The limit of physiological adaptation of the right ventricle to endurance training / El límite de la adaptación fisiológica del ventrículo derecho al entrenamiento de resistencia / O limite da adaptação fisiológica do ventrículo direito ao treino de resistência

The study aims to conduct a review of right ventricle, measured by echocardiography or magnetic resonance imaging, in athletes with high dynamic component and moderate static, the limit of the physiological adaptation. A search was carried out in the Medline database up to the end of 2017. This study showed that the mean values for the different measurements of the right ventricle in athletes are significantly greater than that of sedentary controls. In two of the 12 studies that analyzed mean diameter of the right ventricle in apical 4C, including 1477 endurance athletes and 498 controls, with high heterogeneity. Endurance athletes presented significantly higher longitudinal diameter of the RV in apical absolutes scores compared to control. The end diastolic volume and end systolic volume measured by magnetic resonance imaging, showed a significant standardized mean difference favoring athletes with a moderate heterogeneity.(AU)

El estudio tiene como objetivo realizar una revisión del ventrículo derecho, medido por ecocardiografía o resonancia magnética, en deportistas con alto componente dinámico y estático moderado, el límite de la adaptación fisiológica. Se realizó una búsqueda en la base de datos Medline hasta finales de 2017. Este estudio mostró que los valores medios de las diferentes mediciones del ventrículo derecho en los deportistas son significativamente mayores que los de los controles sedentarios. En dos de los 12 estudios que analizaron el diámetro medio del ventrículo derecho en apical 4C, incluyendo 1477 atletas de resistencia y 498 controles, con alta heterogeneidad. Los atletas de resistencia presentaron un diámetro longitudinal del VD en absolutas apicales significativamente mayor en comparación con los controles. El volumen diastólico final y el volumen sistólico final medidos por resonancia magnética, mostraron una diferencia media estandarizada significativa a favor de los atletas con una heterogeneidad moderada.(AU)

O estudo visa conduzir uma revisão do ventrículo direito, medido por ecocardiografia ou ressonância magnética, em atletas com elevada componente dinâmica e estática moderada, o limite da adaptação fisiológica. Foi realizada uma pesquisa na base de dados Medline até ao final de 2017. Este estudo mostrou que os valores médios das diferentes medidas do ventrículo direito em atletas são significativamente superiores aos dos controlos sedentários. Em dois dos 12 estudos que analisaram o diâmetro médio do ventrículo direito em 4C apical, incluindo 1477 atletas de endurance e 498 controlos, com elevada heterogeneidade. Os atletas de resistência apresentaram um diâmetro longitudinal do VD significativamente mais elevado nas pontuações absolutas apicais, em comparação com os controlos. O volume diastólico final e o volume sistólico final medido por ressonância magnética, mostraram uma diferença média padronizada significativa, favorecendo os atletas com uma heterogeneidade moderada.(AU)

Impact of Sacubitril-Valsartan Treatment on Diastolic Function in Patients with Heart Failure and Reduced Ejection Fraction.

INTRODUCTION: Sacubitril/valsartan (S-V) has been shown to reduce clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This benefit has been mostly attributed to an improvement in systolic function. AIM: This study aimed to evaluate longitudinal changes in several echocardiographic parameters of diastolic function in a cohort of patients with HFrEF receiving S-V. METHODS: Echocardiographic parameters of consecutive patients receiving S-V, such as diastolic dysfunction (DD) grade and other individual diastolic and systolic function parameters, were prospectively collected at baseline and at 6-month follow-up. New York Heart Association (NYHA) functional class was also recorded. RESULTS: 65 patients (73.9% males; 61.5 ± 13 years) with HFrEF in NYHA class II-IV were evaluated. There was a significant reduction in DD grade after treatment with maximal tolerated doses (p < 0.001). Patients with advanced DD showed the most significant improvements: 75% and 60% of patients with initial grade 3 and 2, respectively, had better grade after 6 months of S-V. Moreover, there was a reduction in E/e' ratio (p = 0.004), left atrial longitudinal strain (p = 0.002), and an improvement of left ventricle ejection fraction (p < 0.001) and NYHA functional class (p = 0.001). Among those subjects who improved their functional class, a higher percentage improved their DD grade (39.3%, p = 0.025) in comparison with those not improving their NYHA class (25%, p = 0.434). CONCLUSIONS: In addition to an improvement in systolic function parameters, patients with HFrEF receiving S-V improved their diastolic function. This echocardiographic improvement is particularly relevant in those patients with better NYHA class at 6-month follow-up.

Large-scale assessment of aortic stenosis: facing the next cardiac epidemic?

Aims: Aortic stenosis (AS) is the most frequent valvular disease in developed countries. As society grows older, the prevalence of AS increases. However, the real burden, current aetiology, severity distribution, and echocardiographic patterns of AS are not fully clear. The aim of the present study is to provide an accurate overall picture of AS, focusing on its epidemiology, aetiology, and echocardiographic features. Methods and results: A total of 29 502 consecutive echocardiograpies were prospectively included in this multicentre study. The present sample was composed of patients with advanced age (mean 75.2 years) and similar gender distribution. High proportion (7.2%) showed any grade of AS, with important number of patients (2.8%) presenting severe AS, most of them aged 75 years or more. Coexisting valvular disease appeared in almost half of the sample (49.6%), being the most frequently diagnosed aortic regurgitation (AR) (22%) followed by mitral regurgitation (MR) (15.6%). Degenerative aetiology was found in the vast majority (93.4%) of the studies whereas rheumatic is currently infrequent (3.35%). Low flow-low gradient (LFLG) appeared in 24.6% of patients with severe AS. Atrial fibrillation (23.1% vs. 11.6%; P = 0.002), MR (23.3% vs. 15.1%; P = 0.018), and right ventricle dysfunction (13.3% vs. 5.2%; P = 0.003) appeared frequently in LFLG group. Conclusions: Burden of AS is higher than previously assumed. Degenerative aetiology is the main cause of AS. Most of the patients are elder with high prevalence of significant co-existing valvular disease. LFLG severe AS is present in an important proportion of patients, showing high grade of left ventricle remodelling.

Limits of ventricular function: from athlete's heart to a failing heart.

The interest in the study of ventricular function has grown considerably in the last decades. In this review, we analyse the extreme values of ventricular function as obtained with Doppler echocardiography. We mainly focus on the parameters that have been used throughout the history of Doppler echocardiography to assess left ventricular (LV) systolic and diastolic function. The 'athlete's heart' would be the highest expression of ventricular function whereas its lowest expression is represented by the failing heart, independently from the original aetiology leading to this condition. There are, however, morphological similarities (dilation and hypertrophy) between the athlete's and the failing heart, which emerge as physiological and pathophysiological adaptations, respectively. The introduction of new assessment techniques, specifically speckle tracking, may provide new insight into the properties that determine ventricular filling, specifically left ventricular twisting. The concept of ventricular function must be always considered, although it may not be always possible to distinguish the normal heart of sedentary individuals from that of highly trained hearts based solely on echocardiographic or basic studies.

Changes in the severity of aortic regurgitation at peak effort during exercise.

BACKGROUND: Chronic aortic regurgitation can be well tolerated for a long time. Some patients with normal ventricular function can even reach high levels of sporting performance. How the severity of regurgitation may change during exercise, however, is little known, although some studies suggest it diminishes. The present work examines, during exercise, the functional capacity, ventricular function, and regurgitation fraction (RF) in asymptomatic subjects with moderate or severe aortic regurgitation with preserved ejection fraction. METHODS: The study subjects (n=32; 23 men, 9 women) were patients referred to our echocardiography laboratory with moderate or severe aortic regurgitation, preserved left ventricular systolic function, and sinus rhythm into NYHA functional class I. All underwent transthoracic echocardiography at rest and at peak effort during an exercise protocol involving an inclined cycloergometer. Left atrial and ventricular volume indices were recorded, along with diastolic and systolic function, cardiac index, peripheral resistance, and RF. RESULTS: The mean age of the subjects was 43.8±18.2years; 59% suffered moderate regurgitation, 41% severe aortic regurgitation, and 84% had a dilated left ventricle. All subjects managed exercise loads adequate for their age. Peak effort was associated with a significant reduction (mean 44.5% [range 10-95%]) in the RF (21.8±13.2 vs. 39.3%±14.7% at rest; p=0.0001). The absolute reduction in the RF at peak effort was greater among the subjects with severe aortic regurgitation (21.2% vs. 13.3% in those with moderate regurgitation; p=0.018). CONCLUSIONS: The RF becomes smaller during exercise in asymptomatic subjects with moderate or severe aortic regurgitation and preserved ventricular function.