Post-traumatic stress disorder among heart disease patients: a clinical follow-up of individuals with myocardial infarction in the Tromsø Study.

BACKGROUND: Myocardial infarction is likely to be experienced as a life-threatening and potentially traumatic event. Approximately one-third of patients with myocardial infarction experience clinically significant symptoms of anxiety/depression. However, it is unclear how many of these patients experience these symptoms because of post-traumatic stress disorder (PTSD). We conducted a clinical screening of individuals with a confirmed myocardial infarction diagnosis. Our goal was to examine the prevalence of PTSD in myocardial infarction patients and study how PTSD symptoms were associated with exposure to potentially traumatic events. METHOD: This is epidemiological research with a cross-sectional design following up participants from the Tromsø Study with a confirmed diagnosis of myocardial infarction. We sent invitations to participants in the Tromsø Study with clinically significant self-reported anxiety or depression symptoms following myocardial infarction. A cross-sectional sample of N = 79 participants (61 men and 18 women) was collected. During an interview, participants completed the Stressful Life Events Screening Questionnaire and the PTSD checklist PCL-5. RESULTS: We found nine participants (11.6%) with probable PTSD. This was significantly higher than the postulated population prevalence in Norway (p < 0.015). We found no direct association between myocardial infarction as illness trauma and symptom levels (p = 0.123). However, we found a significant linear trend (p = 0.002), indicating that symptom severity increased proportionately as the number of post-traumatic events increased. CONCLUSION: PTSD prevalence in myocardial infarction patients was related to lifetime exposure to traumatic events, not the myocardial infarction event alone. More research is required to examine the interaction between myocardial infarction and PTSD. Clinicians should be aware that anxiety or depression symptoms after MI could be secondary symptoms of PTSD.

Influence of hypertension on systolic and diastolic left ventricular function including segmental strain and strain rate.

BACKGROUND: Left ventricular (LV) systolic and diastolic functions are important cardiovascular risk predictors in patients with hypertension. However, data on segmental, layer-specific strain, and diastolic strain rates in these patients are limited. The aim of this study was to investigate segmental two-dimensional strain rate imaging (SRI)-derived parameters to characterize LV systolic and diastolic function in hypertensive individuals compared with that in normotensive individuals. METHODS: The study sample comprised 1194 participants from the population-based Know Your Heart study in Arkhangelsk and Novosibirsk, Russia, and 1013 individuals from the Seventh Tromsø Study in Norway. The study population was divided into four subgroups: (A) healthy individuals with normal blood pressure (BP), (B) individuals on antihypertensive medication with normal BP, (C) individuals with systolic BP 140-159 mmHg and/or diastolic BP > 90 mm HG, and (D) individuals with systolic BP ≥160 mmHg. In addition to conventional echocardiographic parameters, global and segmental layer-specific strains and strain rates in early diastole and atrial contraction (SR E, SR A) were extracted. The strain and SR (S/SR) analysis included only segments without strain curve artifacts. RESULTS: With increasing BP, the systolic and diastolic global and segmental S/SR gradually decreased. SR E, a marker of impaired relaxation, showed the most distinctive differences between the groups. In normotensive controls and the three hypertension groups, all segmental parameters displayed apico-basal gradients, with the lowest S/SR in the basal septal and highest in apical segments. Only SR A did not differ between the segmental groups but increased gradually with increasing BP. End-systolic strain showed incremental epi-towards endocardial gradients, irrespective of the study group. CONCLUSION: Arterial hypertension reduces global and segmental systolic and diastolic left ventricular S/SR parameters. Impaired relaxation determined by SR E is the dominant factor of diastolic dysfunction, whereas end-diastolic compliance (by SR A) does not seem to be influenced by different degrees of hypertension. Segmental strain, SR E and SR A provide new insights into the LV cardio mechanics in hypertensive hearts.

Circulatory Response to Rapid Volume Expansion and Cardiorespiratory Fitness in Fontan Circulation.

The role of dysfunction of the single ventricle in Fontan failure is incompletely understood. We aimed to evaluate hemodynamic responses to preload increase in Fontan circulation, to determine whether circulatory limitations in different locations identified by experimental preload increase are associated with cardiorespiratory fitness (CRF), and to assess the impact of left versus right ventricular morphology. In 38 consecutive patients (median age = 16.6 years, 16 females), heart catheterization was supplemented with a rapid 5-mL/kg body weight volume expansion. Central venous pressure (CVP), ventricular end-diastolic pressure (VEDP), and peak systolic pressure were averaged for 15‒30 s, 45‒120 s, and 4‒6 min (steady state), respectively. CRF was assessed by peak oxygen consumption (VO2peak) and ventilatory threshold (VT). Median CVP increased from 13 mmHg at baseline to 14.5 mmHg (p < 0.001) at steady state. CVP increased by more than 20% in eight patients. Median VEDP increased from 10 mmHg at baseline to 11.5 mmHg (p < 0.001). Ten patients had elevated VEDP at steady state, and in 21, VEDP increased more than 20%. The transpulmonary pressure difference (CVP‒VEDP) and CVP were consistently higher in patients with right ventricular morphology across repeated measurements. CVP at any stage was associated with VO2peak and VT. VEDP after volume expansion was associated with VT. Preload challenge demonstrates the limitations beyond baseline measurements. Elevation of both CVP and VEDP are associated with impaired CRF. Transpulmonary flow limitation was more pronounced in right ventricular morphology. Ventricular dysfunction may contribute to functional impairment after Fontan operation in young adulthood.ClinicalTrials.gov identifier NCT02378857.

Echocardiographic assessment of diastolic dysfunction in elderly patients with severe aortic stenosis before and after aortic valve replacement.

BACKGROUND: The 2016 guidelines of the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) for evaluation of left ventricular (LV) diastolic dysfunction by Doppler flow and tissue Doppler- echocardiography do not adjust assessment of high filling pressures for patients with aortic stenosis (AS). However, most of the studies on this patient group indicate age independent specific diastolic features in AS. The aim of this study is to identify disease-specific range and distribution of diastolic functional parameters and their ability to identify high N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels as a marker for high filling pressures. METHODS: In this study, 169 patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Resting echocardiography was performed including Doppler of the mitral inflow, pulmonary venous flow, tricuspid regurgitant flow and tissue Doppler in the mitral ring and indexed volume-estimates of the left atrium (LAVI). Echocardiography, and NT-proBNP levels were assessed before TAVR/SAVR and at two postoperative visits at 6 and 12 months. RESULTS: Pre- and postoperative values were septal e'; 5.1 ± 3.9, 5.2 ± 1.6 cm/s; lateral e' 6.3 ± 2.1; 7.7 ± 2.7 cm/s; E/e'19 ± 8; 16 ± 7 cm/s; E velocity 96 ± 32; 95 ± 32 cm/s; LAVI 39 ± 8; 36 ± 8 ml/m2, pulmonary artery pressure (PAP) 39 ± 8; 36 ± 8 mmHg, respectively. The scoring recommended by ASE/EACVI detected elevated NT pro-BNP with a specificity of 25%. Adjusting thresholds towards PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E deceleration time < 220 ms, and E/septal e' ≥ 20 or septal e' < 5.0 cm/s increased prediction of NT-proBNP levels ≥500 ng/L with substantially improved specificity (> 85%). CONCLUSION: Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and NT-proBNP indicate elevated filling pressures in most of the patients, improving only modestly 6-12 months after TAVR and SAVR. Applying the 2016 ASE/EACVI recommendations for detection of elevated filling pressures to patients with AS, elevated NT pro-BNP levels could not be reliably detected. However, adjusting thresholds of the echocardiographic parameters increased specificities to useful diagnostic levels. TRIAL REGISTRATION: The study was prospectively approved by the regional ethical committee, REK North with the registration number: REK 2010/397-10 .

Left atrial diameter, left ventricle filling indices, and association with all-cause mortality: Results from the population-based Tromsø Study.

AIMS: To examine the associations between diastolic dysfunction indices and long-term risk of all-cause mortality in adults over 23-year follow-up. METHODS AND RESULTS: Participants (n = 2734) of the population-based Tromsø Study of Norway had echocardiography in 1994-1995. Of these 67% were repeated in 2001 and/or 2007-2008. Mortality between 1994 and 2016 was determined by linkage to the national death registry. Cox regression was used to model the hazard of all-cause mortality in relation to left atrial parameters (treated as time-dependent using repeated measurements) adjusted for traditional risk factors and cardiovascular disease. During the follow-up, 1399 participants died. Indexed left atrial diameter, mitral peak E deceleration time, and mitral peak E to peak A ratio showed an U-shaped association with all-cause mortality. Combining left atrial diameter with mitral peak E deceleration time increased the prognostic accuracy for all-cause mortality whereas adding mitral peak E to peak A ratio did not increase prognostic value. We estimated new optimal cutoff values of left atrial diameter, mitral peak E deceleration time, and mitral peak E to peak A ratio for all-cause mortality outcome. E/e' had a cubic relation to mortality. CONCLUSION: Both enlarged and small left atrial diameters were associated with increased all-cause mortality risk. A combination of Doppler-based left ventricle filling parameters had an incremental effect on all-cause mortality risk. The cutoff values of diastolic dysfunction indices we determined had similar all-cause mortality prediction ability as those recommended by American Association of Echocardiography and European Association of Cardiovascular Imaging.

Ventricular mechanics in adolescent and adult patients with a Fontan circulation: Relation to geometry and wall stress.

BACKGROUND: Patients with single ventricle physiology and Fontan circulation are at increased risk for late complications and reduced survival. The aim of the study was to investigate the correlation between ventricular geometry and systolic regional function in different underlying anatomic conditions in adolescent and adult Fontan-palliated patients. METHOD: In a retrospective cross-sectional study, we measured 2D strain, ventricular diameters, ventricular volumes, ejection fraction (EF), global and segmental wall stress, and sphericity index. The same analyses were performed in 99 age- and gender-matched healthy individuals. RESULTS: One hundred and one patients were included at a mean age of 21 (range 14-59) years. In comparison with healthy subjects, patients with Fontan circulation displayed larger ventricular volumes (153 ± 78 mL vs 116 ± 38 mL P < 0.05), reduced EF (43% ± 15% vs 55% ± 8% P < 0.05), reduced longitudinal (-13% ± 6% vs -21% ± 4% P < 0.05) and circumferential strain values (-15% ± 7% vs -22% ± 4% P < 0.05). Functionally single ventricles were more spherical (ratio of longitudinal to short-axis diameters 1.3 ± 0.3 vs 1.7 ± 0.2 P < 0.05). Circumferential strain correlated well with global wall stress and the degree of sphericity (R2  = 0.320), while segmental strain did not correlate with segmental wall stress. The percentage of segments with akinesia was relatively high (16 ± 16% vs 0 ± 0% P < 0.05) indicating reduced segmental contractile function. CONCLUSION: Functionally single ventricles after Fontan palliation have significantly reduced systolic regional and global function with a high intersegmental inhomogeneity. The underlying pathological mechanisms might be multifactorial, including ventricular geometry, sphericity, and regional contractile properties. Future studies are needed to investigate the role of ventricular geometry for clinical performance and outcome.

Assessment of myocardial ischemia by strain dobutamine stress echocardiography and cardiac magnetic resonance perfusion imaging before and after coronary artery bypass grafting.

BACKGROUND: Following coronary artery bypass grafting (CABG), testing for myocardial ischemia by noninvasive imaging is often hampered by false-positive results. The aim of this study was to find test parameters with the best potential to identify myocardial ischemia in post-CABG patients. METHODS: Fifty-two consecutive patients scheduled for CABG, underwent both dobutamine stress echocardiography (DSE) and cardiac magnetic resonance first-pass perfusion imaging (CMR-FPPI) with adenosine vasodilation, before and 8-10 months after the surgical revascularization. A pathologic biphasic stress response (PBR) expresses the presence of contractile reserve during low-dose dobutamine that decreases to hypo- or akinesia provoked by high-dose dobutamine. During DSE, potential PBR, segmental wall-motion score (WMS) as well as peak-systolic longitudinal strain (PLS) at peak-dose dobutamine were assessed. RESULTS: Post-CABG, there was still a relatively high prevalence of ischemia-positive segments evaluated by deformation imaging, but the number of such segments was significantly lower by PBR (20% and 22%) compared with peak-dose strain and WMS (62% and 77%, respectively; P<.05). The use of PBR instead of peak-dose WMS and strain could reduce the number of false-positive test results post-CABG. CONCLUSION: Among all imaging modalities tested, PBR by WMS and strain may be useful parameters for identifying patients with the need for new revascularization. We furthermore found that DSE may be interpreted as positive when revealing at least three ischemia-positive segments. The sensitivity of these test modalities for detecting coronary restenosis needs to be determined in further studies on a cohort of symptomatic post-CABG patients.

Changes in Right Ventricular Shape and Deformation Following Coronary Artery Bypass Surgery-Insights from Echocardiography with Strain Rate and Magnetic Resonance Imaging.

BACKGROUND: This study was designed to assess whether altered RV geometry and deformation parameters persisted well into the recovery period after presumably uncomplicated coronary artery bypass grafting (CABG). It was our hypothesis that the altered geometry of and load in the RV following pericardial opening would change both regional and global deformation indices for an extensive period postoperatively. METHODS AND RESULTS: Fifty-seven patients scheduled for CABG underwent preoperative and 8-10 months postoperative magnetic resonance imaging (MRI) for RV volume measurements, and resting echocardiography with assessment of geometry and RV mechanical function determined by tissue Doppler imaging (TDI) based longitudinal strain. Both MRI and echocardiography revealed postoperative dilatation of the RV apex, shortened longitudinal RV length but unchanged RV ejection fraction. Echocardiography parameters associated with filling of the right atrium showed signs of constraint with a reduced systolic filling fraction and increased right atrial size. Right ventricular segmental strain (-20 ± 13% vs. -29 ± 20% preoperatively; mean ±SD, P < 0.0001) was reduced postoperatively in parallel with TAPSE (1.3 ± 0.3 cm vs. 2.2 ± 0.4 cm; P < 0.0001). CONCLUSION: Post-CABG longitudinal motion of the RV lateral wall is reduced after uneventful CABG despite preserved RV ejection fraction and stroke volume. The discrepancy in various RV systolic performance indicators results from increased sphericity of the RV following opening the pericardium during surgery. Therefore, longitudinal functional parameters may underestimate RV systolic function for at least 8-10 months post-CABG. Changes in deformation parameters should thus always be interpreted in relation to changes in geometry.

Transcatheter aortic valve implantation (from inception to standard treatment): a single-center observational study.

Background: Treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) was introduced in 2002. Since then, TAVI has become the primary treatment approach worldwide for advanced-age patients and younger patients with severe comorbidities. We aimed to evaluate the changes in patient demographics, complications, and mortality rates within 13 years. Methods: This retrospective observational study included 867 patients who underwent TAVI at the University Hospital of North Norway in Tromsø from 2008 to 2021. The 13-year period was divided into period 1 (2008-2012), period 2 (2013-2017), and period 3 (2018-2021). The primary objective was to evaluate the changes in periprocedural (30 days), early (30-365 days), and late mortality rates (>365 days) between the periods. The secondary objective was to evaluate late mortality rates by sex and age groups: <70 years, 70-79 years, 80-89 years, and ≥90 years. Results: The periprocedural mortality rates for periods 1, 2, and 3 were 10.3%, 2.9%, and 1.2%, respectively (P < 0.001). The early mortality rates were 5.6%, 5.8%, and 6.5%, respectively. No significant differences were observed in late mortality by sex or age group (<70, 70-79, and 80-89 years) with a median survival of 5.3-5.6 years. The median survival in patients aged ≥90 years was 4.0 years (P = 0.018). Conclusion: Our findings indicate that most patients are octogenarians, and the burden of their comorbidities should be highly considered compared to their age when evaluating the procedural outcomes. As the incidence of most complications related to TAVI has decreased, the rates of permanent pacemaker implantation remain high. Important advancements in diagnostics, valve technology, and procedural techniques have improved the periprocedural mortality rates; however, early mortality remains unchanged and poses a clinical challenge that needs to be addressed in the future.

Resting segmental speckle tracking strain and strain rate in stable coronary artery disease and revascularized myocardial infarction.

Patients with acute coronary artery disease (CAD) exhibit reduced global and regional strain and strain rate (S/SR). However, knowledge about segmental S/SR in stable CAD patients is still limited. This study aimed to investigate whether resting segmental S/SR measurements differ in patients with chronic chest pain who have normal coronary arteries or stenotic coronary arteries, and to compare these measurements to those in patients with revascularized myocardial infarction (MI). We prospectively enrolled 510 patients with chronic chest pain referred for coronary computed tomography angiography (CCTA) and 102 patients revascularized after MI. All participants underwent transthoracic echocardiography featuring S/SR analysis. In addition to the patients with MI, patients with suspected CAD based on CCTA findings subsequently underwent invasive coronary angiography (CAG). We assessed global longitudinal strain (GLS) and averaged segmental peak longitudinal strain during systole (PLS), peak systolic strain rate (SRs), peak early diastolic strain rate (SRe), and post systolic shortening (PSS). We also determined functionally reduced segment percentages using differing S/SR cut-off values. There were significant disparities in all average segmental S/SR metrics between the No-CAD and MI groups. SRe was the only S/SR metric that differed significantly between the No-CAD and PCI groups. Differences in SRe, PLS and GLS measurements were observed between the No-CAD and CABG groups. The proportion of diminished segmental S/SR mirrored these findings. For the percentage of pathological segments with varying cut-off values, segmental SRe below 1.5 s- 1 displayed the most marked difference among the four groups (p < 0.001). Revascularized MI patients or those referred to CABG present with diminished segmental S/SR values. However, among patients with chronic chest pain, only segmental SRe discerns subtle disparities between the No-CAD and the PCI group. The diagnostic accuracy of SRe warrants further exploration in subsequent studies.

Insomnia and sleep-disordered breathing in FKRP-related limb-girdle muscular dystrophy R9. The Norwegian LGMDR9 cohort study (2020).

Limb-girdle muscular dystrophy R9 (LGMDR9) is a progressive and disabling genetic muscle disease. Sleep is relevant in the patient care as it impacts on health, functioning, and well-being. LGMDR9 may potentially affect sleep by physical or emotional symptoms, myalgia, or sleep-disordered breathing (SDB) through cardiorespiratory involvement. The objective was to investigate the occurrence of insomnia and unrecognized or untreated SDB in LGMDR9, associated factors, and relationships with fatigue and health-related quality of life (HRQoL). All 90 adults in a Norwegian LGMDR9 cohort received questionnaires on sleep, fatigue, and HRQoL. Forty-nine of them underwent clinical assessments and 26 without mask-based therapy for respiration disorders additionally underwent polysomnography (PSG) and capnometry. Among 77 questionnaire respondents, 31% received mask-based therapy. The prevalence of insomnia was 32% of both those with and without such therapy but was significantly increased in fatigued respondents (54% vs 21%). Insomnia levels correlated inversely with mental HRQoL. Among 26 PSG candidates, an apnea-hypopnea index (AHI) ≥ 5/h was observed in 16/26 subjects (≥ 15/h in 8/26) with median 6.8 obstructive apneas and 0.2 central apneas per hour of sleep. The AHI was related to advancing age and an ejection fraction < 50%. Sleep-related hypoventilation was detected in one subject. Fatigue severity did not correlate with motor function or nocturnal metrics of respiration or sleep but with Maximal Inspiratory Pressure (r = - 0.46). The results indicate that insomnia and SDB are underrecognized comorbidities in LGMDR9 and associated with HRQoL impairment and heart failure, respectively. We propose an increased attention to insomnia and SDB in the interdisciplinary care of LGMDR9. Insomnia and pulmonary function should be examined in fatigued patients.

Long-term cardiac effects of modern treatment for Hodgkin's lymphoma.

BACKGROUND: Hodgkin's lymphoma (HL) is a hematological malignancy that affects both children and young adults. Traditional treatment is associated with a life-time prevalence of cardiac disease exceeding 50%. In the late 1990s protocols were modified to reduce cancer therapy-related adverse cardiac effects. This study aimed to assess the long-term impact of advances in treatment protocols on the cardiac health of HL survivors (HLS). METHODS: HLS (n = 246) treated between 1997 and 2007 with anthracycline-based chemotherapy in three centers in Norway were included. Of these, 132 (53%) had also received mediastinal radiotherapy. HLS were compared to controls (n = 58) recruited from the general population and matched for sex, age, smoking status, and heredity for coronary artery disease. All subjects underwent echocardiography, clinical assessment, and blood sampling. RESULTS: The HLS were 46 ± 9 years old and had been treated 17 ± 3 years before inclusion in the study. There was no significant difference between HLS and controls in ejection fraction (EF) (58%±5 vs. 59%±4, p = 0.08) or prevalence of heart failure. HLS treated with both anthracyclines and mediastinal radiotherapy (AC + MRT) had slightly worse left ventricular global longitudinal strain than controls (-19.3 ± 2.5% vs. -20.8 ± 2.0%, p < 0.001), but those treated with only anthracyclines did not. HLS treated with AC + MRT had a higher prevalence of valve disease than those treated only with anthracyclines (12% vs. 4%, p < 0.05). CONCLUSIONS: HLS treated with anthracyclines after the late 1990s have similar cardiac function and morphology as age-matched controls, apart from higher rates of valvular disease in those who also underwent mediastinal radiotherapy.

Atrial Strain and Strain Rate in a General Population: Do These Measures Improve the Assessment of Elevated NT-proBNP Levels?

Background: Noninvasive assessment of elevated filling pressure in the left ventricle (LV) remains an unresolved problem. Of the many echocardiographic parameters used to evaluate diastolic pressure, the left atrial strain and strain rate (LA S/SR) have shown promise in clinical settings. However, only a few previous studies have evaluated LA S/SR in larger populations. Methods: A total of 2033 participants from Norwegian (Tromsø 7) and Russian (Know Your Heart) population studies, equally distributed by age and sex, underwent echocardiography, including atrial and ventricular S/SR and NT-proBNP measurements. Of these, 1069 were identified as healthy (without hypertension (HT), atrial fibrillation (AF), or structural cardiac disease) and were used to define the age- and sex-adjusted normal ranges of LA S/SR. Furthermore, the total study population was divided into groups according to ejection fraction (EF) ≥50%, EF <50%, and AF. In each group, uni- and multiple regression and receiver operating characteristic curve analyses were performed to test LA and LV functional parameters as potential indicators of NT-proBNP levels above 250 ng/ml. Results: The mean LA S/SR values in this study were higher than those in previous large studies, whereas the lower references were comparable. In normal hearts, atrial total strain (ATS) and mitral valve E deceleration time (MV DT) were independent factors indicating elevated NT-proBNP levels, whereas in hearts with reduced EFs, the independent indicators were peak atrial contraction strain (PACS) and LV stroke volume. The areas under the curve for these significant indicators to discriminate elevated NT-proBNP levels were 0.639 (95% confidence interval (CI): 0.577-0.701) for normal EF and 0.805 (CI: 0.675-0.935) for reduced EF. Conclusion: The results confirm good intrastudy reproducibility, with mean values in the upper range of previous meta-analyses. In the future, automated border-detection algorithms may be able to generate highly reproducible normal values. Furthermore, the study showed atrial S/SR as an additional indicator of elevated NT-proBNP levels in the general population, demonstrating the incremental value of both ATS and PACS in addition to conventional and ventricular strain echocardiography. Thus, the LA S/SR may be regarded as an important addition to the multiparametric approach used for evaluating LV filling.

Automatic measurements of left ventricular volumes and ejection fraction by artificial intelligence: clinical validation in real time and large databases.

AIMS: Echocardiography is a cornerstone in cardiac imaging, and left ventricular (LV) ejection fraction (EF) is a key parameter for patient management. Recent advances in artificial intelligence (AI) have enabled fully automatic measurements of LV volumes and EF both during scanning and in stored recordings. The aim of this study was to evaluate the impact of implementing AI measurements on acquisition and processing time and test-retest reproducibility compared with standard clinical workflow, as well as to study the agreement with reference in large internal and external databases. METHODS AND RESULTS: Fully automatic measurements of LV volumes and EF by a novel AI software were compared with manual measurements in the following clinical scenarios: (i) in real time use during scanning of 50 consecutive patients, (ii) in 40 subjects with repeated echocardiographic examinations and manual measurements by 4 readers, and (iii) in large internal and external research databases of 1881 and 849 subjects, respectively. Real-time AI measurements significantly reduced the total acquisition and processing time by 77% (median 5.3 min, P < 0.001) compared with standard clinical workflow. Test-retest reproducibility of AI measurements was superior in inter-observer scenarios and non-inferior in intra-observer scenarios. AI measurements showed good agreement with reference measurements both in real time and in large research databases. CONCLUSION: The software reduced the time taken to perform and volumetrically analyse routine echocardiograms without a decrease in accuracy compared with experts.

Gender Differences in Cardiac Organ Damage in Arterial Hypertension: Assessing the Role of Drug Nonadherence.

INTRODUCTION: Cardiac organ damage like left ventricular (LV) hypertrophy and left atrial (LA) enlargement is more prevalent in women than men with hypertension, but the mechanisms underlying this gender difference remain unclear. METHODS: We tested the association of drug nonadherence with the presence of LV hypertrophy and LA enlargement by echocardiography in 186 women and 337 men with uncontrolled hypertension defined as daytime systolic blood pressure (BP) ≥ 135mmHg despite the prescription of at least two antihypertensive drugs. Drug adherence was assessed by measurements of serum drug concentrations interpreted by an experienced pharmacologist. Aldosterone-renin-ratio (ARR) was measured on actual medication. RESULTS: Women had a higher prevalence of LV hypertrophy (46% vs. 33%) and LA enlargement (79% vs 65%, both p < 0.05) than men, while drug nonadherence (8% vs. 9%, p > 0.514) did not differ. Women were older and had lower serum renin concentration and higher ARR than men, while 24-h systolic BP (141 ± 9 mmHg vs. 142 ± 9 mmHg), and the prevalences of obesity (43% vs. 50%) did not differ (all p > 0.10). In multivariable analyses, female gender was independently associated with a two-fold increased risk of LV hypertrophy (OR 2.01[95% CI 1.30-3.10], p = 0.002) and LA enlargement (OR 1.90 [95% CI 1.17-3.10], p = 0.010), while no association with drug nonadherence was found. Higher ARR was independently associated with LV hypertrophy in men only (OR 2.12 [95% CI 1.12-4.00] p = 0.02). CONCLUSIONS: Among patients with uncontrolled hypertension, the higher prevalence of LV hypertrophy and LA enlargement in women was not explained by differences in drug nonadherence. REGISTRATION: URL:  https://www. CLINICALTRIALS: gov ; Unique identifier: NCT03209154.

Peak longitudinal strain most accurately reflects myocardial segmental viability following acute myocardial infarction - an experimental study in open-chest pigs.

BACKGROUND: The extension and the transmurality of the myocardial infarction are of high predictive value for clinical outcome. The aim of the study was to characterize the ability of longitudinal, circumferential and radial strain measured by 2-dimensional speckle tracking echocardiography (2D-STE) to predict the extent of necrosis in myocardial segments following acute myocardial infarction and to separate transmural necrotic segments from non-transmural necrotic segments in a full 18-segment porcine model. METHODS: 2D-STE strain was assessed in long- and short-axis following myocardial infarction in ten open-chest anesthetized pigs. Strain was defined according to systolic peak values. In segments displaying both negative and positive peaks, only the peak with the highest absolute value was utilized. Necrosis was measured by 2,3,5-triphenyltetrazolium chloride (TTC) staining and expressed as percent of each myocardial segment. RESULTS: Significant correlations were found between the extension of necrosis and all measured parameters of myocardial deformation (p < 0.001), but was stronger for longitudinal strain (r(2) = 0.52) than circumferential strain (r(2) = 0.38) and radial strain (r(2) = 0.23). The area under the receiver operator characteristic curve (AUC) for separating transmural necrotic segments (>50% necrosis) from predominantly viable segments (0-50% necrosis) was significantly larger for longitudinal strain (AUC = 0.98, CI = 0.97-1.00) when compared with circumferential strain (AUC = 0.91, CI = 0.84-0.97, p < 0.05) and radial strain (AUC = 0.90, CI = 0.83 - 0.96, p < 0.01), indicating a stronger ability of longitudinal strain to identify segments with transmural necrosis. CONCLUSION: Peak strain values derived from 2D-STE correlate well with the extent of necrosis in myocardial segments following acute myocardial infarction. Longitudinal strain most accurately reflects myocardial segmental viability in this setting.

Classic-Pattern Dyssynchrony Is Associated with Outcome in Patients with Fontan Circulation.

BACKGROUND: Morbidity and mortality increase as Fontan patients age into adulthood. Limited studies have examined cardiac magnetic resonance and echocardiographic parameters to predict death and transplantation in children after the Fontan operation. The aim of this study was to investigate echocardiographic parameters in adolescents and adults after Fontan operation, including myocardial mechanics such as classic-pattern dyssynchrony (CPD), as predictors of transplantation or death. METHODS: In a cross-sectional retrospective study, strain analysis was performed on echocardiographic studies performed between 2001 and 2015 on 110 patients with single-ventricle physiology after the Fontan procedure. Strain curves were measured and visually assessed for the presence of CPD. The primary end point was death or transplantation after a follow-up period of 85 ± 35 months after echocardiography. RESULTS: The median age at the date of echocardiography was 20 years (range, 3-45 years). Of 110 patients, 28 had undergone transplantation. During the study period, three patients died after transplantation and seven patients died without undergoing transplantation. CPD was seen in 16 and protein-losing enteropathy in 21 of 110 patients. On multivariate analysis, CPD (hazard ratio [HR], 9.4; 95% confidence interval [CI], 2.6-34.6), protein-losing enteropathy (HR, 10.6; 95% CI, 3.4-33.2), systolic blood pressure (HR, 0.954; 95% CI, 0.913-0.996), systolic/diastolic duration ratio (HR, 6.83; 95% CI, 1.33-35.0), and E-wave deceleration time (HR, 0.98; 95% CI, 0.97-0.99) were independently associated with the primary end point. CONCLUSIONS: CPD, protein-losing enteropathy, and systolic and diastolic ventricular dysfunction are significantly associated with transplantation or death in Fontan-operated patients. In selected patients, the presence of CPD may be a basis to investigate cardiac resynchronization therapy as a treatment strategy.

Novel approach to artefact detection and the definition of normal ranges of segmental strain and strain-rate values.

AIMS: Strain artefacts are known to hamper the correct interpretation of segmental strain and strain-rate (S/SR). Defining the normal ranges of myocardial segmental deformation is important in clinical studies and routine echocardiographic practice. In order to define artefact-free normal ranges for segmental longitudinal S/SR parameters, we investigated the extent to which different types of artefacts and their segmental localisation in the three different myocardial layers created a bias in the results of echocardiographic strain measurements. METHODS: The study included echocardiograms from men and women aged 40-69 years from two population-based studies, namely the Know Your Heart study (Russia) and the Tromsø Study (Norway). Of the 2207 individuals from these studies, 840 had normal results, defined as the absence of hypertension or indicators of any cardiovascular disease. Two-dimensional (2D) global and segmental S/SR of the three myocardial layers were analysed using speckle tracking echocardiography. Artefacts were assessed with two different methods: visual identification of image-artefacts and a novel conceptual approach of 'curve-artefacts' or unphysiological strain-curve formation. RESULTS: Segmental strain values were found to have significantly reduced in the presence of strain-curve artefacts (14.9%±5.8% towards -20.7%±4.9%), and increased with the foreshortening of the 2D image. However, the individual global strain values were not substantially altered by discarding segmental artefacts. Reduction due to artefacts was observed in all segments, layers, systolic and diastolic strain, and SR. Thus, we presented normal ranges for basal-septal, basal, medial and apical segment groups after excluding artefacts. CONCLUSION: Strain-curve artefacts introduce systematic errors, resulting in reduced segmental S/SR values. In terms of artefact-robust global longitudinal strain, the detection of curve-artefacts is crucial for the correct interpretation of segmental S/SR patterns. Intersegmental S/SR gradients and artefacts need to be considered for the correct definition of normalcy and pathology.

Quality Assurance of Segmental Strain Values Provided by Commercial 2-D Speckle Tracking Echocardiography Using in Silico Models: A Report from the EACVI-ASE Strain Standardization Task Force.

The aim of this study was to determine the accuracy and reproducibility of vendor-specific regional strain values by echocardiography using in silico data. Synthetic 2-D ultrasound gray-scale images of the left ventricle (LV) were generated with knowledge of the longitudinal segmental strain values from the underlying electromechanical LV model. Four of five models mimicked transmural infarctions with systolic segmental stretching in different vascular areas. Cine loops in the three apical views were synthetically generated at four noise levels. All in silico images were repeatedly analyzed by a single investigator and some by another investigator. The absolute errors varied significantly between vendors from 3.3 ± 3.1% to 11.2 ± 5.9%. The area under the curve for the identification of segmental stretching ranged from 0.80 (confidence interval: 0.77-0.83) to 0.96 (0.95-0.98). The levels of agreement for intra-investigator variability varied between -3.0% to 2.9% and -5.2% to 4.8%, and for inter-investigator variability, between -3.6% to 3.5% and -14.5% to 8.5%. Segmental strain analysis allows the identification of areas with segmental stretching with good accuracy. However, single segmental peak-strain values are not accurate and should be interpreted with caution. Nevertheless, our results indicate the usefulness of semiquantitative strain assessment for the detection of regional dysfunction.

Clinical and Echocardiographic Parameters Predicting 1- and 2-Year Mortality After Transcatheter Aortic Valve Implantation.

Background: Transcatheter aortic valve implantation (TAVI) has become a standard treatment option for patients with symptomatic aortic stenosis. Elderly high-risk patients treated with TAVI have a high residual mortality due to preexisting comorbidities. Knowledge of factors predicting futility after TAVI is sparse and clinical tools to aid the preoperative evaluation are lacking. The aim of this study was to evaluate if echocardiographic measures, including speckle-tracking analysis, in addition to clinical parameters, could aid in the prediction of mortality beyond 30 days after TAVI. Methods: This prospective observational cohort study included 227 patients treated with TAVI at the University Hospital of North Norway, Tromsø and Oslo University Hospital, Rikshospitalet from February 2010 to June 2013. All the patients underwent preoperative echocardiographic evaluation with retrospective speckle-tracking analysis. Primary endpoints were 1- and 2-year mortality beyond 30 days after TAVI. Results: All-cause 1- and 2-year mortality beyond 30 days after TAVI was 12.1 and 19.5%, respectively. Predictors of 1-year mortality beyond 30 days were body mass index [hazard ratio (HR): 0.88, 95% CI: 0.80-0.98, p = 0.018], previous myocardial infarction (HR: 2.69, 95% CI: 1.14-6.32, p = 0.023), and systolic pulmonary artery pressure ≥ 60 mm Hg (HR: 5.93, 95% CI: 1.67-21.1, p = 0.006). Moderate-to-severe mitral regurgitation (HR: 2.93, 95% CI: 1.53-5.63, p = 0.001), estimated glomerular filtration rate (HR: 0.98, 95% CI: 0.96-0.99, p = 0.002), and chronic obstructive pulmonary disease (HR: 1.9, 95% CI: 1.01-3.58, p = 0.046) were predictors of 2-year mortality. Conclusion: Both the clinical and echocardiographic parameters should be considered when evaluating high-risk patients for TAVI, as both are predictive of 1-and 2-year mortality. Our results support the importance of individual risk assessment using a multidisciplinary, multimodal, and individual approach.