Enhancing Arrhythmogenic Right Ventricular Cardiomyopathy Detection and Risk Stratification: Insights from Advanced Echocardiographic Techniques.

INTRODUCTION: The echocardiographic diagnosis criteria for arrhythmogenic right ventricular cardiomyopathy (ARVC) are highly specific but sensitivity is low, especially in the early stages of the disease. The role of echocardiographic strain in ARVC has not been fully elucidated, although prior studies suggest that it can improve the detection of subtle functional abnormalities. The purposes of the study were to determine whether these advanced measures of right ventricular (RV) dysfunction on echocardiogram, including RV strain, increase diagnostic value for ARVC disease detection and to evaluate the association of echocardiographic parameters with arrhythmic outcomes. METHODS: The study included 28 patients from the Heart Institute of São Paulo ARVC cohort with a definite diagnosis of ARVC established according to the 2010 Task Force Criteria. All patients were submitted to ECHO's advanced techniques including RV strain, and the parameters were compared to prior conventional visual ECHO and CMR. RESULTS: In total, 28 patients were enrolled in order to perform ECHO's advanced techniques. A total of 2/28 (7%) patients died due to a cardiovascular cause, 2/28 (7%) underwent heart transplantation, and 14/28 (50%) patients developed sustained ventricular arrhythmic events. Among ECHO's parameters, RV dilatation, measured by RVDd (p = 0.018) and RVOT PSAX (p = 0.044), was significantly associated with arrhythmic outcomes. RV free wall longitudinal strain < 14.35% in absolute value was associated with arrhythmic outcomes (p = 0.033). CONCLUSION: Our data suggest that ECHO's advanced techniques improve ARVC detection and that abnormal RV strain can be associated with arrhythmic risk stratification. Further studies are necessary to better demonstrate these findings and contribute to risk stratification in ARVC, in addition to other well-known risk markers.

The role of galectin-3 in patients with permanent and paroxysmal Atrial Fibrillation and echocardiographic parameters of left atrial fibrosis.

BACKGROUND: Biochemical markers and imaging tests have been used with the aim of stratifying the risk and detecting atrial fibrosis. Speckle-tracking echocardiography (STE) is used for the detection of atrial fibrosis and Gal-3 provides an important prognostic value. The objective of the study was to assess the association between atrial fibrosis markers and serum levels, genetic polymorphisms and genic expression of galectin-3. METHODS: 206 patients with permanent AF and 70 patients with paroxysmal AF were included in the study. Real time PCR (TaqMan) system was used to study SNPs rs4652 and 4644 of the gene LGALS3. Serum levels of Gal-3 were determined by ELISA and STE was performed to assess fibrosis. RESULTS: Mean age of individuals with permanent AF was 66.56 ± 12 years. As for the echocardiography results, those patients showed an decrease in the following parameters peak atrial longitudinal strain (PALS) (p = 0.002) when compared to the same parameters from the paroxysmal AF group of patients. There was a correlation between serum levels of Gal-3 and PALS in the group of patients with permanent AF; the lower the levels of gal-3, the lower the LA strain (r = 0.24; p = 0.01). CONCLUSIONS: Echocardiographic findings showed association with the groups, and with serum levels of Gal-3 in patients with permanent AF. The distribution of allelic and genotypic frequencies, and of the haplotypes of polymorphism LGALS3 rs4652 and rs4644 did not present statistical variation, which suggests that those SNPs are not associated with the AF clinical forms (permanent and paroxysmal).

First study demonstrating speckle tracking echocardiography has prognostic value in patients with idiopathic inflammatory myopathies.

To measure left ventricular (LV) global longitudinal strain (GLS) using speckle tracking echocardiography in idiopathic inflammatory myopathy (IIM) patients and to determine whether the LV GLS predicts outcomes in those patients. Prospective study consisted of a cross-sectional phase with 61 IIM patients and 32 individuals without IIM and longitudinal phase, in which patients were divided into two subgroups: 26 with reduced LV GLS and 35 with normal LV GLS; patients were followed for a mean of 25 months, and the occurrence of cardiovascular events and criteria for IIM activity were compared. The mean LV GLS (18.5 ± 2.9% vs. 21.6 ± 2.5%; p < 0.001) and right ventricle free wall strain (21.9 ± 6.1% vs. 27.5 ± 4.7%; p < 0.001) were lower in patients than in controls. The mean N-terminal pro B-type natriuretic peptide level was higher in patients than in controls. There were no differences regarding other cardiac involvement. Anti-Jo1 antibody was associated with general electrocardiographic abnormality and LV diastolic dysfunction. The subgroup with reduced GLS progressed with higher mean creatine phosphokinase, myositis disease activity assessment visual analogue scales, the physician's and patient's visual analogue scales, the health assessment questionnaire, and a higher proportion of relapses than the subgroup with normal GLS. There was no difference between the subgroups regarding cardiovascular events. The LV GLS appears to be useful for evaluating patients with IIM. Abnormal values are associated with more frequent relapses and increased disease activity during follow-up.

Assessment of Myocardial Function in Infants of Mothers with Gestational Diabetes Mellitus Using Deformation Imaging over the First Year of Age.

OBJECTIVE: To assess serial myocardial performance and pulmonary vascular resistance (PVR) in infants of mothers with gestational diabetes mellitus (GDM) over the first year of life. STUDY DESIGN: This was a prospective, observational study. Echocardiography was performed at birth, 6 months, and 1 year of age. Pulmonary artery acceleration time and left ventricular (LV) eccentricity index provided surrogate measurements of PVR. Biventricular function was assessed by tissue Doppler imaging and deformation analysis. RESULTS: Fifty infants of mothers with GDM were compared with 50 controls with no difference in gestation (38.9 ± 0.8 weeks vs 39.3 ± 0.9 weeks; P = .05) or birthweight (3.55 ± 0.49 kg vs 3.56 ± 0.41 kg; P = .95). At 1 year of age, the pulmonary artery acceleration time was lower (70 ± 11 vs 79 ± 10; P = .01) in the GDM group. LV global longitudinal strain (24.7 ± 1.9 vs 28.8 ± 1.8 %; P < .01), LV systolic strain rate (1.8 ± 0.2 vs 2.1 ± 0.3 1/s; P < .01), and RV free wall strain (31.1 ± 4.8 vs 34.6 ± 3.9 %; P < .01) were lower in the GDM cohort at 1 year of age (all P values adjusted for gestation, mode of delivery, and maternal body mass index). CONCLUSIONS: Our findings demonstrate higher indices of PVR and lower biventricular function in infants of mothers with GDM compared with controls at each time point assessed in this study over the first year of life.

Reproducibility of right ventricular function by longitudinal strain and other echocardiographic parameters in the ELSA-Brasil study.

Right ventricular (RV) free wall longitudinal strain (RVFWLS), and four-chamber longitudinal strain (RV4CLS) using speckle tracking echocardiography have demonstrated increased accuracy and discrimination to measure right ventricular function in different clinical conditions. Reproducibility data of these measures are scarce and mainly tested in small or reference populations. The main objective of this study was to investigate their reproducibility, and of other traditional RV parameters, from unselected participants of a large cohort study. RV strain reproducibility was analyzed using echocardiographic images of 50 participants from a randomly selected sample from The ELSA-Brasil Cohort. Images were acquired and analyzed following the study protocols. The mean RVFWLS was - 26.9 ± 2.6% and the mean RV4CLS was - 24.4 ± 1.9%. The intra-observer reproducibility parameters of RVFWLS demonstrated a coefficient of variation (CV) of 5.1% and an intraclass correlation coefficient (ICC [95%CI] 0.78[0.67-0.89]), and for RV4CLS were CV = 5.1% and ICC = 0.78[0.67-0.89]. Reproducibility for RV fractional area change was CV = 12.1%; ICC = 0.66 [0.50-0.81] and for RV basal diameter was CV = 6.3%; ICC = 0.82 [0.73-0.91]. The inter-observer reproducibility for RVFWLS was CV = 8.3%; ICC 0.54[0.34-0.74] and for RV4CLS, CV = 6.3%; ICC = 0.53[0.34-0.73], following the same pattern among conventional RV parameters. We found adequate reproducibility of RV longitudinal strain parameters. This information is relevant for the long-term follow-up of cohort participants and reinforces the utility of RV longitudinal strain as a tool to monitor subclinical changes in RV systolic function.

Left Ventricular Function and Dimensions Are Altered Early in Infants Developing Brain Injury in the Setting of Neonatal Encephalopathy.

We evaluated the association between left cardiac 3-dimensional echocardiographic parameters and brain injury in a single-center prospective study of neonates with neonatal encephalopathy. On day 2 of life, neonates with brain injury had greater left ventricle end-diastolic and stroke volume but also greater peak global circumferential strain detected by 3-dimensional echocardiogram.

Subcostal right ventricular free wall strain in patients with pulmonary hypertension / Strain subcostal de la pared libre del ventriculo derecho en pacientes con hipertensión pulmonar

Abstract Right ventricular longitudinal strain (RVLS) is frequently used as a measure of right ventricular systolic function. Abnormal RV strain is associated with poor prognosis in patients with pulmonary hyper tension (PH); however, the measure is not always easy to obtain in patients with poor apical acoustic windows. Objective: This study aims to analyze the RVLS and determine if there is a difference when measured from the apical and subcostal views. Methods: In this cross-sectional study, we analyzed 22 adult outpatients (≥ 18 years old), 81% female, mean age 49.9 ± 17.3 years, with a diagnosis of PH using right heart catheterization, followed from January 2016 to January 2020. Results: RVLS measured in the RV free wall from the apical views was -15% (-19% to -10%) and subcostal views -14.5% (-18% to -11%) were highly correlated (Person's r = 0.969, p < 0.0001). Segment by segment analysis did not show significant differences either: basal four-chamber vs. sub costal view was -16.5% (-21% to -11%) vs. -15.5% (-20% to -11%), p = 0.99, mid four-chamber view vs. subcotal view was -16.5% (-21% to -12%) vs. -16.5% (-20% to -11%), p = 0.87, apical four-chamber view vs. subcostal view was -12% (-18% to -8%) vs. -13.5% (-19% to -10%), p = 0.93. Conclusion: Subcostal RVLS free wall is a feasible and accurate alternative to conventional RVLS free wall from the apical view in patients with pulmonary hypertension and could be useful in patients with poor acoustic apical four-chamber windows.

Resumen El strain longitudinal del ventrículo derecho (SLVD) permite medir la función sistólica del ventrículo derecho (VD). La disminución del strain (deformación) del VD se asocia con mal pronóstico en pacientes con hipertensión pulmonar (HP), pero no siempre es fácil de obtener en pacientes con mala ventana acústica apical. Objetivo: Este estudio tiene como objetivo analizar el SLVD y determinar si las vistas apical y subcostal son comparables. Métodos: En este estudio transversal, se incluyeron 22 pacientes adultos ambulatorios (≥18 años), 81% mujeres, edad promedio 49.9 ± 17.3 años, con diagnóstico de HP mediante cateterismo cardíaco derecho, seguidos desde enero de 2016 hasta enero de 2020. Se midió la deformación de la pared libre del ventrículo derecho desde las vistas de cuatro cámaras apical y cuatro cámaras subcostal. Resultados: El SLVD medido en la pared libre del VD desde la vista apical fue -15% (-19% a -10%) vs. -14.5% (-18% a -11%) cuando se midió desde la vista subcostal (p = 0,99). El análisis segmento por s egmento tampoco mostró diferencias significativas: el segmento basal apical vs. subcostal fue -16.5% (-21% a -11%) vs. -15.5% (-20% a -11%), p = 0.99, el segmento medio apical vs. la vista subcotal fue -16.5% (-21% a -12%) vs. a -16.5% (-20% a -11%), p = 0.87, el segmento apical vs. la vista subcostal fue -12% (-18% a -8%) frente a -13.5% (-19% a -10%), p = 0.93. Conclusión: En pacientes con HP, el SLVD obtenido en la pared libre subcostal es una alternativa útil en los casos con ventana acústica apical subóptima.

Mechanical dispersion is a superior echocardiographic feature to predict exercise capacity in preclinical and overt heart failure with preserved ejection fraction.

BACKGROUND: Heart Failure with Preserved Ejection Fraction (HFpEF) is a syndrome characterized by different degrees of exercise intolerance, which leads to poor quality of life and prognosis. Recently, the European score (HFA-PEFF) was proposed to standardize the diagnosis of HFpEF. Even though Global Longitudinal Strain (GLS) is a component of HFA-PEFF, the role of other strain parameters, such as Mechanical Dispersion (MD), has yet to be studied. In this study, we aimed to compare MD and other features from the HFA-PEFF according to their association with exercise capacity in an outpatient population of subjects at risk or suspected HFpEF. METHODS: This is a single-center cross-sectional study performed in an outpatient population of 144 subjects with a median age of 57 years, 58% females, referred to the Echocardiography and Cardiopulmonary Exercise Test to investigate HFpEF. RESULTS: MD had a higher correlation to Peak VO2 (r=-0.43) when compared to GLS (r=-0.26), MD presented a significant correlation to Ventilatory Anaerobic Threshold (VAT) (r=-0.20; p = 0.04), while GLS showed no correlation (r=-0.14; p = 0.15). Neither MD nor GLS showed a correlation with the time to recover VO2 after exercise (T1/2). In Receiver Operator Characteristic (ROC) analysis, MD presented superior performance to GLS to predict Peak VO2 (AUC: 0.77 vs. 0.62), VAT (AUC: 0.61 vs. 0.57), and T1/2 (AUC: 0.64 vs. 0.57). Adding MD to HFA-PEFF improved the model performance (AUC from 0.77 to 0.81). CONCLUSION: MD presented a higher association with Peak VO2 when compared to GLS and most features from the HFA-PEFF. Adding MD to the HFA-PEFF improved the model performance.

Subcostal right ventricular free wall strain in patients with pulmonary hypertension.

Right ventricular longitudinal strain (RVLS) is frequently used as a measure of right ventricular systolic function. Abnormal RV strain is associated with poor prognosis in patients with pulmonary hypertension (PH); however, the measure is not always easy to obtain in patients with poor apical acoustic windows. OBJECTIVE: This study aims to analyze the RVLS and determine if there is a difference when measured from the apical and subcostal views. METHODS: In this cross-sectional study, we analyzed 22 adult outpatients (= 18 years old), 81% female, mean age 49.9 ± 17.3 years, with a diagnosis of PH using right heart catheterization, followed from January 2016 to January 2020. RESULTS: RVLS measured in the RV free wall from the apical views was -15% (-19% to -10%) and subcostal views -14.5% (-18% to -11%) were highly correlated (Person's r = 0.969, p < 0.0001). Segment by segment analysis did not show significant differences either: basal four-chamber vs. subcostal view was -16.5% (-21% to -11%) vs. -15.5% (-20% to -11%), p = 0.99, mid four-chamber view vs. subcotal view was -16.5% (-21% to -12%) vs. -16.5% (-20% to -11%), p = 0.87, apical four-chamber view vs. subcostal view was -12% (-18% to -8%) vs. -13.5% (-19% to -10%), p = 0.93. CONCLUSION: Subcostal RVLS free wall is a feasible and accurate alternative to conventional RVLS free wall from the apical view in patients with pulmonary hypertension and could be useful in patients with poor acoustic apical four-chamber windows.

El strain longitudinal del ventrículo derecho (SLVD) permite medir la función sistólica del ventrículo derecho (VD). La disminución del strain (deformación) del VD se asocia con mal pronóstico en pacientes con hipertensión pulmonar (HP), pero no siempre es fácil de obtener en pacientes con mala ventana acústica apical. Objetivo: Este estudio tiene como objetivo analizar el SLVD y determinar si las vistas apical y subcostal son comparables. Métodos: En este estudio transversal, se incluyeron 22 pacientes adultos ambulatorios (=18 años), 81% mujeres, edad promedio 49.9 ± 17.3 años, con diagnóstico de HP mediante cateterismo cardíaco derecho, seguidos desde enero de 2016 hasta enero de 2020. Se midió la deformación de la pared libre del ventrículo derecho desde las vistas de cuatro cámaras apical y cuatro cámaras subcostal. Resultados: El SLVD medido en la pared libre del VD desde la vista apical fue -15% (-19% a -10%) vs. -14.5% (-18% a -11%) cuando se midió desde la vista subcostal (p = 0,99). El análisis segmento por s egmento tampoco mostró diferencias significativas: el segmento basal apical vs. subcostal fue -16.5% (-21% a -11%) vs. -15.5% (-20% a -11%), p = 0.99, el segmento medio apical vs. la vista subcotal fue -16.5% (-21% a -12%) vs. a -16.5% (-20% a -11%), p = 0.87, el segmento apical vs. la vista subcostal fue -12% (-18% a -8%) frente a -13.5% (-19% a -10%), p = 0.93. Conclusión: En pacientes con HP, el SLVD obtenido en la pared libre subcostal es una alternativa útil en los casos con ventana acústica apical subóptima.

Prevalence and factors associated with impaired left ventricular global longitudinal strain in patients with Chagas disease: SaMi-Trop cohort study.

Cardiomyopathy is a major cause of death in Chagas disease and early detection of cardiac involvement is essential. Myocardial strain is a reliable technique for assessment of subtle left ventricular (LV) contractility alterations. This study assessed LV global longitudinal strain (GLS) in a large Chagas disease population living in remote areas. Between 2015 and 2016, Chagas disease patients were selected in the northern of the Minas Gerais state. All patients underwent T. cruzi antibodies tests and those who had positive tests were included. A resting 12-lead ECG was recorded and classified using the Minnesota Code criteria. Echocardiography was performed at public health primary care units and speckle-tracking strain was analyzed offline. LV dysfunction was defined as ejection fraction (LVEF < 50%) and reduced GLS was defined as < 16% (absolute value). A total of 1387 patients were included, mean age of 60.0 ± 12.5 years, 68% were women, and 14% had LV dysfunction. Among patients with normal LVEF, 59% had impaired LV GLS. Overall, patients with impaired GLS were older, had more comorbidities and ECG abnormalities than those with normal GLS. The independent factors associated with reduced GLS were ST-T abnormalities (OR 1.954; 95% CI 1.027-3.718), QRS duration (OR 1.009; 95% CI 1.002-1.016), LVEF (OR 0.947; 95% CI 0.923-0.972), and E/e' ratio (OR 1.059; 95% CI 1.009-1.112). In a cohort of Chagas disease from endemic areas, impaired LV GLS was detected in a significant proportion of patients, despite normal ECG and preserved LVEF. The main determinants of reduced LV GLS were ST-T abnormalities, QRS duration, LVEF and E/e' ratio, adjusting for demographical and clinical data.

Papel de la ecocardiografía speckle-tracking (rastreo de marcas) y la resonancia magnética cardíaca-feature tracking en la circulación de Fontan. Diferencias entre los ventrículos derecho e izquierdo / Speckle-tracking echocardiography and MCR-feature tracking in Fontan circulation. Differences between right and left ventricles

Resumen Introducción: En los pacientes con DCPT, la disfunción ventricular es inevitable, y más temprana en VU derechos. La deformación miocárdica por STE y RMC-FT parece promisoria. Objetivo: Analizar la función ventricular mediante STE y RMC-FT en pacientes con DCPT, en comparación con RMC convencional según la morfología del VU y la posible implicación en su diagnóstico temprano. Método: Se recogieron medidas del strain longitudinal y circunferencial por STE y RMC-FT, volúmenes ventriculares y FE por RMC en 64 pacientes con DCPT. Resultados: La morfología ventricular no se relacionó con disfunción por RMC. Los VU derechos tuvieron valores por STE y RMC-FT disminuidos respecto de los VU izquierdos, con FE similares. Existe correlación entre STE y RMC-FT, no equivalentes, con buena factibilidad y reproducibilidad. Conclusiones: La RMC-FT y el STE son técnicas útiles en el diagnóstico temprano y la vigilancia de la función ventricular en VU derechos con FE preservada.

Abstract Introduction: In patients with TCPC, the development of ventricular dysfunction is inevitable and is more precocious in SRVs. Myocardial deformation by STE and CMR-FT is promising. Objective: To analize ventricular function in patients with TCPC using STE and CMR-FT compared with conventional cMRI, depending on SV morphology, to determine their role in early diagnosis of ventricular dysfunction. Method: Sixty-four patients with TCPC were included. Longitudinal and circumferential strain by STE and CMR-FT and ventricular volume and EF were obtained. Results: Dysfunction analyzed by cMRI showed no association with ventricular morphology. SRVs had lower values in STE and CMR-FT compared with SLVs, with similar EF. While not equivalent, correlation was observed between the STE and the CMR-FT values, demonstrating good feasibility and reproducibility. Conclusion: The strain data in CMR-FT and STE could be useful for diagnosis and monitoring of ventricular function and as markers of early SRV dysfunction with preserved EF.

Vasodilator Strain Stress Echocardiography in Suspected Coronary Microvascular Angina.

Background: In patients with Ischemia and non-obstructive coronary artery stenosis (INOCA) wall motion is rarely abnormal during stress echocardiography (SE). Our aim was to determine if patients with INOCA and reduced coronary flow velocity reserve (CVFR) have altered cardiac mechanics using two-dimensional speckle-tracking echocardiography (2DSTE) during SE. Methods: In a prospective, multicenter, international study, we recruited 135 patients with INOCA. Overall, we performed high dose (0.84 mg/kg) dipyridamole SE with combined assessment of CVFR and 2DSTE. The population was divided in patients with normal CVFR (>2, group 1, n = 95) and abnormal CVFR (≤2, group 2, n = 35). Clinical and 2DSTE parameters were compared between groups. Results: Feasibility was high for CFVR (98%) and 2DSTE (97%). A total of 130 patients (mean age 63 ± 12 years, 67 women) had complete flow and strain data. The two groups showed similar 2DSTE values at rest. At peak SE, Group 1 patients showed lower global longitudinal strain (p < 0.007), higher mechanical dispersion (p < 0.0005), lower endocardial (p < 0.001), and epicardial (p < 0.0002) layer specific strain. Conclusions: In patients with INOCA, vasodilator SE with simultaneous assessment of CFVR and strain is highly feasible. Coronary microvascular dysfunction is accompanied by an impairment of global and layer-specific deformation indices during stress.

Subclinical Ventricular Dysfunction in Long-Term Acromegaly Assessed by Speckle-Tracking Echocardiography.

Introduction: Symptomatic heart disease may be present in patients with advanced-stage acromegaly. However, earlier assessment of subclinical ventricular systolic dysfunction can be accomplished through speckle-tracking echocardiography (STE) for the study of myocardial strain. The few such studies in this population to date have produced conflicting results. This study was performed to evaluate the parameters of ventricular strain in patients with acromegaly with no cardiac symptoms. Methods: In this prospective observational study, STE was performed in patients with active acromegaly with no detectable heart disease and in a control group to assess ventricular dysfunction through global longitudinal strain (GLS), radial strain, circumferential strain, and twist. The left ventricular (LV) ejection fraction, LV mass index, and relative wall thickness were also compared between the groups. Results: Twenty-five patients with active acromegaly (median age, 49 years; median disease duration, 11 years) and 44 controls were included. LV hypertrophy was more prevalent in the acromegaly group (40% vs. 19%, p < 0.01). The LV ejection fraction was similar between the groups (65.2% ± 5.99% vs. 62.9% ± 7.41%). The mean GLS (-18.8 ± 2.49 vs. -19.7 ± 3.29, p = 0.24), circumferential strain (-16.7 ± 3.18 vs. -16.6 ± 3.42, p = 0.90), and twist (14.6 ± 5.02 vs. 15.1 ± 3.94, p = 0.60) were not significantly different between the groups. Conclusion: Despite showing higher rates of LV hypertrophy, patients with long-term acromegaly had no impairment of ventricular contractility as assessed by strain echocardiography when compared with a control group.

Heart function in juvenile idiopathic arthritis patients: A biventricular two-dimensional speckle-tracking echocardiography study.

OBJECTIVES: We evaluated cardiac function in juvenile idiopathic arthritis (JIA) patients by 2D speckle-tracking echocardiography (2DSTE) and to assess possible associations with clinical, laboratorial, and treatment data. METHODS: A group of 42 JIA patients and 42 healthy controls were evaluated using both conventional echocardiography and 2DSTE. JIA patients underwent clinical and laboratory assessment. RESULTS: Conventional echocardiography data demonstrated normal left ventricular (LV) ejection fraction in both groups (71 vs. 71%; p = .69). 2DSTE analysis demonstrated that JIA patients presented significantly lower LV global systolic longitudinal strain (LVGLS) (-18.76 vs. -22%; p < .0001), LV systolic strain rate (LVSSR) (1.06 vs. 1.32 s-1; p < .0001), LV diastolic strain rate (LVDSR) (1.58 vs. 1.8 s-1; p < .0137), right ventricular global systolic strain (RVGLS) (-24.1% vs. -27.7%; p = .0002), and right ventricular systolic strain rate (RVSSR) (1.4 vs. 1.8 s-1; p = .0035). JIA patients under biological agents presented higher LVGLS (p = .02) and RVLS (p = .01). We also detected an association between LVGLS and C-reactive protein [CRP; -20% in normal CRP (10/42) vs. -18% in elevated CRP patients (32/42), p = .03]. CONCLUSIONS: JIA patients present different echocardiographic status from healthy patients. Moreover, our data suggest that JIA patients under biological agents present association with better cardiac function as shown by strain analysis.

Late Gadolinium Enhancement by Cardiac Magnetic Resonance and Speckle Tracking Echocardiography in the Evaluation of Cardiac Complications in Chagas Cardiomyopathy: A Systematic Review.

Background: Chagas cardiomyopathy (CC) increases cardiovascular mortality associated with congestive heart failure (CHF), ventricular arrhythmias (VA), and sudden cardiac death (SCD). Different imaging techniques have been tested to assess disease progression and cardiac risk in individuals with Chagas disease (ChD). In this systematic review, we evaluated the accuracy in detecting cardiac complications in CC patients using cardiac magnetic resonance (CMR) and speckle tracking echocardiography (STE). Methods: A search was done on PubMed, Cochrane, and Embase for studies in humans over 18 years of age with ChD. Demographic data, research methodology, imaging parameters, and cardiac outcomes were extracted, and study quality was assessed, resulting in a narrative description. Results: Twelve studies with 1124 patients were analyzed. One study discovered a contractility pattern by STE. Four studies assessed the identification of Early Cardiac Impairment (ECI) and VA risk, respectively, while three studies evaluated the risk of SCD. Global Longitudinal Strain (GLS) identified patients with ECI (-18.5 ± 3.4% non-fibrosis vs -14.0 ± 5.8% fibrosis, p = 0.006 and -18 ± 2% non-fibrosis vs -15 ± 2% fibrosis, p = 0.004). The amount of fibrosis > 11.78% or in two or more contiguous transmural segments were markers for VA risk. GLS and the amount of fibrosis were found to be predictors of SCD. Conclusions: STE may be considered a screening technique for identifying the subclinical status of CHF. CMR using Late Gadolinium Enhancement (LGE) is considered a relevant parameter for stratifying patients with ChD who are at risk of SCD. Fibrosis and GLS can be used as markers to categorize patients at risk for arrhythmias.

Deformación miocárdica (strain) circunferencial global en pacientes con cardiopatía isquémica / Global circumferential strain in patients with ischemic heart disease

RESUMEN Introducción: Las enfermedades cardiovasculares constituyen la primera causa de muerte en Cuba y la mayoría de los países desarrollados. La ecocardiografía con rastreo de marcas o speckle-tracking bidimensional (ST-2D) es una técnica reciente en la evaluación de la función cardíaca. Objetivo: Determinar la relación entre la deformación miocárdica (strain) circunferencial (GCS) medida por ST-2D y el estado de la circulación coronaria, en pacientes con cardiopatía isquémica. Método: Se realizó un estudio analítico, transversal, con 55 pacientes con indicación de coronariografía a los que se les realizó ecocardiograma para medir la GCS mediante ST-2D, en el Centro de Investigaciones Médico Quirúrgicas (CIMEQ, La Habana, Cuba), durante un año. Se crearon dos grupos: con enfermedad coronaria significativa (ECS=32) y no significativa (ECNS=23). Se utilizó SSPS para análisis de los resultados. Resultados: La edad promedio fue mayor en ECS (55,6 ±9,3 vs. 61,8±8,8; p=0,014). Predominaron los hombres con ECS (47,3%), los hipertensos (ECS=90,6% y ENCS=65,2%; p=0,02) y los fumadores (ECS=59,4% y ENCS=17,4%; p=0,002). El diagnóstico más frecuente fue la angina crónica estable (87%). En ECS predominó la enfermedad de tres vasos (75%). La GCS fue menor en ECS [(-19,5±3.8 vs. -25,2±5,7; p=0,033); área bajo la curva = 0,208]. No hubo diferencias en GCS, según el número de vasos significativamente enfermos. Conclusiones: Los resultados encontrados no justifican el empleo de la GCS por ST-2D para discriminar la presencia o no de ECS.

ABSTRACT Introduction: Cardiovascular diseases are the top cause of death in Cuba as well as in most developed countries. Two-dimensional speckle-tracking (2D-ST) echocardiography is a recent technique in the evaluation of cardiac function. Objective: To determine the relationship between global circumferential strain (GCS) measured through 2D-ST echocardiography and the state of coronary circulation in patients with ischemic heart disease. Method: An analytical, cross-sectional study was carried out on 55 patients with indication of coronary angiography, who underwent echocardiography to measure the GCS through 2D-ST at the Centro de Investigaciones Medico Quirúrgicas (CIMEQ, Havana, Cuba), during one year. Two groups were created: with significant coronary artery disease (SCAD = 32) and non-significant coronary artery disease (NSCAD = 23). The statistical package for the social sciences (SPSS) was used to analyze the results. Results: Mean age was higher in the SCAD group (55.6 ± 9.3 vs. 61.8± 8.8, p=0.014). Men with SCAD (47.3%), patients with high blood pressure (SCAD = 90.6% and NSCAD = 65.2%, p = 0.02) and smokers (SCAD = 59.4% and NSCAD = 17.4%, p = 0.002) predominated. The most frequent diagnosis was chronic stable angina (87%). Three-vessel disease predominated in the SCAD group (75%). The GCS was lower in the SCAD group [(-19.5.0 ± 3.8 vs. -25.2 ± 5.7, p = 0.033); area under the curve = 0.208]. There were no differences in GCS according to the number of significantly diseased vessels. Conclusions: The results found do not justify the use of GCS through 2D-ST echocardiography to discriminate the presence or nor of SCAD.

Usefulness of speckle tracking echocardiography and biomarkers for detecting acute cellular rejection after heart transplantation.

BACKGROUND: Acute cellular rejection (ACR) is a major complication after heart transplantation. Endomyocardial biopsy (EMB) remains the gold standard for its diagnosis, but it has concerning complications. We evaluated the usefulness of speckle tracking echocardiography (STE) and biomarkers for detecting ACR after heart transplantation. METHODS: We prospectively studied 60 transplant patients with normal left and right ventricular systolic function who underwent EMB for surveillance 6 months after transplantation. Sixty age- and sex-matched healthy individuals constituted the control group. Conventional echocardiographic parameters, left ventricular global longitudinal, radial and circumferential strain (LV-GLS, LV-GRS and LV-GCS, respectively), left ventricular systolic twist (LV-twist) and right ventricular free wall longitudinal strain (RV-FWLS) were analyzed just before the procedure. We also measured biomarkers at the same moment. RESULTS: Among the 60 studied patients, 17 (28%) had severe ACR (grade ≥ 2R), and 43 (72%) had no significant ACR (grade 0 - 1R). The absolute values of LV-GLS, LV-twist and RV-FWLS were lower in transplant patients with ACR degree ≥ 2 R than in those without ACR (12.5% ± 2.9% vs 14.8% ± 2.3%, p=0.002; 13.9° ± 4.8° vs 17.1° ± 3.2°, p=0.048; 16.6% ± 2.9% vs 21.4%± 3.2%, p < 0.001; respectively), while no differences were observed between the LV-GRS or LV-GCS. All of these parameters were lower in the transplant group without ACR than in the nontransplant control group, except for the LV-twist. Cardiac troponin I levels were significantly higher in patients with significant ACR than in patients without significant ACR [0.19 ng/mL (0.09-1.31) vs 0.05 ng/mL (0.01-0.18), p=0.007]. The combination of troponin with LV-GLS, RV-FWLS and LV-Twist had an area under curve for the detection of ACR of 0.80 (0.68-0.92), 0.89 (0.81-0.93) and 0.79 (0.66-0.92), respectively. CONCLUSION: Heart transplant patients have altered left ventricular dynamics compared with control individuals. The combination of troponin with strain parameters had higher accuracy for the detection of ACR than the isolated variables and this association might select patients with a higher risk for ACR who will benefit from an EMB procedure in the first year after heart transplantation.

Speckle tracking echocardiography in the indeterminate form of Chagas disease.

BACKGROUND: Chagas disease is one of the most common diseases in Latin-America, and cardiac involvement is a significant cause of death. Assessment of myocardial strain may detect early myocardial damage. OBJECTIVES: To determine differences in longitudinal strain using speckle tracking to assess regional and global left ventricular function in patients with the indeterminate form of Chagas disease, in comparison with a control group. METHODS: This is a retrospective matched case-control study, conducted in a single center. We evaluated 45 adult patients with Chagas disease, diagnosed with 2 serological methods, without evidence of cardiac involvement, who were compared with 45 healthy control subjects, who were sex- and age-matched. All patients underwent Doppler echocardiography and longitudinal strain with speckle tracking. RESULTS: Median age was 59 years, and 60% were female. Echocardiographic parameters were similar in patients with Chagas and control subjects. In patients with Chagas, global strain differed significantly from that of control subjects (-17 vs -20.3, P < .001). Segmental strain showed 7 abnormal segments in patients with Chagas (P < .05). CONCLUSIONS: In patients with the indeterminate form of Chagas disease, global and segmental longitudinal peak systolic strain is reduced compared with healthy subjects, thus suggesting that it could be a sensitive technique to detect early myocardial damage. These findings could provide useful information regarding the pathophysiology of cardiac involvement and understand whether they might have prognostic usefulness or help develop strategies to modify the course and prognosis of patients with Chagas disease. A longitudinal prospective study would be necessary to validate our findings.

Prognostic value of left ventricular longitudinal strain by speckle-tracking echocardiography in patients with sickle cell disease.

Cardiovascular complications have been increasingly detected in patients with sickle cell disease (SCD). Two-dimensional speckle-tracking echocardiography (STE) detects early myocardial changes in a number of pathophysiological processes, which may be useful in SCD. This study was designed to examine the value of STE in predicting clinical outcome in adult patients with SCD. A total of 219 patients, mean age 33 ± 12 years were prospectively enrolled. Several clinical, laboratory and echocardiographic variables including left ventricular global longitudinal strain (LVGLS) by STE were assessed. The endpoint was a composite of the following events: (1) all-cause mortality, (2) three or more acute painful episodes that require hospitalization in one year, (3) acute chest syndrome and (4) hospitalization due to disease complication. The majority of the patients had enlargement of LV and left atrial (LA) with preserved ejection fraction. During the mean follow-up of 30 months, 69 patients (32%) had reached the endpoint, including eight deaths (3.7%). No difference was observed in the parameters of diastolic function comparing the patients with and without events. LVGLS ranged from - 12.25 to - 25.44 (mean - 20.26 ± 2.5), with higher values in the patients who had events compared with those who did not. In the multivariable analysis, higher LVGLS values were associated with adverse events (adjusted OR 1.25; 95% CI 1.04-1.51; p = 0.021), independently of the TR maximal velocity and LV ejection fraction. In patients with SCD, higher LV global longitudinal strain was a predictor of adverse outcome, independently of age, TR velocity and LV function.

Strain de la aurícula izquierda por speckle tracking: evaluación de su reproducibilidad global y segmentaria / Left atrium strain by speckle tracking: evaluation of its global and segmental reproducibility / Strain do atrio esquerdo por speckle tracking: avaliação da sua reprodutibilidade global e segmentar

Resumen: Objetivos: evaluar la reproducibilidad intra e interobservador en la medición del strain auricular izquierdo función reservorio mediante speckle tracking, usando un protocolo para su análisis global y segmentario. Métodos y resultados: se estableció un protocolo para la adquisición y medición del strain de la aurícula izquierda (SAI), para un análisis global y segmentario, utilizando un modelo tipo "ojo de buey". Se evaluó su reproducibilidad mediante el coeficiente de correlación intraclase (CCI) en 20 participantes de la cohorte GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY (GEFA-HT-UY). Se obtuvo una excelente reproducibilidad global intraobservador de 0,92 (IC: 0,81-0,97) y buena reproducibilidad interobservador de 0,82 (IC: 0,59-0,92). El análisis segmentario de SAI no fue reproducible. Los valores promedio de SAI fueron 31,0% (± 7,5) para la vista de 4 cámaras; 34,6% (± 9,9) para la vista de 2 cámaras, y 36,8% (± 13,9) para la vista de 3 cámaras. El valor global de SAI tomando las tres vistas fue de 34,1% (± 7,8) y de 32,8% (± 6,5) considerando las vistas de 4 y 2 cámaras. Conclusión: el protocolo de adquisición y análisis de SAI para la función de reservorio fue reproducible para su análisis global, no así para su análisis segmentario.

Summary: Objective: to evaluate intra and inter-observer reproducibility of speckle tracking left atrial strain reservoir function using a protocol for its global and segmental analysis. Methods: a protocol for acquisition and measurement of left atrial strain was created (bull's-eye type), for its global and segmental analysis. Reproducibility was assessed using intraclass correlation coefficient in twenty participants from the GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY cohort. For global assessment intra-observer reproducibility graded excellent (0.92 (IC: 0.81-0.97)) while inter-observer reached good reproducibility (0.82 (IC: 0.59-0.92)). Left atrial strain segmental analysis was not reproducible. Mean (±SD) left atrial strain was 31.0±7.5% for 4 chamber view, 34.6±9.9% for 2 chamber view and 36.8±13.9% for 3 chamber view. Global left atrial strain considering three views was 34.1±7.8%, and 32.8±6.5% considering 4 and 2 chamber views. Conclusion: left atrial strain acquisition and analysis protocol for reservoir function was reproducible for its global but not for its segmental analysis.

Resumo: Objetivo: avaliar a reprodutibilidade intra e interobservador do strain speckle tracking atrial esquerdo função de reservatório usando um protocolo para sua análise global e segmentar. Métodos: foi criado um protocolo de aquisição e mensuração de strain do atrio esquerdo, por sua análise global e segmentar (tipo olho de boi). A reprodutibilidade foi avaliada por meio do coeficiente de correlação intraclasse em vinte participantes da coorte GEnotipo, Fenotipo e Ambiente da Hiper-Tensiologia arterial em UruguaY. Para a avaliação global, a reprodutibilidade intra-observador foi excelente (0,92 (IC: 0,81-0,97)), enquanto o interobservador alcançou boa reprodutibilidade (0,82 (IC: 0,59-0,92)). A análise segmentar de strain do atrio esquerdo não foi reprodutível. A média (± SD) de strain do atrio esquerdo foi 31,0 ± 7,5% para 4 câmaras, 34,6 ± 9,9% para 2 câmaras e 36,8 ± 13,9% para 3 câmaras. A strain global, considerando três visualizações, foi de 34,1 ± 7,8% e 32,8 ± 6,5% considerando a visão de 4 e 2 câmaras. Conclusão: o protocolo de aquisição e análise de strain do atrio esquerdo para função de reservatório foi reproduzível para sua análise global, mas não para sua segmentação.