Clinical Usefulness of Speckle-Tracking Echocardiography in Patients with Heart Failure with Preserved Ejection Fraction.

Heart failure with preserved ejection fraction (HFpEF) is defined as HF with left ventricular ejection fraction (LVEF) not less than 50%. HFpEF accounts for more than 50% of all HF patients, and its prevalence is increasing year to year with the aging population, with its prognosis worsening. The clinical assessment of cardiac function and prognosis in patients with HFpEF remains challenging due to the normal range of LVEF and the nonspecific symptoms and signs. In recent years, new echocardiographic techniques have been continuously developed, particularly speckle-tracking echocardiography (STE), which provides a sensitive and accurate method for the comprehensive assessment of cardiac function and prognosis in patients with HFpEF. Therefore, this article reviewed the clinical utility of STE in patients with HFpEF.

Decreased ventricular systolic function in chemotherapy-naive patients with acute myeloid leukemia: a three-dimensional speckle-tracking echocardiography study.

Background: The relationship between acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) and cardiac function is not well established. This study aimed to evaluate whether AML patients exist early myocardial damages prior to chemotherapy and to investigate its association with cardiovascular biomarkers. Methods: Conventional echocardiography and three-dimensional speckle-tracking strain analysis were performed prospectively in 72 acute leukemia (AL) patients before any chemotherapy therapy (of whom 44 were AML patients, 28 ALL patients). The results were compared with those from 58 control group matched for age and gender. Results: There were no significant differences in conventional biventricular systolic function parameters between AL patients and controls. The left ventricular global longitudinal strain (LVGLS) and right ventricular free wall longitudinal strain (RVFWLS) were significantly lower in AL patients (-23.0 ± 1.4% vs. -24.1 ± 1.3% and -27.9 ± 7.1% vs. -33.0 ± 4.6%, respectively, P < 0.001 for all). Compared with ALL patients, AML patients had lower LVGLS and RVFWLS (-22.7 ± 1.3% vs. -23.5 ± 1.6% and -26.2 ± 7.6% vs. -30.4 ± 5.5%, respectively, P < 0.05 for all). LVGLS was lower in ALL patients compared with controls (-23.5 ± 1.6% vs. -24.7 ± 1.4%, P < 0.05), however, there was no difference in right ventricular systolic function parameters between the two groups. LVGLS in AL patients was independently correlated with left ventricular ejection fraction (LVEF) and the absolute number of circulating lymphocytes. Conclusions: Our findings suggest that baseline myocardial systolic function is lower in AL patients than controls. AML patients had lower baseline LVGLS and RVFWLS than controls and ALL patients. The decreased LVGLS is correlated with LVEF and the absolute number of circulating lymphocytes.

Clinical Usefulness of Right Ventricle-Pulmonary Artery Coupling in Cardiovascular Disease.

Right ventricular-pulmonary artery coupling (RV-PA coupling) refers to the relationship between RV contractility and RV afterload. Normal RV-PA coupling is maintained only when RV function and pulmonary vascular resistance are appropriately matched. RV-PA uncoupling occurs when RV contractility cannot increase to match RV afterload, resulting in RV dysfunction and right heart failure. RV-PA coupling plays an important role in the pathophysiology and progression of cardiovascular diseases. Therefore, early and accurate evaluation of RV-PA coupling is of great significance for a patient's condition assessment, clinical decision making, risk stratification, and prognosis judgment. RV-PA coupling can be assessed by using invasive or noninvasive approaches. The aim of this review was to summarize the pathological mechanism and evaluation methods of RV-PA coupling, the advantages and disadvantages of each method, and the application value of RV-PA coupling in various cardiovascular diseases.

Clinical Utility of Strain Imaging in Assessment of Myocardial Fibrosis.

Myocardial fibrosis (MF) is a non-reversible process that occurs following acute or chronic myocardial damage. MF worsens myocardial deformation, remodels the heart and raises myocardial stiffness, and is a crucial pathological manifestation in patients with end-stage cardiovascular diseases and closely related to cardiac adverse events. Therefore, early quantitative analysis of MF plays an important role in risk stratification, clinical decision, and improvement in prognosis. With the advent and development of strain imaging modalities in recent years, MF may be detected early in cardiovascular diseases. This review summarizes the clinical usefulness of strain imaging techniques in the non-invasive assessment of MF.

Application of Speckle Tracking Echocardiography for Evaluating Ventricular Function after Transcatheter Pulmonary Valve Replacement.

Pulmonary regurgitation usually leads to right heart dilatation and eventually right heart dysfunction, which is associated with a poor prognosis. Transcatheter pulmonary valve replacement is a developing treatment for pulmonary valve dysfunction that can take the place of traditional surgery and make up for the shortcomings of a large injury. Echocardiography plays a significant role in assessing ventricular function; however, conventional echocardiographic parameters have several limitations. Speckle tracking echocardiography has been regarded as a more accurate tool for quantifying cardiac function than conventional echocardiography. Therefore, the aim of this review was to summarize the application of speckle tracking echocardiography for evaluating right and left ventricular functions in patients after transcatheter pulmonary valve replacement.

Clinical Utility of Three-Dimensional Speckle-Tracking Echocardiography in Heart Failure.

Heart failure (HF) is an extremely major health problem with gradually increasing incidence in developed and developing countries. HF may lead to cardiac remodeling; thus, advanced imaging techniques are required to comprehensively evaluate cardiac mechanics. Recently, three-dimensional speckle-tracking echocardiography (3D-STE) has been developed as a novel imaging technology that is based on the three-dimensional speckle-tracking on the full volume three-dimensional datasets. Three-dimensional speckle-tracking echocardiography allows a more accurate evaluation of global and regional myocardial performance, assessment of cardiac mechanics, detection of subclinical cardiac dysfunction, and prediction of adverse clinical events in a variety of cardiovascular diseases. Therefore, this review summarizes the clinical usefulness of 3D-STE in patients with HF.

Superior prognostic value of right ventricular free wall compared to global longitudinal strain in patients with repaired tetralogy of Fallot.

Objectives: Both right ventricular free wall longitudinal strain (RVFWLS) and right ventricular global longitudinal strain (RVGLS) using two-dimensional speckle tracking echocardiography (2D-STE) has been demonstrated to predict adverse outcomes in patients with repaired tetralogy of Fallot (r-TOF). However, RVGLS may be affected by left ventricular (LV) function owing to the fact that the interventricular septum is also a part of the left ventricle. Therefore, the aim of our study was to compare the predictive value of RVFWLS with that of RVGLS in patients with r-TOF. Materials and methods: A total of 179 patients with r-TOF were included in this study. RVFWLS, RVGLS, and left ventricle global longitudinal strain (LVGLS) were evaluated by 2D-STE. The adverse clinical events were death or r-TOF-related rehospitalization. Prognostic performance was evaluated by C-statistic and Akaike information criterion (AIC). Results: Thirty-one patients developed poor outcomes during a median follow-up period of 2.8 years. Compared with patients without end-point events, those with end-point events had higher incidence of moderate/severe pulmonary regurgitation, larger right heart sizes, and lower RV fractional area change (RVFAC), RVFWLS, RVGLS, and LVGLS than those without. Multivariate Cox regression analysis revealed that RVFAC, RVFWLS, RVGLS, and LVGLS were predictive of poor outcomes in patients with r-TOF after adjustment for transannular patch and QRS duration. A Cox model using RVFWLS (C index = 0.876, AIC = 228) was found to predict unfavorable outcomes more accurately than a model with RVGLS (C index = 0.856, AIC = 243), RVFAC (C index = 0.811, AIC = 248), and LVGLS (C index = 0.830, AIC = 248). Conclusion: Although both RVGLS and RVFWLS are associated with adverse events, RVFWLS provides superior prognostic value than that of RVGLS in patients with r-TOF.

Multimodality Imaging of Benign Primary Cardiac Tumor.

Primary cardiac tumors (PCTs) are rare, with benign PCTs being relatively common in approximately 75% of all PCTs. Benign PCTs are usually asymptomatic, and they are found incidentally by imaging. Even if patients present with symptoms, they are usually nonspecific. Before the application of imaging modalities to the heart, our understanding of these tumors is limited to case reports and autopsy studies. The advent and improvement of various imaging technologies have enabled the non-invasive evaluation of benign PCTs. Although echocardiography is the most commonly used imaging examination, it is not the best method to describe the histological characteristics of tumors. At present, cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT) are often used to assess benign PCTs providing detailed information on anatomical and tissue features. In fact, each imaging modality has its own advantages and disadvantages, multimodality imaging uses two or more imaging types to provide valuable complementary information. With the widespread use of multimodality imaging, these techniques play an indispensable role in the management of patients with benign PCTs by providing useful diagnostic and prognostic information to guide treatment. This article reviews the multimodality imaging characterizations of common benign PCTs.

Prognostic relevance of left atrial function and stiffness in heart failure with preserved ejection fraction patients with and without diabetes mellitus.

Background: Although the left atrium (LA) plays a key role in the pathophysiology and disease progression of heart failure with preserved ejection fraction (HFpEF), the impact of type 2 diabetes mellitus (T2DM) on LA function and stiffness in HFpEF patients remains unclear. Furthermore, the prognostic value of different phases of LA function and stiffness is less well-established in HFpEF patients. Methods: This study prospectively enrolled 164 HFpEF patients who were in sinus rhythm at the time of echocardiography, including 61 (37%) HFpEF patients with T2DM. LA reservoir, conduit, and pump function were assessed using two-dimensional volume indices and speckle tracking echocardiography. The LA stiffness was calculated as the ratio of early mitral inflow velocity-to-early annular tissue velocity (E/e') and LA reservoir function. The primary end point was a combined outcome of heart failure hospitalization or death. Results: Left atrium reservoir function [measured by peak LA strain (LAS-peak)] and LA pump function (measured by LAS-active) remained significantly lower in the HFpEF patients with T2DM compared with those without T2DM, even after adjustment for potential confounders. In addition, the LA stiffness of HFpEF patients with T2DM was higher than those without T2DM. After a median follow-up of 13.7 months, 46 patients (28.1%) reached the composite end point. LAS-peak (hazard ratios: 0.88; 95% confidence interval: 0.81-0.95; P = 0.001) was significantly associated with the risk of heart failure hospitalization or death after adjusting for demographic and clinical characteristics, LV global longitudinal strain, E/e', and LA volume index. In contrast, other LA function and stiffness parameters did not independently predict the risk of adverse events. Kaplan-Meier analysis showed that HFpEF patients with T2DM and low LAS-peak (<27.2%) had a significantly increased risk of heart failure-related hospitalization or death (log-rank P < 0.001). Conclusion: Left atrium reservoir and pump function are impaired, whereas LA stiffness is increased in HFpEF patients with T2DM compared with those without T2DM. LAS-peak is a powerful predictor of adverse clinical outcomes and may be crucial for risk stratification in HFpEF patients with and without T2DM.

Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia with significant morbidity and mortality. Exacerbated by the aging population, the prevalence of AF is gradually increasing. Accurate evaluation of structure and function of left atrium (LA) has important prognostic significance in patients with AF. Echocardiography is the imaging technique of first choice to assess LA structure and function due to its better availability, accessibility and safety over cardiac computed tomography and cardiac magnetic resonance. Therefore, the aim of this review is to summarize the recent research progress of evaluating LA size by three-dimensional echocardiography and LA function by speckle tracking echocardiography (STE) in predicting the occurrence and recurrence of AF and determining the risk of stroke in AF. In addition, we summarized the role of traditional echocardiography in detecting AF patients that are at high risk of heart failure or cardiovascular death.

Evaluation of Right Ventricular Myocardial Mechanics by 2- and 3-Dimensional Speckle-Tracking Echocardiography in Patients With an Ischemic or Non-ischemic Etiology of End-Stage Heart Failure.

Background: The aims of our study were (1) to assess the right ventricular (RV) myocardial mechanics by two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography (STE) in patients with an ischemic or non-ischemic etiology of end-stage heart failure (HF) and (2) to explore which RV index evaluated by 2D- and 3D-STE was the most powerful indicator for identifying the ischemic and non-ischemic etiologies of end-stage HF. Methods: A total of 96 patients with left ventricular ejection fraction (LVEF) < 30% were enrolled in our study: 42 patients (mean age, 52 ± 10 years; 9.5% female) with ischemic cardiomyopathy and 54 patients (mean age, 46 ± 14 years; 16.7% female) with non-ischemic cardiomyopathy. A total of 45 healthy subjects (mean age, 46 ± 13 years; 24.4% female) served as controls. The longitudinal strain of the RV free wall (RVFWLS) was determined by both 2D- and 3D-STE. Results: Compared to controls, patients with an ischemic or non-ischemic etiology of end-stage HF had lower 2D-RVFWLS, 3D-RVFWLS and RV ejection fraction (RVEF) values (P < 0.05). Patients with non-ischemic cardiomyopathies (NICMs) had significantly lower 3D-RVFWLS and RVEF values than in those with ischemic cardiomyopathies (ICMs), whereas 2D-RVFWLS and conventional RV function parameters did not differ between the two subgroups. RVEF was highly related to 3D-RVFWLS (r = 0.72, P < 0.001), modestly related to 2D-RVFWLS (r = 0.51, P < 0.001), and weakly related to conventional RV function indices (r = -0.26 to 0.46, P < 0.05). Receiver operating characteristic curve analysis revealed that the optimal 3D-RVFWLS cut-off value to distinguish NICM from ICM patients was -14.78% (area under the curve: 0.73, P < 0.001), while 2D-RVFWLS and conventional RV echocardiographic parameters did not. Conclusion: Our study demonstrated the superiority of 3D-RVFWLS over 2D-RVFWLS and conventional RV function indices in identifying the ischemic and non-ischemic etiologies of end-stage HF. These findings support the idea that 3D-RVFWLS may be a promising non-invasive imaging marker for distinguishing NICM from ICM.

Three-Dimensional Echocardiography Assessment of Right Ventricular Volumes and Function: Technological Perspective and Clinical Application.

Right ventricular (RV) function has important prognostic value in a variety of cardiovascular diseases. Due to complex anatomy and mode of contractility, conventional two-dimensional echocardiography does not provide sufficient and accurate RV function assessment. Currently, three-dimensional echocardiography (3DE) allows for an excellent and reproducible assessment of RV function owing to overcoming these limitations of traditional echocardiography. This review focused on 3DE and discussed the following points: (i) acquisition of RV dataset for 3DE images, (ii) reliability, feasibility, and reproducibility of RV volumes and function measured by 3DE with different modalities, (iii) the clinical application of 3DE for RV function quantification.

Dysbiosis of Cervical and Vaginal Microbiota Associated With Cervical Intraepithelial Neoplasia.

Cervical intraepithelial neoplasia (CIN) is a precancerous condition inducing local lesions on the surface of the squamocolumnar junction of the cervix. Despite the role of vaginal microbiota having been under-discussed, the role of the cervical microbiome and the microbial migration across the reproductive tract involved in CIN was limitedly studied. We aimed to synchronously characterize the dysbiosis associated with CIN in both the cervix and vagina in a Chinese population. Profiling of cervical and vaginal microbiota from 60 CIN women and 60 healthy women was conducted. 16S rRNA sequencing was adopted. By comparing the microbial profiles between different parts of the reproductive tract, our results demonstrated an increased shift of microbial diversity in the cervix compared with that in the vagina for the CIN patients, specifically in CIN 1. Less dysbiosis was found between the CIN patients and controls, in either the vagina or cervix. The microbial community may be modulated by the onset of sexual activity, a known clinical risk factor for cervical neoplasia. Distinct patterns of perturbated bacteria were found in the vaginal and cervical microbiota, in which reduced Actinobacteria-related operational taxonomic units (OTUs) and increased Proteobacteria-related OTUs were found in the vagina and cervix, respectively. A good agreement between the direction of the top-significant perturbated OTUs was observed between the vaginal and cervical microbiome, suggesting a potential microbial migration in the reproductive tract. Enriched genera such as Sphingomonas and Stenotrophomonas were found in cervical microbiota-associated CIN. Multivariate analysis revealed Comamonas, Rhizobium, and Pseudomonas as independent genera contributing to CIN in the cervix. In summary, this study revealed the perturbation of microbiota in the presence of CIN and demonstrated a distinct pattern of characteristic bacteria community between the vagina and cervix involved in the development of CIN.

Feasibility, Reproducibility, and Prognostic Value of Fully Automated Measurement of Right Ventricular Longitudinal Strain.

BACKGROUND: Right ventricular free wall longitudinal strain (RVFWLS) carries important diagnostic and prognostic significance in a variety of clinical settings, but its measurement is time consuming and operator dependent, limiting its value in routine clinical practice. Automated RVFWLS measurements can overcome these limitations. The purpose of this study was to determine the feasibility, reproducibility, and prognostic implications of automated RVFWLS compared with manual assessment of RVFWLS. METHODS: A total of 206 patients with a wide range of right ventricular (RV) function were retrospectively selected for this study. Fully automated (Auto-Strain), semiautomated (automated with editing), and manual (standard manual assessment) RVFWLS were measured using two-dimensional speckle-tracking echocardiography in the same RV-focused apical four-chamber view. RV ejection fraction (RVEF) was measured using three-dimensional echocardiography. Abnormal RV systolic function was defined as RVEF < 45%. Agreement for RVFWLS measurements among the three different methods was based on a combination of Pearson correlation, Bland-Altman analyses, and coefficients of variation (CVs). RESULTS: Automated RVFWLS measurements were feasible in 204 subjects (99%). Automated (8 ± 1 sec/patient) and semiautomated (50 ± 10 sec/patient) assessments had shorter analysis times compared with manual measurement (103 ± 25 sec/patient, P < .001 for both). Semiautomated RVFWLS had a stronger correlation with manual RVFWLS than automated RVFWLS (r = 0.850 vs r = 0.708, P < .001). Semiautomated RVFWLS had smaller biases, narrower limits of agreement (LOA), and lower CVs against manual assessment in comparison with the fully automated method in the whole study population (bias of 0.62 and 1.15, LOA of 6.54 and 10.50, and CVs of 9.3% and 16.9%, respectively), in the subgroup with RVEF < 45% (bias of 0.81 and 1.43, LOA of 6.32 and 10.42, and CVs of 10.2% and 18.6%, respectively), and in those with RVEF ≥ 45% (bias of 0.34 and 0.73, LOA of 6.86 and 10.63, and CVs of 8.0% and 14.5%, respectively). Seventy-six patients experienced adverse cardiovascular events during a median follow-up period of 26 months. Fully automated, semiautomated, and manual RVFWLS were associated with poor outcomes. The prognostic implications of fully automated RVFWLS were inferior to those of semiautomated and manual RVFWLS. Three RVFWLS measurements were highly reproducible. CONCLUSIONS: Both fully automated and semiautomated RVFWLS provide rapid and reproducible assessments of RV function and carry important prognostic implication. Moreover, the semiautomated approach performs better than the fully automated method. Therefore, semiautomated RVFWLS can provide a better balance between feasibility and clinical significance and displays potential for clinical application.

Right Ventricular Longitudinal Strain in Patients with Heart Failure.

Patients with heart failure (HF) have high morbidity and mortality. Accurate assessment of right ventricular (RV) function has important prognostic significance in patients with HF. However, conventional echocardiographic parameters of RV function have limitations in RV assessments due to the complex geometry of right ventricle. In recent years, speckle tracking echocardiography (STE) has been developed as promising imaging technique to accurately evaluate RV function. RV longitudinal strain (RVLS) using STE, as a sensitive index for RV function evaluation, displays the powerfully prognostic value in patients with HF. Therefore, the aim of the present review was to summarize the utility of RVLS in patients with HF.

Feasibility and Accuracy of a Fully Automated Right Ventricular Quantification Software With Three-Dimensional Echocardiography: Comparison With Cardiac Magnetic Resonance.

Background: A novel, fully automated right ventricular (RV) software for three-dimensional quantification of RV volumes and function was developed. The direct comparison of the software performance with cardiac magnetic resonance (CMR) was limited. Therefore, the aim of this study was to test the feasibility, accuracy, and reproducibility of a fully automated RV quantification software against CMR imaging as a reference. Methods: A total of 170 patients who underwent both CMR and three-dimensional echocardiography were enrolled. RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), and RV ejection fraction (RVEF) were obtained using fully automated three-dimensional RV quantification software and compared with a CMR reference. For inter-technical agreement, Spearman correlation and Bland-Altman analysis were used. Results: The fully automated RV quantification software was feasible in 149 patients. RVEDV and RVESV were underestimated, and RVEF was overestimated compared with CMR values. RV measurements obtained from the manual editing method correlated better with CMR values than that without manual editing (RVEDV, 0.924 vs. 0.794: RVESV, 0.955 vs. 0.854; RVEF, 0.941 vs. 0.781 respectively, all p < 0.0001) with less bias and narrower limit of agreement (LOA). The bias and LOA for RV volumes and EF using the automated software without and with manual editing were greater in patients with severely impaired RV function or low frame rate than those with normal and mild impaired RV function, or high frame rate. The fully automated RV three-dimensional measurements were highly reproducible. Conclusion: The novel fully automated RV software shows good feasibility and reproducibility, and the measurements had a high correlation with CMR values. These findings support the routine application of the novel 3D automated RV software in clinical practice.

Prognostic Value of Right Ventricular 3D Speckle-Tracking Strain and Ejection Fraction in Patients With HFpEF.

Background: Right ventricular longitudinal strain of free wall (RV FWLS) assessed by two-dimensional speckle-tracking echocardiography (2D-STE) is recognized as an independent predictor of poor prognosis in patients with heart failure with preserved ejection fraction (HFpEF). However, the prognostic implications of three-dimensional STE (3D-STE) parameters in patients with HFpEF have not been well-established. The purpose of our study was to determine whether 3D-STE parameters were the more powerful predictors of poor outcomes in HFpEF patients compared with 2D-STE indices. Methods: Eighty-one consecutive patients with HFpEF were studied by 2D-STE and 3D-STE. RV volumes, ejection fraction (EF) and 3D-RVFWLS were measured by 3D-STE. 2D-RVFWLS was determined by 2D-STE. Patients were followed for the primary end point of heart failure (HF)-related hospitalization and death for HF. Results: After a median follow-up period of 17 months, 39 (48%) patients reached the end point of cardiovascular events. Compared with HFpEF patients without end-point events, those with end-point events had lower RVEF and 3D-RVFWLS (P < 0.05). Separate multivariate Cox regression analyses revealed that 3D-RVFWLS (HR 5.73; 95% CI 2.77-11.85; P < 0.001), RVEF (HR 3.47; 95% CI 1.47-8.21; P = 0.005), and 2D-RVFWLS (HR 3.17; 95% CI 1.54-6.53; P = 0.002) were independent predictors of adverse outcomes. The models with 3D-RVFWLS (AIC = 246, C-index = 0.75) and RVEF (AIC = 247, C-index = 0.76) had similar predictive performance for future clinical events as with 2D-RVFWLS (AIC = 248, C-index = 0.74). Conclusions: 3D-STE parameters are powerful predictors of poor outcomes, providing a similar predictive value as 2D-STE indices in patients with HFpEF. These findings support the potential of RV 3D-STE to identify HFpEF patients at higher risk for adverse cardiac events.