± 12; 77 women) were included. The eGLSR was weakly correlated with LV end-diastole volume index (Pearson correlation coefficient [r] = -0.35; P < .001), heart rate (r = 0.35; P < .001), and LV ejection fraction (r = 0.30; P < .001) and moderately correlated with LV end-systole volume index (r = -0.41; P < .001). At a median follow-up of 9.2 years (interquartile range, 8.7-10.0 years), 72 patients experienced primary composite outcomes. Impaired eGLSR, defined as an eGLSR of less than 0.57 per second, was associated with a greater rate of heart failure hospitalization or all-cause death (hazard ratio, 2.0 [95% CI: 1.1, 3.7]; P = .02) after adjusting for multiple clinical and imaging-based variables. Conclusion Left ventricular global early diastolic longitudinal strain rate obtained from cardiovascular MRI feature tracking was independently associated with adverse outcomes in patients with heart failure with preserved ejection fraction. © RSNA, 2021 Online supplemental material is available for this article. An earlier incorrect version appeared online. This article was corrected on October 22, 2021.

Heart Failure With Preserved Ejection Fraction in Hypertension Patients: A Myocardial MR Strain Study.

BACKGROUND: Despite current recommendations for heart failure with preserved ejection fraction (HFpEF), few studies have demonstrated the ability of MRI to identify subtle functional differences between HFpEF with essential hypertension (HFpEF-HTN) patients and hypertension patients (HTN). PURPOSE: This study aimed to detect and evaluate HFpEF in patients with HTN using feature-tracking (FT) and to ascertain optimal strain cutoffs for the diagnosis of HFpEF-HTN. STUDY TYPE: Retrospective study. POPULATION: Three groups (84 with HFpEF-HTN; 72 with HTN; and 70 healthy controls). FIELD STRENGTH: 1.5T, steady-state free precession (SSFP), and half-Fourier single-shot turbo spin-echo (HASTE) sequences. ASSESSMENT: All patients underwent laboratory testing and imaging protocols (echocardiography and MRI). FT-derived left ventricular (LV) strain and strain rate (SR) were measured and compared among the three groups with adjustment for confounding factors. STATISTICAL TESTS: Kolmogorov-Smirnov's test, independent-sample t-tests, one-way analysis of variance (ANOVA), Pearson's correlation coefficient, area under the receiver-operator characteristic (ROC) curve (AUC), and logistic regression. RESULTS: Compared to 72 HTN patients and 70 healthy controls, HFpEF-HTN patients (84 patients) demonstrated significantly impaired LV strains (except for global peak systolic radial strain, GRS, P < 0.05 for all). Only LV global peak systolic longitudinal strain (GLS) was significantly impaired in HTN patients vs. controls (P < 0.05). The global peak systolic circumferential SR (sGCSR) showed the highest diagnostic value for the differentiation of HFpEF-HTN patients from HTN patients (AUC, 0.731; cutoff value, -1.11/s; sensitivity, 56.0%; specificity, 84.7%). Only global peak early diastolic longitudinal SR (eGLSR) remained independently associated with a diagnosis of HFpEF-HTN in multilogistic analysis. The major strain parameters significantly correlated with LV ejection fraction, end-systolic volume index, and N-terminal pro-brain natriuretic peptide (P < 0.05 for all) and also demonstrated differences between NYHA functional class. DATA CONCLUSION: HFpEF-HTN patients suffer from both systolic and diastolic cardiac dysfunction. FT-derived strain parameters have potential value for the diagnosis and risk stratification of HFpEF-HTN patients. Level of Evidence 3. Technical Efficacy Stage 2.

Dimethyl Sulfoxide-Free and Water-Soluble Fluorescent Probe for Detection of Bovine Serum Albumin Prepared by Ionic Co-assembly of Amphiphiles.

Detection of bovine serum albumin (BSA) is an important issue in the sense of medical applications and enzymatic reactions; however, the recently developed fluorescent probes require the involvement of dimethyl sulfoxide (DMSO), which may be detrimental to proteins. In this study, we demonstrated a DMSO-free and water-soluble fluorescent probe prepared by ionic co-assembly of amphiphiles. The cationic amphiphile is a newly designed molecule (denoted by DPP-12) bearing a conjugated diketopyrrolopyrrole (DPP) and two tetraphenylethylene groups. It turns out that the fluorescence emission of DPP-12 depends on the amount of anionic amphiphilic sodium dodecyl benzene sulfonate (SDBS). The fluorescence intensity first increases and then decreases with the concentration of SDBS, and each branch presents a linear relationship. BSA consumes SDBS by the formation of complexes, thus leading to an increase of fluorescence intensity of the mixed solution of DPP-12 and SDBS. Therefore, the mixed solution of DPP-12 and SDBS was applied as a fluorescent probe to detect the low concentration of BSA by back-titration. This fluorescent probe does not require DMSO and has good tolerance to metal ions in blood and good photostability. The limit of detection is as low as 940 nM, almost 3 orders of magnitude lower than the content in organisms.

Left atrial reservoir strain combined with E/E' as a better single measure to predict elevated LV filling pressures in patients with coronary artery disease.

BACKGROUND: The 2016 guidelines for left ventricular diastolic dysfunction diagnosis has been simplified from previous versions; however, multiparametric diagnosis approach still exists indeterminate left ventricular diastolic dysfunction category. Left atrial (LA) strain was recently found useful to predict elevated left ventricular (LV) filling pressures noninvasively. This study aimed to (1) analyze the diagnostic value of LA strain for noninvasive assessment of LV filling pressures in patients with stable coronary artery disease (CAD) with preserved LV ejection fraction (LVEF), using invasive hemodynamic assessment as the gold standard, and (2) explore whether LA strain combined with conventional diastolic parameters could detect elevated LV filling pressures alone. METHODS: Sixty-four patients with stable CAD having LVEF > 50% and 30 healthy controls were enrolled. Two-dimensional speckle-tracking echocardiography was used to measure LA strain during the reservoir (LASr), conduit, and contraction phases. LV end-diastolic pressure (LVEDP), as a surrogate for LV filling pressures, was invasively obtained by left heart catheterization. Logistic regression was used to calculate the odds ratio to predict LV filling pressures. Pearson's correlation was used to analyze associations between echocardiographic parameters and LVEDP. The area under the receiver-operating characteristic curve was calculated to determine the capability of the echocardiographic parameters to detect elevated LVEDP. Inter-technique agreement was analyzed by contingency tables and tested by kappa statistics. RESULTS: LASr and the ratio of early-diastolic transmitral flow velocity (E) to tissue Doppler early-diastolic septal mitral annular velocity (E/E'septal) significantly predicted elevated LV filling pressures. LASr was combined with E/E'septal to generate a novel parameter (LASr/E/E'septal). LASr/E/E'septal had the best predictive ability of elevated LV filling pressures. LVEDP was negatively correlated with LASr and LASr/E/E'septal but positively correlated with E/E'septal. The area under the receiver-operating characteristic curve of LASr/E/E'septal was higher than that of LASr alone (0.83 vs. 0.75), better than all conventional LV diastolic parameters. Inter-technique agreement analysis showed that LASr/E/E'septal had good agreement with the invasive LVEDP measurement, better than the 2016 guideline (kappa = 0.63 vs. 0.25). CONCLUSIONS: LASr provided additive diagnostic value for the noninvasive assessment of LV filling pressures. LASr/E/E'septal had the potential to be a better single noninvasive index to predict elevated LV filling pressures in patients with stable CAD and preserved LVEF.

A rare case of mitral valve dissection and aortic-left ventricular tunnel associated with possible autoimmune vasculitis.

We report a very rare case of mitral valve dissection and aortic-left ventricular tunnel caused by possible autoimmune vasculitis. We suspected Behcet's disease in this patient. There was no obvious clinical evidence of infective endocarditis. Echocardiography is the diagnostic tool of choice to recognize valvular dysfunction, related pathology, and possible complications. The patient may require immunosuppressive therapy due to the high likelihood of recurrence in the perioperation period.

Evaluation of Left Ventricular Diastolic Dysfunction with Early Systolic Dysfunction Using Two-Dimensional Speckle Tracking Echocardiography in Canine Heart Failure Model.

BACKGROUND: This study evaluated the role of two-dimensional speckle tracking echocardiography (2DSTE) for predicting left ventricular (LV) diastolic dysfunction in pacing-induced canine heart failure. METHODS: Pacing systems were implanted in 8 adult mongrel dogs, and continuous rapid right ventricular pacing (RVP, 240 beats/min) was maintained for 2 weeks. The obtained measurements from 2DSTE included global strain rate during early diastole (SRe) and during late diastole (SRa) in the longitudinal (L-SRe, L-SRa), circumferential (C-SRe, C-SRa), and radial directions (R-SRe, R-SRa). Changes in heart morphology were observed by light microscopy and transmission electron microscopy at 2 weeks. RESULTS: The onset of LV diastolic dysfunction with early systolic dysfunction occurred 3 days after RVP initiation. Most of the strain rate imaging indices were altered at 1 or 3 days after RVP onset and continued to worsen until heart failure developed. Light and transmission electron microscopy showed myocardial vacuolar degeneration and mitochondrial swelling in the left ventricular at 2 weeks after RVP onset. Pearson's correlation analysis revealed that parameters of conventional echocardiography and 2DSTE showed moderate correlation with LV pressure parameters, including E/Esep' (r = 0.58, P < 0.01), L-SRe (r = -0.58, P < 0.01), E/L-SRe (r = 0.65, P < 0.01), and R-SRe (r = 0.53, P < 0.01). ROC curves analysis showed that these indices of conventional echocardiography and strain rate imaging could effectively predict LV diastolic dysfunction (area under the curve: E/Esep' 0.78; L-SRe 0.84; E/L-SRe 0.80; R-SRe 0.80). CONCLUSION: 2DSTE was a sensitive and accurate technique that could be used for predicting LV diastolic dysfunction in canine heart failure model.

Prediction of Left Ventricular Filling Pressure by 3-Dimensional Speckle-Tracking Echocardiography in Patients With Coronary Artery Disease.

OBJECTIVES: The purpose of this study was to investigate the diagnostic value of 3-dimensional (3D) speckle-tracking echocardiography for estimating left ventricular filling pressure in patients with coronary artery disease (CAD) and a preserved left ventricular ejection fraction. METHODS: Altogether, 84 patients with CAD and 30 age- and sex-matched healthy control participants in sinus rhythm were recruited prospectively. All participants underwent conventional and 3D speckle-tracking echocardiography. Global strain values were automatically calculated by 3D speckle-tracking analysis. The left ventricular end-diastolic pressure (LVEDP) was determined invasively by left heart catheterization. Echocardiography and cardiac catheterization were performed within 24 hours. RESULTS: Compared with the controls, patients with CAD showed lower global longitudinal strain, global circumferential strain, global area strain, and global radial strain. Patients with CAD who had an elevated LVEDP had much lower levels of all 4 3D-speckle-tracking echocardiographic variables. Pearson correlation analysis revealed that the LVEDP correlated positively with the early transmitral flow velocity/early diastolic myocardial velocity (E/E') ratio, global longitudinal strain, global circumferential strain, and global area strain. It correlated negatively with global radial strain. Receiver operating characteristic curve analysis revealed that these 3D speckle-tracking echocardiographic indices could effectively predict elevated left ventricular filling pressure (LVEDP >15 mm Hg) in patients with CAD (areas under the curve: global longitudinal strain, 0.78; global radial strain, 0.77; global circumferential strain, 0.75; and global area strain, 0.74). These parameters, however, showed no advantages over the commonly used E/E' ratio (area under the curve, 0.84). CONCLUSIONS: Three-dimensional speckle-tracking echocardiography was a practical technique for predicting elevated left ventricular filling pressure, but it might not be superior to the commonly used E/E' ratio in patients with CAD who have a normal left ventricular ejection fraction.

Clinical risk factors of prediabetes in Taiwanese women without substance uses (tobacco, alcohol, or areca nut).

BACKGROUND/PURPOSE: Individuals with prediabetes (100-125 mg/dL) and diabetes mellitus (DM) increase the risk of all-cause and cardiovascular disease (CVD) mortality. Since personal substance use such as cigarette smoking, alcohol drinking, and areca nut chewing may confound the true effect of clinical biochemistries on the risk of prediabetes, this study aims to examine the relationship between clinical biochemical parameters and the risk of prediabetes among Taiwanese without the habits of consuming tobacco, alcohol drinking, or areca nut. METHODS: Women aged between 40 years and 64 years who came to one community teaching hospital between January 1, 2001 and December 31, 2008 for general health screening for the first time were studied. The general health screening is provided every 3 years gratis. The package of this health screening includes personal history, physical examination, and biochemical tests in serum and urine. RESULTS: In total, 8580 nonsmoking, nondrinking, and nonareca nut chewing women who did not have a history of DM were eligible for this study. Of these, 1861 (21.7%) out of 8580 women were prediabetic. Compared to women with normal fasting glucose (NFG), we found a dose-response relationship of the risk of prediabetes with age and body mass index (BMI) and total cholesterol, triglyceride, glutamic-pyruvic transaminase (GPT), and uric acid in serum. Women with hypertension or proteinuria (≥30 mg/dL) had also an increased risk to have prediabetes. CONCLUSION: Besides age, the factors of BMI, hypertension, dyslipidemia, GPT, hyperuricemia, and proteinuria are the main risk factors for prediabetes in Taiwanese women without substance uses. A follow-up study is necessary to clarify the causality of these important biochemical parameters and prediabetes.

Unravelling the intricacies of left ventricular haemodynamic forces: age and gender-specific normative values assessed by cardiac MRI in healthy adults.

AIMS: Haemodynamic forces (HDFs) provided a feasible method to early detect cardiac mechanical abnormalities by estimating the intraventricular pressure gradients. The novel advances in assessment of HDFs using routine cardiac magnetic resonance (CMR) cines shed new light on detection of preclinical dysfunction. However, definition of normal values for this new technique is the prerequisite for application in the clinic. METHODS AND RESULTS: A total of 218 healthy volunteers [38.1 years ± 11.1; 111 male (50.9%)] were recruited and underwent CMR examinations with a 3.0T scanner. Balanced steady state free precession breath hold cine images were acquired, and HDF assessments were performed based on strain analysis. The normal values of longitudinal and transversal HDF strength [root mean square (RMS)] and ratio of transversal to longitudinal HDF were all evaluated in overall population as well as in both genders and in age-specific groups. The longitudinal RMS values (%) of HDFs were significantly higher in women (P < 0.05). Moreover, the HDF amplitudes significantly decreased with ageing in entire heartbeat, systole, diastole, systolic/diastolic transition, and diastolic deceleration, while increased in atrial thrust. In multivariable linear regression analysis, age, heart rate, and global longitudinal strain emerged as independent predictors of the amplitudes of longitudinal HDFs in entire heartbeat and systole, while left ventricular end-diastole volume index was also independently associated with longitudinal HDFs in diastole and diastolic deceleration (P < 0.05 for all). CONCLUSION: Our study provided comprehensive normal values of HDF assessments using CMR as well as presented with specific age and sex stratification. HDF analyses can be performed with excellent intra- and inter-observer reproducibility.

Geometric remodeling of tricuspid valve in pulmonary hypertension and its correlation with pulmonary hypertension severity: a prospectively case-control study using four-dimensional automatic tricuspid valve quantification technology.

Background: Evaluation of the tricuspid valve (TV) is crucial for clinical decision making and post-treatment follow-up in pulmonary hypertension (PH) patients. However, little is known about 4-dimensional (4D) TV geometric remodeling in patients with PH. The aim of this study was to examine the 4D geometry of the TV in PH and its correlation with PH severity. Methods: A total of 74 PH patients with mean pulmonary arterial pressure >25 mmHg and 15 age- and gender-matched healthy individuals were consecutively included from September 2017 to December 2018 in National Center for Cardiovascular Diseases, Fuwai Hospital. All participants underwent 2-dimensional (2D) and 4D transthoracic echocardiography and PH patients underwent right heart catheterization (RHC) within 48 hours of echocardiography. TV geometry was analyzed using a dedicated 4D echocardiography from the right ventricular-focused apical view. Results: Compared with controls, PH patients had significantly larger 4D tricuspid annular (TA) and TV tenting sizes except in the 2-chamber diameter. In high-quality image cases, maximal tenting height (MTH), coaptation point height, tenting volume and 4-chamber diameter had good or moderate correlation with PH severity graded according to RHC mean pulmonary artery pressure (r=0.705, r=0.644, r=0.602, r=0.472, respectively; P<0.001 for all). In multivariable linear regression analysis, PH severity was independently associated with coaptation point height (F=18.070, P<0.001 with an R2=0.647) and MTH (F=25.576, P<0.001 with an R2=0.378). Among all 4D TV parameters, MTH had the highest area under the receiver operating characteristic (ROC) curve (AUC) in high-quality image cases [AUC =0.857, 95% confidence interval (CI): 0.743-0.972; P<0.001], comparable to echocardiographic systolic pulmonary arterial pressure (AUC =0.847, 95% CI: 0.733-0.961; P<0.001). Conclusions: In PH, TV geometric remodeling occurs mainly in TA septal-lateral dimension and TV tenting height. Worsening PH is an independent determinant of TV coaptation point height and MTH, not TA size. MTH shows a great diagnostic potential to detect severe PH.

Developing and evaluating a chronic ischemic cardiomyopathy in swine model by rest and stress CMR.

A large animal model of chronic coronary artery disease (CAD) is crucial for the understanding the underlying pathophysiological processes of chronic CAD and consequences for cardiac structure and function. The goal of this study was to develop a chronic model of CAD in a swine model and to evaluate the changes of myocardial structure, myocardial motility, and myocardial viability during coronary stenosis. A total of 30 swine (including 24 experimental animals and 6 controls) were enrolled. The chronic ischemia model was constructed by using Ameroid constrictor in experimental group. The 24 experimental animals were further divided into 4 groups (6 animals in each group) and were sacrificed at 1, 2, 3 and 4 weeks after operation for pathological examination, respectively. Cardiac magnetic resonance (CMR) was performed preoperatively and weekly postoperatively until sacrificed both in experimental and control group. CMR cine images, rest/adenosine triphosphate (ATP) stress myocardial contrast perfusion and LGE were performed and analyzed. The rest wall thickening (WT) score was calculated from rest cine images. The MPRI (myocardial perfusion reserve index) and MPR (myocardial perfusion reserve) were calculated based on rest and stress perfusion images. Pathology staining including triphenyltetrazolium chloride, HE and picrosirus red staining were performed after swine were sacrificed and collagen volume fraction (CVF) was calculated. The time to formation of ischemic, hibernating, and infarcted myocardium was recorded. In experimental group, from 1w to 4w after surgery, the rest WT score decreased gradually from 35.2 ± 2.0%, 32.0 ± 2.9% to 30.5 ± 3.0% and finally 29.06 ± 1.78%, p < 0.001. Left ventricular ejection fraction was gradually impaired after modeling (58.9 ± 12.6%, 56.3 ± 10.1%, 55.3 ± 9.0%, 53.8 ± 9.9%, respectively). And the MPR and MPRI also decreased stepwise with extent of surgery time (MPRI dropped from 2.1 ± 0.4, 2.0 ± 0.2 to 1.8 ± 0.3 and finally 1.7 ± 0.1, p = 0.004; MPR dropped from 2.3 ± 0.4, 2.1 ± 0.2 to 1.9 ± 0.4 and finally 1.8 ± 0.1, p < 0.001). Stronger associations between MPR, MPRI and CVF were paralleled lower wall thickening scores in fibrosis-affected areas. The ischemic myocardium was first appeared in the first week after surgery (involving ten segments), hibernated myocardium was first appeared in the second week after surgery (involving seventeen segments). LGE was first appeared in eight swine in the third weeks after surgery (16 segments). At 4w after surgery, average 9.6 g scar tissue was found among 6 swine. At the same time, histological analysis established the presence of fibrosis and ongoing apoptosis in the infarcted area. In conclusion, our study provided valuable insights into the pathophysiological processes of chronic CAD and its consequences for cardiac structure and function in a large animal model through combining myocardial motion and stress perfusion.

B-cell maturation antigen chimeric antigen receptor-T therapy alleviated heart failure in patients with multiple myeloma.

Patients with multiple myeloma (MM) are likely to achieve poor therapeutic response when organs are involved. We produced anti-B-cell maturation antigen (BCMA) chimeric antigen receptor (CAR)-T cells, which are in a trial for patients with relapsed/refractory MM. One enrolled patient developed severe heart failure, highly suspected as light chain cardiac amyloidosis. He exhibited increased N-terminal pro-brain natriuretic peptide with a peak of 32 299 ng/mL and heart failure with an ejection fraction of 30%. Anti-BCMA CAR-T cells were administered following lymphodepletion. The patient achieved cardiac response within 1 week with a decrease in N-terminal pro-brain natriuretic peptide by 80%, an increase in ejection fraction from 30% to 56%, and a haematological response with negative minimal residual disease at 1 month and a complete response at 1 year. To date, this patient has maintained good health without heart failure or haematological relapse. Herein, we show the efficacy of anti-BCMA CAR-T cells in patients with MM and severe heart failure.