Acute recoordination rather than functional hemodynamic improvement determines reverse remodelling by cardiac resynchronisation therapy.

PURPOSE: Cardiac resynchronisation therapy (CRT) improves left ventricular (LV) function acutely, with further improvements and reverse remodelling during chronic CRT. The current study investigated the relation between acute improvement of LV systolic function, acute mechanical recoordination, and long-term reverse remodelling after CRT. METHODS: In 35 patients, LV speckle tracking longitudinal strain, LV volumes & ejection fraction (LVEF) were assessed by echocardiography before, acutely within three days, and 6 months after CRT. A subgroup of 25 patients underwent invasive assessment of the maximal rate of LV pressure rise (dP/dtmax,) during CRT-implantation. The acute change in dP/dtmax, LVEF, systolic discoordination (internal stretch fraction [ISF] and LV systolic rebound stretch [SRSlv]) and systolic dyssynchrony (standard deviation of peak strain times [2DS-SD18]) was studied, and their association with long-term reverse remodelling were determined. RESULTS: CRT induced acute and ongoing recoordination (ISF from 45 ± 18 to 27 ± 11 and 23 ± 12%, p < 0.001; SRS from 2.27 ± 1.33 to 0.74 ± 0.50 and 0.71 ± 0.43%, p < 0.001) and improved LV function (dP/dtmax 668 ± 185 vs. 817 ± 198 mmHg/s, p < 0.001; stroke volume 46 ± 15 vs. 54 ± 20 and 52 ± 16 ml; LVEF 19 ± 7 vs. 23 ± 8 and 27 ± 10%, p < 0.001). Acute recoordination related to reverse remodelling (r = 0.601 and r = 0.765 for ISF & SRSlv, respectively, p < 0.001). Acute functional improvements of LV systolic function however, neither related to reverse remodelling nor to the extent of acute recoordination. CONCLUSION: Long-term reverse remodelling after CRT is likely determined by (acute) recoordination rather than by acute hemodynamic improvements. Discoordination may therefore be a more important CRT-substrate that can be assessed and, acutely restored.

Thebesian Veins Draining to the Left Ventricle, Mimicking Left Ventricular Noncompaction.

Left ventricular noncompaction cardiomyopathy (LVNC) was diagnosed in a 59-year-old woman, based on echocardiography. Later, diagnostic criteria were also found positive by cardiac magnetic resonance (CMR). However, coronary angiography revealed thebesian veins were causing the noncompacted appearance. The complementary role of CMR and echocardiography criteria, including flow assessment in the recesses, is discussed. (Level of Difficulty: Advanced.).

Altered Left Ventricular Geometry and Torsional Mechanics in High Altitude-Induced Pulmonary Hypertension: A Three-Dimensional Echocardiographic Study.

BACKGROUND: Changes in left ventricular (LV) torsion have been related to LV geometry in patients with concomitant long-standing myocardial disease or pulmonary hypertension (PH). We evaluated the effect of acute high altitude-induced isolated PH on LV geometry, volumes, systolic function, and torsional mechanics. METHODS: Twenty-three volunteers were prospectively studied at low altitude and after the second (D3) and third night (D4) at high altitude (4,559 m). LV ejection fraction, multidirectional strains and torsion, LV volumes, sphericity, and eccentricity were derived by speckle-tracking on three-dimensional echocardiographic data sets. Pulmonary pressure was estimated from the transtricuspid pressure gradient (TRPG), LV preload from end-diastolic LV volume, and transmitral over mitral annular E velocity (E/e'). RESULTS: At high altitude, oxygen saturation decreased by 15%-20%, heart rate and cardiac index increased by 15%-20%, and TRPG increased from 21 ± 2 to 37 ± 9 mm Hg (P < .01). LV volumes, preload, ejection fraction, multidirectional strains, and sphericity remained unaffected, but diastolic (1.04 ± 0.07 to 1.09 ± 0.09 on D3/D4, P < .05) and systolic (1.00 ± 0.06 to 1.08 ± 0.1 [D3] and 1.06 ± 0.07 [D4], P < .05) eccentricity slightly increased, indicating mild septal flattening. LV torsion decreased from 2.14 ± 0.85 to 1.34 ± 0.68 (P < .05) and 1.65 ± 0.54 (P = .08) degrees/cm on D3/D4, respectively. Changes in torsion showed a weak inverse relationship to changes in systolic (r = -0.369, P = .013) and diastolic (r = -0.329, P = .032) eccentricity but not to changes in TRPG, heart rate or preload. CONCLUSIONS: High-altitude exposure was associated with mild septal flattening of the LV and reduced ventricular torsion at unchanged global LV function and preload, suggesting a relation between LV geometry and torsional mechanics.

Echocardiographic Prediction of Cardiac Resynchronization Therapy Response Requires Analysis of Both Mechanical Dyssynchrony and Right Ventricular Function: A Combined Analysis of Patient Data and Computer Simulations.

BACKGROUND: Pronounced echocardiographically measured mechanical dyssynchrony is a positive predictor of response to cardiac resynchronization therapy (CRT), whereas right ventricular (RV) dysfunction is a negative predictor. The aim of this study was to investigate how RV dysfunction influences the association between mechanical dyssynchrony and left ventricular (LV) volumetric remodeling following CRT. METHODS: One hundred twenty-two CRT candidates (mean LV ejection fraction, 19 ± 6%; mean QRS width, 168 ± 21 msec) were prospectively enrolled and underwent echocardiography before and 6 months after CRT. Volumetric remodeling was defined as percentage reduction in LV end-systolic volume. RV dysfunction was defined as RV fractional area change < 35%. Mechanical dyssynchrony was assessed as time to peak strain between the septum and LV lateral wall, interventricular mechanical delay, and septal systolic rebound stretch. Simulations of heart failure with an LV conduction delay in the CircAdapt computer model were used to investigate how LV and RV myocardial contractility influence LV dyssynchrony and acute CRT response. RESULTS: In the entire patient cohort, higher baseline septal systolic rebound stretch, time to peak strain between the septum and LV lateral wall, and interventricular mechanical delay were all associated with LV volumetric remodeling in univariate analysis (R = 0.599, R = 0.421, and R = 0.410, respectively, P < .01 for all). The association between septal systolic rebound stretch and LV volumetric remodeling was even stronger in patients without RV dysfunction (R = 0.648, P < .01). However, none of the mechanical dyssynchrony parameters were associated with LV remodeling in the RV dysfunction subgroup. The computer simulations showed that low RV contractility reduced CRT response but hardly affected mechanical dyssynchrony. In contrast, LV contractility changes had congruent effects on mechanical dyssynchrony and CRT response. CONCLUSIONS: Mechanical dyssynchrony parameters do not reflect the negative impact of reduced RV contractility on CRT response. Echocardiographic prediction of CRT response should therefore include parameters of mechanical dyssynchrony and RV function.

Mechanistic evaluation of echocardiographic dyssynchrony indices: patient data combined with multiscale computer simulations.

BACKGROUND: The power of echocardiographic dyssynchrony indices to predict response to cardiac resynchronization therapy (CRT) appears to vary between indices and between studies. We investigated whether the variability of predictive power between the dyssynchrony indices can be explained by differences in their operational definitions. METHODS AND RESULTS: In 132 CRT-candidates (left ventricular [LV] ejection fraction, 19 ± 6%; QRS width, 170 ± 22 ms), 4 mechanical dyssynchrony indices (septal systolic rebound stretch [SRSsept], interventricular mechanical dyssynchrony [IVMD], septal-to-lateral peak shortening delay [Strain-SL], and septal-to-posterior wall motion delay [SPWMD]) were quantified at baseline. CRT response was quantified as 6-month percent change of LV end-systolic volume. Multiscale computer simulations of cardiac mechanics and hemodynamics were used to assess the relationships between dyssynchrony indices and CRT response within wide ranges of dyssynchrony of LV activation and reduced contractility. In patients, SRSsept showed best correlation with CRT response followed by IVMD, Strain-SL, and SPWMD (R=-0.56, -0.50, -0.48, and -0.39, respectively; all P<0.01). In patients and simulations, SRSsept and IVMD showed a continuous linear relationship with CRT response, whereas Strain-SL and SPWMD showed discontinuous relationships characterized by data clusters. Model simulations revealed that this data clustering originated from the complex multipeak pattern of septal strain and motion. In patients and simulations with (simulated) LV scar, SRSsept and IVMD retained their linear relationship with CRT response, whereas Strain-SL and SPWMD did not. CONCLUSIONS: The power to predict CRT response differs between indices of mechanical dyssynchrony. SRSsept and IVMD better represent LV dyssynchrony amenable to CRT and better predict CRT response than the indices assessing time-to-peak deformation or motion.

Early detection of regional functional abnormalities in asymptomatic ARVD/C gene carriers.

BACKGROUND: The overt stage of arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C) is preceded by a concealed stage with minor or no signs of disease. However, sudden death may occur in this early phase. Deformation imaging may contribute to early diagnosis. The aims of this study were to compare the diagnostic accuracy of the conventional (1994) versus the recently published (2010) new echocardiographic criteria for ARVD/C and to evaluate the additional value of echocardiographic tissue deformation imaging to detect subclinical RV functional abnormalities in asymptomatic carriers of pathogenic ARVD/C mutations. METHODS: Fourteen asymptomatic first-degree relatives of ARVD/C probands (the ARVD/C-r group; mean age, 38.0 ± 13.2 years) with a pathogenic plakophilin-2 mutation and a group of age-matched controls (n = 56; mean age, 38.2 ± 12.7 years) were included at a 1:4 ratio. A complete echocardiographic evaluation (dimensions, global systolic parameters, and visual assessment and deformation imaging of the RV free wall including Doppler tissue imaging and two-dimensional strain echocardiography) was obtained. Peak systolic strain less negative than -18% and/or postsystolic shortening (postsystolic index > 15%) in any RV segment was considered abnormal. RESULTS: RV dimensions in the ARVD/C-r group were similar to those in controls (RV outflow tract, 15.4 ± 2.9 vs 14.4 ± 1.9 mm/m(2), P = NS; RV inflow tract, 18.6 ± 2.6 vs 19.1 ± 2.6 mm/m(2), P = NS), and global systolic parameters were moderately reduced (tricuspid annular plane systolic excursion, 20.0 ± 3.2 vs 23.9 ± 2.8 mm, P = .001; RV fractional area change, 40.3 ± 8.4 vs 40.6 ± 7.1, P = NS). According to task force criteria, 57% of the ARVD/C-r group and 29% of controls were classified as abnormal when applying the 1994 criteria and 29% and 4% when applying the 2010 criteria, respectively. Doppler tissue imaging and two-dimensional strain deformation (and strain rate) values were reduced in the ARVD/C-r group in the basal and mid RV segments compared with controls (P < .001). In the ARVD/C-r group, peak systolic strain less negative than -18% was seen in six patients (43%), postsystolic strain in nine (64%), and either abnormality in 10 (71%), almost exclusively in the basal segment; these findings were observed in none of the controls. CONCLUSIONS: The 2010 criteria for ARVD/C improve specificity, whereas sensitivity is significantly reduced in this asymptomatic population. In contrast, echocardiographic deformation imaging detects functional abnormalities in the subtricuspid region in 71% of asymptomatic carriers of a pathogenic plakophilin-2 mutation, while regional deformation was normal in all control subjects, indicating superiority of both sensitivity and specificity with these new modalities.

Septal rebound stretch is a strong predictor of outcome after cardiac resynchronization therapy.

BACKGROUND: Septal rebound stretch (SRSsept) is a distinctive characteristic of discoordination-related mechanical inefficiency. We assessed how intermediate- and long-term outcome after cardiac resynchronization therapy (CRT) relate to baseline SRSsept. METHODS AND RESULTS: A total of 101 patients (age 65 ± 11 years, 69 men, 18 New York Heart Association (NYHA) class IV, QRS 173 ± 23 ms) scheduled for CRT underwent clinical assessment, echocardiography, and brain-type natriuretic peptide (BNP) measurements before and 6.4 ± 2.3 months after CRT. Baseline SRSsept (all systolic stretch after initial shortening in the septum) was quantified by speckle tracking echocardiography. Primary composite end point was death, urgent cardiac transplantation, or left ventricular assist device implantation at the end of the study. Secondary end points were intermediate-term (6 months) response, quantified as decreases in left ventricular end-systolic volume (ΔLVESV) and BNP (ΔBNP). After a mean clinical follow-up of 15.6 ± 9.0 months; 23 patients had reached the primary end point. Baseline SRSsept (hazard ratio [HR] 0.742; 95% confidence intervals [CI] 0.601-0.916, P < .01]) was independently associated with a better outcome and NYHA class (HR 5.786: 95% CI 2.341-14.299, P < .001) with a worse outcome. Contrary to baseline NYHA class, baseline SRSsept was an independent predictor of both ΔLVESV (beta 0.53; P < .001) and ΔBNP (beta 0.29; P < .01). Intermediate-term ΔLVESV and ΔBNP were associated with a favorable long-term outcome. CONCLUSIONS: SRSsept at baseline is a strong, independent predictor of long-term prognosis after CRT and of improvements in left ventricular remodeling and neurohormonal activation at intermediate term.

Septal deformation patterns delineate mechanical dyssynchrony and regional differences in contractility: analysis of patient data using a computer model.

BACKGROUND: Response to cardiac resynchronization therapy depends both on dyssynchrony and (regional) contractility. We hypothesized that septal deformation can be used to infer integrated information on dyssynchrony and regional contractility, and thereby predict cardiac resynchronization therapy response. METHODS AND RESULTS: In 132 cardiac resynchronization therapy candidates with left bundle branch block (LBBB)-like electrocardiogram morphology (left ventricular ejection fraction 19±6%; QRS width 170±23 ms), longitudinal septal strain was assessed by speckle tracking echocardiography. To investigate the effects of dyssynchronous activation and differences in septal and left ventricular free wall contractility on septal deformation pattern, we used the CircAdapt computer model of the human heart and circulation. In the patients, 3 characteristic septal deformation patterns were identified: LBBB-1=double-peaked systolic shortening (n=28); LBBB-2=early systolic shortening followed by prominent systolic stretching (n=34); and LBBB-3=pseudonormal shortening with less pronounced late systolic stretch (n=70). LBBB-3 revealed more scar (2 [2-5] segments) compared with LBBB-1 and LBBB-2 (both 0 [0-1], P<0.05). In the model, imposing a time difference of activation between septum and left ventricular free wall resulted in pattern LBBB-1. This transformed into pattern LBBB-2 by additionally simulating septal hypocontractility, and into pattern LBBB-3 by imposing additional left ventricular free wall or global left ventricular hypocontractility. Improvement of left ventricular ejection fraction and reduction of left ventricular volumes after cardiac resynchronization therapy were most pronounced in LBBB-1 and worst in LBBB-3 patients. CONCLUSIONS: A double-peaked systolic septal deformation pattern is characteristic for LBBB and results from intraventricular dyssynchrony. Abnormal contractility modifies this pattern. A computer model can be helpful in understanding septal deformation and predicting cardiac resynchronization therapy response.

Cardiovascular magnetic resonance imaging for diagnosis and clinical management of suspected cardiac masses and tumours.

AIMS: To evaluate the diagnostic accuracy of cardiovascular magnetic resonance (CMR) imaging from a risk-stratification and therapeutic-management perspective in patients with suspected cardiac tumours. METHODS AND RESULTS: Cardiovascular magnetic resonance exams of 41 consecutive patients (aged 61 ± 14 years, 21 men) referred for evaluation of a suspected cardiac mass were reviewed for tumour morphology and signal characteristics in various unenhanced and contrast-enhanced sequences. Cardiovascular magnetic resonance-derived diagnosis and treatment were compared with clinical outcome and histology in patients undergoing surgery or autopsy (n = 20). In 18 of 41 patients, CMR excluded masses or reclassified them as normal variants; all were treated conservatively. In 23 of 41 patients, CMR diagnosed a neoplasm (14 'benign', 8 'malignant', and 1 'equivocal'); 18 of these patients were operated on, 2 managed conservatively, and 3 by palliation. During follow-up of 705 (inter-quartile range 303-1472) days, 13 patients died. No tumour-related deaths occurred in conservatively managed patients. Patients with a CMR-based diagnosis and treatment of benign tumour had a similar survival as patients without detectable tumour. Compared with histology, CMR correctly classified masses as 'benign or malignant' in 95% of the cases. Tumour perfusion, invasiveness, localization, and pericardial fluid were valuable to distinguish between malignant and benign tumours. Soft tissue contrast and signal intensity patterns in various sequences were valuable for excluding neoplastic lesions and helped to obtain tissue characterization at the histological level in selected tumour cases, respectively. CONCLUSION: Comprehensive CMR provides a confident risk-stratification and clinical-management tool in patients with suspected tumours. Patients where CMR excludes tumours can be managed conservatively.

Redistribution of left ventricular strain by cardiac resynchronization therapy in heart failure patients.

AIMS: The aim of this study was to investigate (i) the baseline patterns of segmental peak myocardial strain (PMS) in heart failure (HF) patients with ventricular conduction delay, (ii) changes in patterns of segmental PMS induced by cardiac resynchronization therapy (CRT), and (iii) whether they differ between CRT responders and non-responders. METHODS AND RESULTS: Segmental and global longitudinal (L-) and radial (R-) PMS measurements derived from speckle tracking were prospectively obtained in 85 HF patients with intraventricular conduction delay before and 6 months after CRT device implantation and in 30 healthy subjects. Segmental strain analysis in HF patients showed pronounced heterogeneity both in longitudinal and in radial directions with the lowest amplitudes in the septum and the highest amplitudes in the lateral and posterior walls. After CRT, 60% of the patients were responders (≥ 15% reduction in end-systolic volume). Before CRT, responders showed higher global R-PMS than non-responders (19.5 ± 13.4 vs.13.1 ± 4.8%, respectively; P = 0.04) despite similar global L-PMS. After CRT, responders showed an increase in L-PMS in most segments and a homogeneous increase in R-PMS, leading to a more uniform pattern of strain and an improved global L-PMS and R-PMS. In contrast, in non-responders, the gain in L-PMS and R-PMS in septal segments was completely offset by a decrease in posterolateral segments, failing to decrease segmental heterogeneity and to increase global L-PMS and R-PMS. CONCLUSION: Heart failure patients with ventricular conduction delay show pronounced heterogeneous patterns of segmental PMS, which can be reversed by CRT.

Mechano-energetics of the asynchronous and resynchronized heart.

Abnormal electrical activation of the ventricles creates major abnormalities in cardiac mechanics. Local contraction patterns, as reflected by measurements of local strain, are not only out of phase, but often also show opposing length changes in early and late activated regions. As a consequence, the efficiency of cardiac pump function (the amount of stroke work generated by a unit of oxygen consumed) is approximately 30% lower in asynchronous than in synchronous hearts. Moreover, the amount of work performed in myocardial segments becomes considerably larger in late than in early activated regions. Cardiac Resynchronization Therapy (CRT) improves mechano-energetics of the previously asynchronous heart in various ways: it alleviates impediment of the abnormal contraction on blood flow, it increases myocardial efficiency, it recruits contraction in the previously early activated septum and it creates a more uniform distribution of myocardial blood flow. These factors act together to increase the range of cardiac work that can be delivered by the patients' heart, an effect that can explain the increased exercise tolerance and quality of life reported in several CRT trials.

Echocardiographic prediction of outcome after cardiac resynchronization therapy: conventional methods and recent developments.

Echocardiography plays an important role in patient assessment before cardiac resynchronization therapy (CRT) and can monitor many of its mechanical effects in heart failure patients. Encouraged by the highly variable individual response observed in the major CRT trials, echocardiography-based measurements of mechanical dyssynchrony have been extensively investigated with the aim of improving response prediction and CRT delivery. Despite recent setbacks, these techniques have continued to develop in order to overcome some of their initial flaws and limitations. This review discusses the concepts and rationale of the available echocardiographic techniques, highlighting newer quantification methods and discussing some of the unsolved issues that need to be addressed.

Detection and quantification by deformation imaging of the functional impact of septal compared to free wall preexcitation in the Wolff-Parkinson-White syndrome.

Pacing experiments in healthy animal hearts have suggested a larger detrimental effect of septal compared to free wall preexcitation. We investigated the intrinsic relation among the site of electrical preexcitation, mechanical dyssynchrony, and dysfunction in human patients. In 33 patients with Wolff-Parkinson-White (WPW) syndrome and 18 controls, regional myocardial deformation was assessed by speckle tracking mapping (ST-Map) to assess the preexcitation site, shortening sequences and dyssynchrony, and the extent of local and global ejecting shortening. The ST-Map data in patients with accessory atrioventricular pathways correctly diagnosed as located in the interventricular septum (IVS) (n = 11) or left ventricular free wall (LFW) (n = 12) were compared to the corresponding control values. A local ejecting shortening of <2 SD of the control values identified hypokinetic segments. The localization of the atrioventricular pathways by ST-Map matched with the invasive electrophysiology findings in 23 of 33 patients and was one segment different in 5 of 33 patients. In both WPW-IVS and WPW-LFW, local ejecting shortening was impaired at the preexcitation site (p <0.01). However, at similar electrical and mechanical dyssynchrony, WPW-IVS had more extensive hypokinesia than did WPW-LFW (3.6 +/- 0.9 vs 1.8 +/- 1.3 segments, p <0.01). Compared to controls, the left ventricular function was significantly reduced only in WPW-IVS (global ejecting shortening 17 +/- 2% vs 19 +/- 2%, p = 0.01; ejection fraction 55 +/- 5% vs 59 +/- 3%, p = 0.02). In conclusion, preexcitation is associated with local hypokinesia, which at comparable preexcitation is more extensive in WPW-IVS than in WPW-LFW and could adversely affect ventricular function. ST-Map might have a future role in detecting and guiding treatment of septal pathways with significant mechanical effects.

Effects of on-pump and off-pump coronary artery bypass grafting on left ventricular relaxation and compliance: a comprehensive perioperative echocardiography study.

AIMS: The short-term effect of coronary artery bypass grafting (CABG) on diastolic function is only moderately investigated. Furthermore, it remains unknown whether avoidance of cardioplegic arrest by an off-pump CABG procedure has advantages over on-pump procedure regarding diastolic relaxation and compliance. We investigated whether components of diastolic function would be improved the day after CABG depending on the type of the surgical procedure. METHODS AND RESULTS: Spontaneously breathing on-pump (n = 20) and off-pump CABG (n = 12) patients underwent a comprehensive transthoracic echocardiography examination the day before and the day after elective CABG, including transmitral and pulmonary vein flow parameters, colour M-mode flow propagation velocity (Vp) and tissue Doppler assessment of the average mitral annulus diastolic velocity (Em). Isovolumic relaxation and E-wave deceleration time were corrected for heart rate (IVRTcHR and DTcHR). Left ventricular (LV) relaxation time (τ) and LV operating stiffness (LVOS) were calculated. Overall and independent from operation type and preload, CABG decreased IVRTcHR (107 ± 20 vs. 93 ± 15 ms) (P < 0.01) and τ (54 ± 10 vs. 45 ± 10 ms) (P < 0.01), increased Vp (49 ± 22 vs. 75 ± 37 cm/s) (P < 0.01), and increased Em (6.6 ± 2.0 vs. 7.3 ± 1.3 cm/s, P = 0.06), indicating improved relaxation. LVOS increased (0.13 ± 0.06 vs. 0.22 ± 0.05 mmHg/mL) (P < 0.01), compatible with an impaired compliance. A similar improvement in relaxation and impairment in compliance were observed in both groups. CONCLUSION: Myocardial relaxation improved the day after CABG irrespective of the use of cardiopulmonary bypass with cardioplegic arrest. Impairment in compliance could not be prevented by the avoidance of cardioplegia.

Effect of long term and intensive endurance training in athletes on the age related decline in left and right ventricular diastolic function as assessed by Doppler echocardiography.

The aim of this study was to evaluate (1) the effect of endurance training on left ventricular and right ventricular diastolic function and (2) whether the normal aging effect on left ventricular and right ventricular diastolic function is slowed by endurance training. A total of 269 healthy subjects were prospectively enrolled for echocardiographic evaluation. Five groups were defined on the basis of age and athletic activities: (1) young (18 to 39 years) nonathletes (n = 62), (2) veteran (>or=40 years) nonathletes (n = 33), (3) young regular athletes (9 to 18 hours of sports/week; n = 58), (4) young elite athletes (>18 hours of sports/week; n = 63), and (5) veteran athletes (>or=40 years and >or=9 hours of sports/week; n = 53). Pulsed-wave Doppler indexes for diastolic function in the left and right ventricles were obtained at rest. No significant differences were found among the young controls, regular athletes, and elite athletes in left ventricular and right ventricular pulsed-wave and tissue Doppler diastolic parameters. These were also comparable between the veteran athletes and controls. In athletes and controls, similar and significant correlations were found between age and diastolic parameters. Age was the most important determinant in almost all parameters in multivariate analysis, while the influence of the amount of training did not account for >2% of the observed variance in any of these parameters. In conclusion, the amount of endurance training did not alter diastolic parameters in either ventricle in the young. Furthermore, the biventricular decreases in diastolic function observed in healthy, nonathletic subjects with age was also observed in aging athletes' hearts.

Septal rebound stretch reflects the functional substrate to cardiac resynchronization therapy and predicts volumetric and neurohormonal response.

AIMS: To develop a novel myocardial deformation index that is highly sensitive to the effect of cardiac resynchronization therapy (CRT) and that can be used to predict response to CRT. METHODS AND RESULTS: Before and 6.5 +/- 2.3 months after implantation of a CRT device, longitudinal shortening and stretch were timed and quantified by speckle tracking echocardiography in a cohort of 62 patients. Distinction was made between systolic total stretch (STS; all systolic stretch) and systolic rebound stretch (SRS; only systolic stretch following initial shortening). Systolic total stretch and SRS could be measured in all wall segments in 41 of 62 patients. Septal SRS quantification was possible in all 62 patients and was performed by a blinded observer. Cardiac resynchronization therapy reduced STS (-55 +/- 30%) but reduced SRS (-77 +/- 21%) significantly more (P < 0.01). The largest amount of baseline SRS and the largest reductions in SRS (-90 +/- 22%) were found in the septum. Reductions in local SRS were paralleled by increases in local systolic shortening that were twice as large (r = 0.79), thereby strongly improving septal function. Baseline values of septal SRS correlated with reductions in left ventricular end-systolic volume index (Delta LVESVi; r = 0.62) and brain-type natriuretic peptide (BNP) (Delta log(10)BNP; r = 0.57). Septal SRS was an independent predictor of CRT response in linear regression analysis and predicted Delta LVESVi of >or=15% with a sensitivity and specificity of 81% at ROC analysis (areas under the curve 0.89 +/- 0.04). CONCLUSION: Septal rebound stretch appears to be a sensitive and practical diagnostic criterion to quantify the functional substrate amenable to CRT and to predict response.

Echocardiographic tissue deformation imaging quantifies abnormal regional right ventricular function in arrhythmogenic right ventricular dysplasia/cardiomyopathy.

BACKGROUND: The aim of this study was to determine the accuracy of new quantitative echocardiographic strain and strain-rate imaging parameters to identify abnormal regional right ventricular (RV) deformation associated with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). METHODS: A total of 34 patients with ARVD/C (confirmed by Task Force criteria) and 34 healthy controls were prospectively enrolled. Conventional echocardiography, including Doppler tissue imaging (DTI), was performed. Doppler and two-dimensional strain-derived velocity, strain, and strain rate were calculated in the apical, mid, and basal segments of the RV free wall. RESULTS: RV dimensions were significantly increased in patients with ARVD/C (RV outflow tract 19.3+/-5.2 mm/m2 vs 14.1+/-2.2 mm/m2, P<.001; RV inflow tract 23.4+/-4.8 mm/m2 vs 18.8+/-2.4 mm/m2, P<.001), whereas left ventricular dimensions were not significantly different compared with controls. Strain and strain rate values were significantly lower in patients with ARVD/C in all 3 segments. All deformation parameters showed a higher accuracy to detect functional abnormalities compared with conventional echocardiographic criteria of dimensions or global systolic function. The lowest DTI strain value in any of the 3 analyzed segments showed the best receiver operating characteristics (area under the curve 0.97) with an optimal cutoff value of -18.2%. CONCLUSIONS: DTI and two-dimensional strain-derived parameters are superior to conventional echocardiographic parameters in identifying ARVD/C. This novel technique may have additional value in the diagnostic workup of patients with suspected ARVD/C.

Echocardiographic tissue deformation imaging of right ventricular systolic function in endurance athletes.

AIMS: To investigate the physiological adaptation of the right ventricle (RV) in response to endurance training and to define reference values for regional deformation in the RV in endurance athletes. METHODS AND RESULTS: Healthy controls (n = 61), athletes (n = 58), and elite athletes (n = 63) were prospectively enrolled with a training intensity of 2.2 +/- 1.6, 12.5 +/- 2.3 and 24.2 +/- 5.7 h/week, respectively (P < 0.001). Conventional echocardiographic parameters, tissue Doppler imaging (TDI), and 2D strain echo (2DSE)-derived velocity, strain, and strain rate (SR) were calculated in three RV segments. Left ventricular and RV dimensions were significantly increased (P < 0.001) in both groups of athletes compared with controls. Right ventricular systolic velocities and displacement were not different between the groups. Right ventricular strain and SR values were reduced in the RV basal and mid-segment in athletes. Athletes with marked RV dilatation showed lower strain and SR values in the basal (-20.9 +/- 4.7 vs. -24.5 +/- 4.9%, P < 0.001 and -1.23 +/- 0.31 vs. -1.50 +/- 0.33 s(-1), P < 0.001) and mid (-29.3 +/- 5.4 vs. -32.1 +/- 5.3%, P = 0.017 and -1.58 +/- 0.41 vs. -1.82 +/- 0.42 s(-1), P = 0.009) segment, whereas athletes without RV dilatation showed no significant difference compared with the controls. CONCLUSION: Regional deformation and deformation rates (TDI and 2DSE) are reduced in the basal RV segment in athletes. This phenomenon is most pronounced in athletes with RV dilatation and should be interpreted as normal when evaluating athletes suspected for RV pathology.