Myocardial Inflammation in Heart Failure With Reduced and Preserved Ejection Fraction.

Heart failure (HF) is characterized by a progressive decline in cardiac function and represents one of the largest health burdens worldwide. Clinically, 2 major types of HF are distinguished based on the left ventricular ejection fraction (EF): HF with reduced EF and HF with preserved EF. While both types share several risk factors and features of adverse cardiac remodeling, unique hallmarks beyond ejection fraction that distinguish these etiologies also exist. These differences may explain the fact that approved therapies for HF with reduced EF are largely ineffective in patients suffering from HF with preserved EF. Improving our understanding of the distinct cellular and molecular mechanisms is crucial for the development of better treatment strategies. This article reviews the knowledge of the immunologic mechanisms underlying HF with reduced and preserved EF and discusses how the different immune profiles elicited may identify attractive therapeutic targets for these conditions. We review the literature on the reported mechanisms of adverse cardiac remodeling in HF with reduced and preserved EF, as well as the immune mechanisms involved. We discuss how the knowledge gained from preclinical models of the complex syndrome of HF as well as from clinical data obtained from patients may translate to a better understanding of HF and result in specific treatments for these conditions in humans.

Excess Mortality and Loss of Life Expectancy After Myocardial Infarction: A Registry-Based Matched Cohort Study.

BACKGROUND: The effect of myocardial infarction (MI) on life expectancy is difficult to study because the prevalence of MI hinders direct comparison with the life expectancy of the general population. We sought to assess this in relation to age, sex, and left ventricular ejection fraction (LVEF) by comparing individuals with MI with matched comparators without previous MI. METHODS: We included patients with a first MI between 1991 and 2022 from the nationwide SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), each matched with up to 5 comparators on age, sex, and region of residence. Flexible parametric survival models were used to estimate excess mortality and mean loss of life expectancy (LOLE) depending on index year, age, sex, and LVEF, and adjusted for differences in characteristics. RESULTS: A total of 335 748 cases were matched to 1 625 396 comparators. A higher LOLE was observed in younger individuals, women, and those with reduced LVEF (<50%). In 2022, the unadjusted and adjusted mean LOLE spanned from 11.1 and 9.5 years in 50-year-old women with reduced LVEF to 5 and 3.7 months in 80-year-old men with preserved LVEF. Between 1992 and 2022, the adjusted mean LOLE decreased by 36% to 55%: from 4.4 to 2.0 years and from 3.3 to 1.9 years in 50-year-old women and men, respectively, and from 1.7 to 1.0 years and from 1.4 to 0.9 years in 80-year-old women and men, respectively. CONCLUSIONS: LOLE is higher in younger individuals, women, and those with reduced LVEF, but is attenuated when adjusting for comorbidities and risk factors. Advances in MI treatment during the past 30 years have almost halved LOLE, with no clear sign of leveling off to a plateau.

The Characterization and Evaluation of the Soluble Triggering Receptor Expressed on Myeloid Cells-like Transcript-1 in Stable Coronary Artery Disease.

Platelets play crucial roles in the development and progression of coronary artery disease (CAD). The triggering receptor expressed in myeloid cells-like transcript-1 (TLT-1) is stored in platelet α granules, and activated platelets release a soluble fragment (sTLT-1). We set out to better characterize the constituent amino acids of sTLT-1 and to evaluate sTLT-1 for use as a biomarker in patients with stable CAD. We evaluated sTLT-1 release using immunoprecipitation and mass spectrometry and employed statistical methods to retrospectively correlate sTLT-1 concentrations, utilizing ELISA in plasma samples from 1510 patients with documented stable CAD. We identified TLT-1 residues to 133 in platelet releasates. ADAM17 cuts TLT-1, suggesting that S136 is the C-terminal amino acid in sTLT-1. Our results revealed that for CAD patients, sTLT-1 levels did not differ significantly according to primary outcomes of death or major cardiac event; however, patients with left ventricular (LV) dysfunction had significantly lower plasma sTLT-1 levels as compared to those with normal LV function (981.62 ± 1141 pg/mL vs. 1247.48 ± 1589 pg/mL; p = 0.003). When patients were stratified based on sTLT-1 peak frequency distribution (544 pg/mL), a significant association with congestive heart failure was identified (OR = 2.94; 1.040-8.282; p = 0.042), which could be explained by LV dysfunction.

Health-Related Quality of Life and Mortality in Heart Failure: The Global Congestive Heart Failure Study of 23 000 Patients From 40 Countries.

BACKGROUND: Poor health-related quality of life (HRQL) is common in heart failure (HF), but there are few data on HRQL in HF and the association between HRQL and mortality outside Western countries. METHODS: We used the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) to record HRQL in 23 291 patients with HF from 40 countries in 8 different world regions in the G-CHF study (Global Congestive Heart Failure). We compared standardized KCCQ-12 summary scores (adjusted for age, sex, and markers of HF severity) among regions (scores range from 0 to 100, with higher score indicating better HRQL). We used multivariable Cox regression with adjustment for 15 variables to assess the association between KCCQ-12 summary scores and the composite of all-cause death, HF hospitalization, and each component over a median follow-up of 1.6 years. RESULTS: The mean age of participants was 65 years; 61% were men; 40% had New York Heart Association class III or IV symptoms; and 46% had left ventricular ejection fraction ≥40%. Average HRQL differed between regions (lowest in Africa [mean± SE, 39.5±0.3], highest in Western Europe [62.5±0.4]). There were 4460 (19%) deaths, 3885 (17%) HF hospitalizations, and 6949 (30%) instances of either event. Lower KCCQ-12 summary score was associated with higher risk of all outcomes; the adjusted hazard ratio (HR) for each 10-unit KCCQ-12 summary score decrement was 1.18 (95% CI, 1.17-1.20) for death. Although this association was observed in all regions, it was less marked in South Asia, South America, and Africa (weakest association in South Asia: HR, 1.08 [95% CI, 1.03-1.14]; strongest association in Eastern Europe: HR, 1.31 [95% CI, 1.21-1.42]; interaction P<0.0001). Lower HRQL predicted death in patients with New York Heart Association class I or II and III or IV symptoms (HR, 1.17 [95% CI, 1.14-1.19] and HR, 1.14 [95% CI, 1.12-1.17]; interaction P=0.13) and was a stronger predictor for the composite outcome in New York Heart Association class I or II versus class III or IV (HR 1.15 [95% CI, 1.13-1.17] versus 1.09 [95% CI, [1.07-1.11]; interaction P<0.0001). HR for death was greater in ejection fraction ≥40 versus <40% (HR, 1.23 [95% CI, 1.20-1.26] and HR, 1.15 [95% CI, 1.13-1.17]; interaction P<0.0001). CONCLUSION: HRQL is a strong and independent predictor of all-cause death and HF hospitalization across all geographic regions, in mildly and severe symptomatic HF, and among patients with preserved and reduced ejection fraction. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078166.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials.

BACKGROUND: Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. METHODS: The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). RESULTS: Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. CONCLUSIONS: Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

[Sudden-onset dyspnea, cough and hemoptysis in a previously healthy 46-year-old female swimmer]. / Akut einsetzende Dyspnoe, Husten und Hämoptysen bei einer 46-jährigen bisher gesunden Schwimmerin.

This case report describes the case of a patient that developed suddenly dyspnea, cough and hemoptysis while swimming. Under the clinical presentation of pulmonary edema she required short-term invasive ventilation. Initially, echocardiography showed globally highly reduced systolic left ventricular function, which rapidly normalized. After exclusion of other pulmonary or cardiac causes swimming-induced pulmonary edema was diagnosed. This should be considered in cases of pulmonary edema, particularly in patients practicing sports with contact to water.

Biventricular function in exercise during autonomic (thoracic epidural) block.

BACKGROUND: Blockade of cardiac sympathetic fibers by thoracic epidural anesthesia (TEA) was previously shown to reduce right and left ventricular systolic function and effective pulmonary arterial elastance. At conditions of constant paced heart rate, cardiac output and systemic hemodynamics were unchanged. In this study, we further investigated the effect of cardiac sympathicolysis during physical stress and increased oxygen demand. METHODS: In a cross-over design, 12 patients scheduled to undergo thoracic surgery performed dynamic ergometric exercise tests with and without TEA. Hemodynamics were monitored and biventricular function was measured by transthoracic two-dimensional and M-mode echocardiography, pulsed wave Doppler and tissue Doppler imaging. RESULTS: TEA attenuated systolic RV function (TV S': - 21%, P < 0.001) and LV function (MV S': - 14%, P = 0.025), but biventricular diastolic function was not affected. HR (- 11%, P < 0.001), SVI (- 15%, P = 0.006), CI (- 21%, P < 0.001) and MAP (- 12%, P < 0.001) were decreased during TEA, but SVR was not affected. Exercise resulted in significant augmentation of systolic and diastolic biventricular function. During exercise HR, SVI, CI and MAP increased (respectively, + 86%, + 19%, + 124% and + 17%, all P < 0.001), whereas SVR decreased (- 49%, P < 0.001). No significant interactions between exercise and TEA were found, except for RPP (P = 0.024) and MV E DT (P = 0.035). CONCLUSION: Cardiac sympathetic blockade by TEA reduced LV and RV systolic function but did not significantly blunt exercise-induced increases in LV and RV function. These data indicate that additional mechanisms besides those controlled by the cardiac sympathetic nervous system are involved in the regulation of cardiac function during dynamic exercise. Trial registration Clinical trial registration: Nederlands Trial Register, NTR 4880 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4880 .

Heart failure with preserved ejection fraction, atrial fibrillation, and increased NT­proBNP levels : An emergent clinical dilemma.

BACKGROUND: The co-presence of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) may cause some diagnostic difficulties, because AF itself is associated with elevated levels of N­terminal pro-B-type natriuretic peptide (NT-proBNP). In the present study we aimed to investigate NT-proBNP levels of patients with HFpEF and AF. METHODS: This was a retrospective cohort study. Outpatient data were reviewed through the hospital data management system. Consecutive patients with the diagnosis of HFpEF and AF, who had at least one NT-proBNP measurement, were included in the study. RESULTS: The study population comprised 235 patients. Median NT-proBNP levels were 1242 pg/ml in the stable phase and 2321.5 pg/ml during decompensation. NT-proBNP was correlated positively with age, CHA2DS2 and CHA2DS2VASc scores, left atrial diameter (LAD), tricuspid annulus diameter, and systolic pulmonary artery pressure but negatively correlated with left ventricular ejection fraction (LVEF) and hemoglobin level. The change in NT-proBNP was positively correlated with heart rate and LAD. CONCLUSION: Patients with HFpEF and AF have higher levels of NT-proBNP, which may exceed the upper limits defined in guidelines. This study underlines the importance of measuring NT-proBNP levels in the stable phase and proposes a rule-in level for the decompensated phase.

Percutaneous mitral valve repair in recurrent severe mitral valve regurgitation after mitral annuloplasty : MitraClip-in-the-ring as a complementary strategy.

BACKGROUND: Patients with reduced left ventricular (LV) function undergoing coronary artery bypass graft surgery or/and aortic valve replacement occasionally show severe mitral valve (MV) regurgitation and thus also undergo surgical mitral annuloplasty. Over time, further deterioration of LV function and additional ischemic events cause recurrence of severe MV regurgitation due to the Carpentier IIIb morphology of the MV that is not adequately addressed by the previously implanted annuloplasty ring. METHODS: Seven patients (Society of Thoracic Surgeons score: 7.5 ± 1.5%) with Carpentier type-IIIb recurrent severe MV regurgitation, having undergone prior cardiothoracic surgery (median: 40 months) including mitral annuloplasty, were treated with the MitraClip device. RESULTS: MitraClip implantation resulted in significantly reduced MV regurgitation and improved New York Heart Association functional state, translating into an increased exercise capability and improved cardiac biomarkers. The morphology of the MV was adequately addressed without causing relevant MV stenosis, while the MV annulus area remained unaltered. The procedure was safe with a 30-day mortality rate of 0%. CONCLUSION: MitraClip-in-the-ring is feasible and in principle safe for treating Carpentier type IIIb severe MV regurgitation after surgical MV repair using mitral annuloplasty. MitraClip-in-the-ring resulted in immediate amelioration of clinical symptoms and increased physical exercise capacity.

Effect of Liraglutide on Cardiovascular Function and Myocardial Tissue Characteristics in Type 2 Diabetes Patients of South Asian Descent Living in the Netherlands: A Double-Blind, Randomized, Placebo-Controlled Trial.

BACKGROUND: The glucagon-like peptide-1 (GLP-1) receptor agonist liraglutide may be beneficial in the regression of diabetic cardiomyopathy. South Asian ethnic groups in particular are at risk of developing type 2 diabetes. PURPOSE: To assess the effects of liraglutide on left ventricular (LV) diastolic and systolic function in South Asian type 2 diabetes patients. STUDY TYPE: Prospective, double-blind, randomized, placebo-controlled trial. POPULATION: Forty-seven type 2 diabetes patients of South Asian ancestry living in the Netherlands, with or without ischemic heart disease, who were randomly assigned to 26-week treatment with liraglutide (1.8 mg/day) or placebo. FIELD STRENGTH/SEQUENCE: 3T (balanced steady-state free precession cine MRI, 2D and 4D velocity-encoded MRI, 1 H-MRS, T1 mapping). ASSESSMENT: Primary endpoints were changes in LV diastolic function (early deceleration peak [Edec], ratio of early and late peak filling rate [E/A], estimated LV filling pressure [E/Ea]) and LV systolic function (ejection fraction). Secondary endpoints were changes in aortic stiffness (aortic pulse wave velocity [PWV]), myocardial steatosis (myocardial triglyceride content), and diffuse fibrosis (extracellular volume [ECV]). STATISTICAL TESTS: Data were analyzed according to intention-to-treat. Between-group differences were reported as mean (95% confidence interval [CI]) and were assessed using analysis of covariance (ANCOVA). RESULTS: Liraglutide (n = 22) compared with placebo (n = 25) did not change Edec (+0.2 mL/s2 × 10-3 (-0.3;0.6)), E/A (-0.09 (-0.23;0.05)), E/Ea (+0.1 (-1.2;1.3)) and ejection fraction (0% (-3;2)), but decreased stroke volume (-9 mL (-14;-5)) and increased heart rate (+10 bpm (4;15)). Aortic PWV (+0.5 m/s (-0.6;1.6)), myocardial triglyceride content (+0.21% (-0.09;0.51)), and ECV (-0.2% (-1.4;1.0)) were unaltered. DATA CONCLUSION: Liraglutide did not affect LV diastolic and systolic function, aortic stiffness, myocardial triglyceride content, or extracellular volume in Dutch South Asian type 2 diabetes patients with or without coronary artery disease. LEVEL OF EVIDENCE: 1 Technical Efficacy Stage: 4 J. Magn. Reson. Imaging 2020;51:1679-1688.

Mesenchymal stem cell therapy for heart failure: a meta-analysis.

BACKGROUND: Mesenchymal stem cell (MSC) treatment has emerged as an important adjunct therapy for heart failure. However, the use of MSC to treat heart failure has not been well established. We conducted a systematic review and meta-analysis to evaluate the efficacy of MSC treatment for heart failure. METHODS: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched. Randomized controlled trials (RCTs) assessing the influence of MSC treatment on cardiac function in heart failure were included in this analysis. Two investigators independently searched the articles, extracted data, and assessed the quality of the included studies. Meta-analysis was performed using the fixed-effect model or random-effect model when appropriate. RESULTS: Six RCTs involving 625 patients were included in the meta-analysis. Compared with control interventions in heart failure patients, MSC treatment had no significant influence on cardiovascular death (RR = 0.76; 95% CI = 0.38-1.52; p = 0.43); however, it was associated with significantly increased left ventricular ejection fraction (LVEF; mean = 9.64; 95% CI = 7.56-11.71; p < 0.00001) and reduced rehospitalization rate (RR = 0.41; 95% CI = 0.23-0.73; p = 0.003). In addition, no significant difference between the two groups was observed for the incidence of myocardial infarction (RR = 0.72; 95% CI = 0.10-5.02; p = 0.74), the recurrence of heart failure (RR = 0.88; 95% CI = 0.28-2.81; p = 0.83), and total death (RR = 0.68; 95% CI = 0.37-1.25; p = 0.21). CONCLUSION: Although MSC treatment can significantly improve LVEF and reduce rehospitalization rates, it does not have a significant influence on cardiovascular death, myocardial infarction, heart failure, and total death.

[Feasibility of evaluating the left ventricular function in patients with cardiovascular diseases by fully automatic quantified three-dimensional transthoracic echocardiography].

Objective: To investigate the clinical value of left ventricular function assessment in patients with cardiovascular disease by fully automatic quantified three-dimensional transthoracic echocardiography. Methods: One hundred and ninety-seven patients with cardiac diseases were examined by three-dimensional transthoracic echocardiography from September 2017 to May 2019. Data from 61 patients with grade 1 echocardiographic image quality were used to determine the default boundary values of endocardial end-diastolic and end-systolic phases. Clinical features were analyzed based on electronic medical records. The accuracy and repeatability of this strategy was evaluated by comparing left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV) and left ventricular ejection fraction (LVEF) measured by automated quantitative three-dimensional echocardiography and those measured by conventional manual transthoracic echocardiography, the latter served as gold standard. Results: The levels of LVEDV, LVESV and LVEF measured by automatic three-dimensional echocardiography were positively correlated with values obtained by manual measurement（r=0.97，0.97, 0.98, 0.97, 0.97, 0.96；P<0.05). The levels of LVEDV and LVESV measured by full-automatic three-dimensional echocardiography were significantly higher than those obtained by manual three-dimensional echocardiography（all P<0.05）. The classification and correlation of systolic dysfunction in patients with abnormal ventricular wall motion by automatic three-dimensional echocardiography were significantly improved after manual calibration (κ=0.74, P=0.00) as compared to without manual calibration (κ=0.63, P=0.00). The inter-observer and intra-observer variability of fully automated three-dimensional echocardiography were significantly smaller than manual three-dimensional echocardiography（both P<0.05）. Conclusion: Fully automatic quantified three-dimensional transthoracic echocardiography possesses excellent accuracy and repeatability in measuring left ventricular volume and function， and it is feasible for clinical application.

Quantification of myocardial deformation by deformable registration-based analysis of cine MRI: validation with tagged CMR.

OBJECTIVES: To validate deformable registration algorithms (DRAs) for cine balanced steady-state free precession (bSSFP) assessment of global longitudinal strain (GLS) and global circumferential strain (GCS) using harmonic phase (HARP) cardiovascular magnetic resonance as standard of reference (SoR). METHODS: Seventeen patients and 17 volunteers underwent short axis stack and 2-/4-chamber cine bSSFP imaging with matching slice long-axis and mid-ventricular spatial modulation of magnetization (SPAMM) myocardial tagging. Inverse DRA was applied on bSSFP data for assessment of GLS and GCS while myocardial tagging was processed using HARP. Intra- and inter-observer variability assessment was based on repeated analysis by a single observer and analysis by a second observer, respectively. Standard semi-automated short axis stack segmentation was performed for analysis of left ventricular (LV) volumes and ejection fraction (EF). RESULTS: DRA demonstrated strong relationships to HARP for myocardial GLS (R2 = 0.75; p < 0.0001) and endocardial GLS (R2 = 0.61; p < 0.0001). GCS result comparison also demonstrated significant relationships between DRA and HARP for myocardial strain (R2 = 0.61; p < 0.0001) and endocardial strain (R2 = 0.51; p < 0.0001). Both methods demonstrated small systematic errors for intra- and inter-observer variability but DRA demonstrated consistently lower CV. Global LVEF was significantly lower (p = 0.0099) in patients (53.7%; IQR 43.9/64.0%) than in healthy volunteers (62.6%; IQR 61.1/66.2%). DRA and HARP strain data demonstrated significant relationships to LVEF. CONCLUSIONS: Non-rigid deformation method-based DRA provides a reliable measure of peak systolic GCS and GLS based on cine bSSFP with superior intra- and inter-observer reproducibility compared to HARP. KEY POINT: • Myocardial strain can be reliably analyzed using inverse deformable registration algorithms (DRAs) on cine CMR. • Inverse DRA-derived strain shows higher reproducibility than tagged CMR. • DRA and tagged CMR-based myocardial strain demonstrate strong relationships to global left ventricular function.

Evaluation of elevated left ventricular end diastolic pressure in patients with preserved ejection fraction using cardiac magnetic resonance.

OBJECTIVES: This study aims to validate the reliability of cardiac magnetic resonance (CMR) parameters for estimating left ventricular end diastolic pressure (LVEDP) in heart failure patients with preserved ejection fraction (HFpEF) and compare their accuracy to conventional echocardiographic ones, with reference to left heart catheterisation. METHODS: Sixty patients with exertional dyspnoea (New York Heart Association function class II to III) were consecutively enrolled. CMR-derived time-volume curve and deformation parameters, conventional echocardiographic diastolic indices as well as LVEDP evaluated by left heart catheterisation were collected and analysed. RESULTS: Fifty-one patients, who accomplished all three examinations, were divided into HFpEF group and non-HFpEF group based on LVEDP measurements. Compared to the non-HFpEF group, CMR-derived time-volume curve showed lower peak filling rate adjusted for end diastolic volume (PFR/EDV, p = 0.027), longer time to peak filling rate (T-PFR, p < 0.001), and increased T-PFR in one cardiac cycle (%T-PFR, p < 0.001) in HFpEF group. In multivariable linear regression analysis, %T-PFR (ß = 0.372, p = 0.024), left ventricular global peak longitudinal diastolic strain rate (LDSR, ß = -0.471, p = 0.006), and E/e' (ß = 0.547, p = 0.001) were independently associated with invasively measured LVEDP. The sensitivity and specificity of E/e' and LDSR for predicting the elevated LVEDP were 76%, 92% and 76%, 89%, respectively. CONCLUSIONS: These findings suggest that CMR-derived time-volume curve and strain indices could predict HFpEF patients. Not only E/e' assessed by echocardiography but also the CMR-derived %T-PFR and LDSR correlated well with LVEDP. These non-invasive parameters were validated to evaluate the left ventricular diastolic function. KEY POINTS: • The abnormal time-volume curve revealed insufficient early diastole in HFpEF patients. • Non-invasive parameters including E/e', %T-PFR, and LDSR correlated well with LVEDP.

Clinical value of myocardial performance index in patients with isolated diastolic dysfunction.

AIMS: The Doppler-derived myocardial performance index (MPI) has been considered as a diagnostic and prognostic Doppler marker for many different clinical conditions. The purpose of this study was to determine the diagnostic accuracy of traditional Pulsed-wave Doppler (PWD-MPI) and Pulsed-wave tissue Doppler imaging (TDI-MPI) and the degree of agreement between these methods in patients with grade-I diastolic dysfunction (DDI) and a normal ejection fraction. METHODS: Forty-seven consecutive ambulatory patients with DDI were compared to 51 healthy subjects with normal echocardiograms. All subjects underwent measurement of time intervals and MPI with PWD and pulsed TDI. RESULTS: TDI-MPI and PWD-MPI were significantly higher in patients with DDI than in control subjects: 0.49 ± 0.14 vs. 0.40 ± 0.09 (P < 0.001) and 0.45 ± 0.11 vs. 0.37 ± 0.08 (P < 0.001), respectively. Cutoff values of TDI-MPI > 0.42 and PWD-MPI > 0.40 identified DDI subjects, with sensitivities of 74 and 64%; specificities of 61 and 69%; positive likelihood ratios of 1.9 and 2.0; and negative likelihood ratios of 0.42 and 0.53, respectively; no significant difference was noted between the areas under the ROC curves of TDI-MPI and PWD-MPI (P = 0.77). Bland-Altman plots showed wide limits of agreement between these indices: - 0.17 to 0.23 in healthy subjects and - 0.24 to 0.32 in DDI patients. CONCLUSION: PWD-MPI and TDI-MPI showed poor clinical agreement and were not reliable parameters for the assessment of left ventricular diastolic function.

[Superiority of three-dimensional quantitative analysis technique and automatic cardiac motion quantification technique in evaluating left ventricular systolic function in patients with chronic kidney disease].

Objective: To investigate the value of three-dimensional quantitative analysis (3DQA) and automatic cardiac motion quantification (aCMQ) in evaluating the left ventricular systolic function in patients with different stages of chronic kidney disease (CKD). Methods: A total of 127 cases of CKD patients between June 2016 and December 2017 who were admitted to Department of Nephrology of Wuxi No.2 People's Hospital were divided into three groups: Group A (44 cases in CKD stage 1 and 2), Group B (38 cases in CKD stage 3) and Group C (45 cases in CKD stage 4 and 5). Another 50 age and sex matched normal controls were selected during the same period. The left ventricular segments and global longitudinal strain (GLS), left ventricular segments and global three-dimensional displacement (3DD) obtained by aCMQ and 3DQA techniques were compared and analyzed. Results: Compared with the control group, as for the longitudinal strain (LS) of each segment of left ventricular 5 (17 in all) segments in Group A, 10 segments in Group B and all segments in Group C decreased (P<0.05). As for the 3DD of each segment of left ventricular, 6 segments in Group A, 12 segments in Group B and all segments in group C decreased (P<0.05). As for the GLS, there was no statistically significant difference in group A, however, absolute value of GLS in group B and C [(19.82±3.62)%, (16.62±5.48)% vs (21.98±4.32)%] decreased statistically significantly (both P<0.05). As for the left ventricular global 3DD, the global 3DD of group A, group B and group C [(6.24±0.51) mm, (5.54±0.29) mm, (4.62±0.55) mm vs (7.11±0.51) mm] decreased (all P<0.05). Conclusions: Three-dimensional quantitative analysis and automatic cardiac motion quantification can detect the abnormality of left ventricular systolic function in patients with chronic kidney disease at an early stage. And the global 3DD of left ventricle of 3DQA is more sensitive than the global longitudinal strain of left ventricle of aCMQ.

Is Cardioprotection Dead?

For >4 decades, the holy grail in the treatment of acute myocardial infarction has been the mitigation of lethal injury. Despite promising initial results and decades of investigation by the cardiology research community, the only treatment with proven efficacy is early reperfusion of the occluded coronary artery. The remarkable record of failure has led us and others to wonder if cardioprotection is dead. The path to translation, like the ascent to Everest, is certainly littered with corpses. We do, however, highlight a therapeutic principle that provides a glimmer of hope: cellular postconditioning. Administration of cardiosphere-derived cells after reperfusion limits infarct size measured acutely, while providing long-term structural and functional benefits. The recognition that cell therapy may be cardioprotective, and not just regenerative, merits further exploration before we abandon the pursuit entirely.

Body mass index, type 2 diabetes, and left ventricular function.

A recent study found that among individuals with a preserved left ventricular ejection fraction ≥ 55%, global longitudinal strain was significantly lower in overweight patients (i.e., body mass index ≥ 25 kg/m2) with, but not in those without, type 2 diabetes mellitus. These results contrast previous observations of body mass index as a significant predictor of incident diastolic dysfunction and increased left ventricular mass index among subjects without prevalent diabetes. We discuss potential explanations for the observed discrepancies and general difficulties associated with cardiovascular risk assessment based on body mass index and related metabolic factors.

Left ventricular myocardial deformation in Takotsubo syndrome: a cardiovascular magnetic resonance myocardial feature tracking study.

OBJECTIVES: This study assessed the applicability and prognostic value of cardiovascular magnetic resonance (CMR) left ventricular deformation analysis in Takotsubo syndrome (TTS). METHODS: CMR-feature tracking was performed blinded in a core laboratory to determine circumferential (CS), radial (RS) and longitudinal strain (LS) in 141 TTS patients participating in this cohort study. A subgroup of consecutive TTS patients (n = 20) was compared with age- and sex-matched controls with anterior ST-segment elevation myocardial infarction (STEMI) and non-STEMI as well as healthy subjects. RESULTS: Median global CS, RS and LS were -19%, 19% and -12%, respectively. Apical ballooning was associated with significantly lower global CS (p < 0.01) and LS (p < 0.01) compared with midventricular and basal ballooning. Global RS was lowest in patients with basal ballooning (p < 0.01). Segmental analysis resulted in a reliable discrimination of different ballooning patterns using CS and LS. Strain values were significantly lower in TTS compared with non-STEMI patients and healthy subjects, whereas STEMI patients showed similar values. While global CS and RS were not associated with long-term mortality, global LS (cutoff -14.75%) was identified as a potential parameter for long-term risk stratification (mortality rate 17.9% versus 2.5%; p = 0.02). CONCLUSIONS: The transient contraction abnormalities in TTS can be quantitatively assessed with CMR-feature tracking. GLS is a potential determinant of outcome in TTS, which, however, requires further validation. KEY POINTS: • Cardiovascular magnetic resonance myocardial feature tracking enables accurate assessment of regional and global left ventricular dysfunction in Takotsubo syndrome (TTS). • Global strain in TTS is similar to patients with anterior STEMI and lower compared with non-STEMI and healthy subjects. • Global longitudinal strain is a potential tool for risk prediction in TTS patients.

Ultrasonic image analysis of longitudinal strain in uremic patients with preserved left ventricular ejection fraction.

BACKGROUND: Patients with uremia have high cardiovascular disease morbidity and mortality despite having normal left ventricular ejection fraction (LVEF). Longitudinal strain (LS) can be associated with subtle changes in LV systolic function. The aim of this study was to use two-dimensional speckle-tracking echocardiography (2DSTE) to assess subclinical LV myocardial dysfunction and to explore strain-changing regularities in uremic patients with LVEF ≥ 55%. METHODS: The study population included 40 uremic patients and 40 healthy volunteers. 2DSTE was performed on all participants to assess peak LS in the basal, mid and apical LV (BLS, MLS and ALS) and the respective time to peak LS (T-BLS, T-MLS, T-ALS). RESULTS: BLS, MLS, and ALS were significantly decreased in the uremic group relative to healthy controls and LS increased going in a basal to apical direction in both groups. T-BLS, T-MLS and T-ALS was significantly increased in the uremic group compared with the control group. In uremic patients, T-BLS, but not T-MLS or T-ALS, was significantly delayed relative to the control group. Bivariate analysis of creatinine (Cr) or urea nitrogen and strain parameters revealed a correlation only between ALS and Cr. CONCLUSION: 2DSTE can identify LV myocardial abnormalities in uremic patients with preserved LVEF at early stage, as well as some changing regularities of LS and T-LS in the left ventricle.