Evaluation of left atrial dysfunction by speckle tracking echocardiography in systolic and diastolic heart failure.

The study aimed to assess the accuracy of two-dimensional speckle tracking echocardiography (2DSTE) to evaluate the left atrial (LA) function in patients with heart failure. And can it differentiate accurately between heart failure preserved ejection fraction (HFpEF, HF with mid-range ejection fraction (HFmrEF=EF 41-49%) and heart failure with reduced ejection fraction (HFrEF= EF<40%)? It included 186 patients of heart failure who were classified into 74 patients with HFpEF (LVEF>50%), 56 patients with HFmrEF (LVEF 41-49%), 56 patients with HFrEF (LVEF<40%), and 50 normal matched subjects. B-type natriuretic peptide (BNP) was more than 35 pg/mL for all patients. The conventional echocardiography evaluated left ventricle systolic and diastolic functions. The 2DSTE evaluated the LV global strain (LVGS), and strain and strain rate (SR) in each phase of LA function. LVGS was -19.3±2.3%, -18.0±1.7%, -16.1±2.0%, and -14.3±2.2 in controls, HFpEF, and HFmrEF, and HFrEF, respectively (p<0.0001); GPALS was 34.1±6.7%, 27.5±4.7%, 21.7±4.8% and 16.9±4.9% in controls, HFpEF, HFmrEF, HFrEF, respectively (p<0.0001); The GPACS was 14.8±4.3%, 12.3±2.2%, 9.7±2.3%, and 7.5±2.6%  in controls, HFpEF, HFmrEF, and HFrEF, respectively (p<0.0001); The PALS-PACS was 19.4±3%, 15.1±4.4%, 12.0±3.4%, and  9.3±3.3% in controls, HFpEF, HFmrEF, and HFrEF (p<0.0001). Therefore, early LA dysfunction in heart failure can be detected accurately and easily by speckle tracking technique that could be a promising independent tool to better understand of heart failure and its classification.

Quantification of mitral regurgitation using transthoracic echocardiography and cardiac magnetic resonance imaging.

Both Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) have well-established role in mitral regurgitation (MR) quantification for optimal management strategy. We assessed the correlation between TTE and CMR in the quantification of MR. Participants with isolated MR and echocardiographic mitral regurgitant volume (RVol) ≥ 30 mL/beat were included. A consecutive sample of 30 participants (Mean age 52.7 ± 19.3 years, 50% males) was selected and referred for indirect and direct CMR quantification of mitral RVol. There was a statistically significant strong positive correlation between the echocardiographic and indirect CMR quantification of the mitral RVol (r = 0.753, P < 0.001) and a statistically significant moderate positive correlation between the echocardiographic and direct CMR quantification of the mitral RVol (r = 0.530, P < 0.003). The inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant moderate agreement (κ = 0.502, P = 0.0001) when the observers used the echocardiographic mitral RVol for grading of MR. On the other hand, the inter-observer reliability of the MR grade between TTE and CMR showed a statistically significant faint agreement (κ = 0.251, P = 0.024) when the observers used the echocardiographic regurgitant fraction (RF) for grading of MR. The positive reciprocal relationship between the CMR and the TTE highlights the potential role of the CMR as a concomitant imaging tool for quantification of the mitral RVol and grading of isolated MR, especially with limited or inconclusive TTE studies. This will enhance the management strategy and improve outcomes.

Vitamin D and vitamin B12 profiles in children with primary nocturnal enuresis, an analytical cross-sectional study.

PURPOSE: To outline the prevalence of vitamin D and vitamin B12 deficiencies in enuretic children. METHODS: An analytical descriptive study was conducted on enuretic children who were followed up at the outpatient clinic for nocturnal enuresis at the Children's Hospital, Cairo University. Sociodemographic and clinical data were recorded. The levels of vitamin D and vitamin B12 were assessed and correlated with the severity of enuresis. RESULTS: Two hundred and eighty-eight children were enrolled. Insufficiency of Vitamin D predominated (n = 139; 48.3%). Vitamin D deficiency was present in 31.3%, n = 90 and it was normal in 20.5%, n = 59). Vitamin B12 deficiency was observed in 25% of the studied children, n = 72). The one-sample Wilcoxon signed-rank test was significant for both vitamins (P value =0.001). Vitamin D showed a stronger inverse correlation with the number of enuresis episodes per day than vitamin B12 (-0.680 vs. -0.219 respectively). A cut-off of 13.7 ng/ml for vitamin D was detected, below which the child was predicted to have failed dry nights. Using multivariate logistic regression, higher vitamin D levels and behavioural treatment coexistence were significant protective factors for the absence of dry nights. CONCLUSION: Low levels of vitamin D and B12 were detected in children with primary nocturnal enuresis, which could be considered a burden on the clinical severity of enuresis.

What is already known on this topic?Children with Primary Nocturnal Enuresis may have vitamin D and vitamin B₁₂ abnormalities as deficienciesWhat does this study add?Vitamin D insufficiency may be the most prevalent vitamin D abnormality in children with primary nocturnal enuresis. Vitamin D insufficiency may be more common in children with severe enuresis than vitamin B₁₂ deficiency.How might this study affect research, practice, or policy?This study may invite further research to examine the possible use of vitamin D and vitamin B12 as potential adjuvant therapies for children with Primary Nocturnal Enuresis.

Correlation between obstructive sleep apnea and ventricular function: a cross-sectional hospital-based study.

BACKGROUND: Obstructive sleep apnoea (OSA) is a major cause of cardiovascular morbidity and mortality worldwide. Previous studies showed high prevalence of OSA in heart failure. We aimed to evaluate the association of OSA with cardiac dysfunction and the importance of myocardial performance index (Tei) in identifying cardiac dysfunction. METHODS: Participants with OSA and sinus rhythm were included, while participants with arrhythmia, debilitating disease, or significant valvular heart disease were excluded. Thirty participants were enrolled, consecutively allocated in a single group, and underwent nocturnal polysomnography, electrocardiogram, and transthoracic echocardiography. RESULTS: The prevalence of hypertension, diabetes, and smoking in the study population was 50%, 30%, and 23.3%, respectively. The mean body mass index and apnoea-hypopnoea index (AHI) of the study population was 40.11 ± 7.5 kg/m2 and22.12 ± 13.54 events/h, respectively. There were statistically significant differences between mild, moderate, and severe OSA regarding the left ventricular end diastolic diameter, left ventricular end systolic diameter, ejection fraction, and fractional shortening (p = 0.006, p = 0.002, p = 0.014 and p = 0.011),respectively. There were statistically significant regular positive correlations between the AHI and the right and left Tei (r = 0.447, p = 0.001 and r = 0.391, p = 0.003),respectively. CONCLUSIONS: The prevalence of OSA was more in patients with comorbidities especially hypertension and diabetes. OSA was significantly associated with ventricular remodelling and cardiac dysfunction. A significant regular positive correlation was observed between the severity of OSA and worsening cardiac function as measured by Tei. Echocardiographic evaluation of the right and left ventricles and the right and left Tei could be considered as potentially valid, reproducible, and clinically applicable non-invasive methods for estimation of ventricular global function in patients with OSA.

A Comparison Between Two-Dimensional and Three-Dimensional Regional and Global Longitudinal Strain Echocardiography to Evaluate Complex Coronary Lesions in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

Introduction A preliminary assessment of patients who suffer from severe and complex coronary artery lesions, such as three-vessel disease and/or a left main (LM) artery lesion, plays a critical contribution in determining prognosis and treatment plans for non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Therefore, a pre-angiography (i.e., before angiography) predictor was required to cost-effectively evaluate severe and complex coronary lesions to efficiently direct our subsequent dealing. Aim This study aimed to compare two-dimensional (2D) and three-dimensional (3D) global longitudinal strain (GLS) at the regional level to assess extremely complicated coronary lesions using the SYNTAX score as a standard of reference in 100 patients with NSTE-ACS. Materials and methods This research included 100 patients with non-ST-segment elevation acute coronary syndrome who presented at the Cardiology Department at Fayoum University from December 2019 to July 2020. All patients underwent a complete history and physical examination, hemoglobin A1c (HbA1c), lipid profile, creatinine assessment, 12-lead electrocardiogram (ECG), and transthoracic echocardiography (TTE) to detect global and regional longitudinal strain by 2D and 3D speckle-tracking echocardiography (STE). Coronary angiography was done on all patients within 24 hours of admission after acquiring echo images. Then, the results of 2D and 3D regional and global longitudinal strain (GLS) to predict the severity and coronary lesion complexity in terms of the SYNTAX score were compared. Results This study revealed that 2D GLS was -12.10 ± 3.51, which is significantly higher than 3D GLS of -11.64 ± 4.05 (p < 0. 001). The left anterior descending coronary artery (LAD) and left circumflex artery (LCX) territories revealed a significantly higher value using 2D regional longitudinal strain (-11.13 ± 4.47 and -12.54 ± 4.11, respectively) than using 3D regional longitudinal strain (-10.84 ± 5.18 and -12.05 ± 4.29, respectively) (p= 0.017 and p < 0.001, respectively). There were significantly lower 2D GLS, 3D GLS, global circumferential strain (GCS), area strain, and global radial strain (GRS) in the intermediate and high score group than in the low score group of patients (p < 0.001 for all). Conclusion 2D and 3D strain echocardiography including GLS, GCS, GRS, and area strain are a noninvasive and rapid tool with clinical utility for evaluating coronary lesions in patients with NSTE-ACS. They can be routinely used to diagnose and stratify high-risk patients with NSTE-ACS, thereby potentially resulting in improved patient assessment. GLS as measured by 2D and 3D STE at minimal effort is a significant risk factor for patients with complex NSTE-ACS. In NSTE-ACS cases, the GLS absolute value is significantly associated with the degree of complexity of coronary artery lesions.

Strain and strain rate echocardiographic imaging predict occurrence of atrial fibrillation in post-coronary artery bypass grafting patients.

BACKGROUND: Atrial fibrillation (AF) occurs very frequently after coronary artery bypass grafting (CABG); it occurs in about 20-edictors can be used for the dedicatio40% of patients. It is associated with several adverse events. This study aimed to extrapolate a predictor for postoperative atrial fibrillation (POAF) occurrence which is reproducible and simple to be a part of routine echocardiography screening before CABG. This study included 89 patients scheduled for isolated coronary artery bypass surgery. History, clinical examination, and complete 2D echocardiography with LA speckle tracking analysis were done preoperatively. Patients were then followed up post-surgery for incidence of AF till discharge from the hospital. The patients were divided into 2 groups according to POAF occurrence. RESULTS: Patients who developed postoperative AF had older age (P = 0.0032) and longer hospital stay (P = 0.021) and higher stroke incidence but statistically non-significant (14.3% vs 3.3%). The POAF patients showed less peak atrial longitudinal strain (PALS) value than non-POAF patients. The left atrial strain rate values showed a significant difference with the lower left atrial systolic strain rate and less negative (higher) early diastolic strain rate and late diastolic strain rate. After multivariate logistic regression analysis, the independent predictors for POAF were PALS (OR 0.770, 95% CI 0.627-0.946), late LA diastolic strain rate (LASRa) (OR 3.476, 95% CI 1.207-12.186), and age (OR 1.181, 95% CI 1.011-1.379). CONCLUSION: Preoperative LA global strain assessed by 2D speckle tracking analysis could be helpful as a predictor for AF post-CABG surgery, and identification of these patients may reduce its morbidity and mortality. The study suggested PALS value less than 29.8 to be a predictor for the occurrence of POAF.

Correlation between global longitudinal strain and SYNTAX score in coronary artery disease evaluation.

BACKGROUND: Speckle tracking echocardiography may allow the evaluation of myocardial systolic and diastolic dynamics across different physiologic and pathologic conditions beyond traditional echocardiographic techniques. The use of STE longitudinal strain in identification and risk stratification of CAD has good reproducibility and accuracy. The study aims to detect the relationship between SYNTAX score and global longitudinal peak systolic strain (GLPSS) in patients undergoing coronary angiography, with no history of myocardial infarction. RESULTS: The study included 70 symptomatic patients suspected to have chronic coronary syndrome aging 20-80 years (excluding those with significant structural heart disease). All patients underwent clinical evaluation, surface ECG, laboratory assessment, transthoracic echocardiographic (TTE), color TDI tracings, two-dimensional speckle tracking, and conventional coronary angiography with SYNTAX score calculation. Patients were divided into 3 groups based on the results of the coronary angiogram: normal CAD on angiogram (n = 10, control group), low SS (n = 25, SS < 22), and high SS (n = 35, SS ≥ 22). The mean age was 55 ± 9.6 years; 54% were males; two third of patients were hypertensive; 52% were diabetic; high percentage of high syntax score were noticed among males, diabetic patients, and smokers; and also low mean of GLS was noticed among diabetic patients and smokers. There was a statistically significant positive correlation between syntax score and each of LVEDD and LVESD and, on the other hand, statistically significant negative correlation between syntax score and each of E/A, GLS, AP2LS, AP3LS, and AP4LS was noticed. Peak GLS cutoff value of 17.8 and 16.5 showed 84% and 93% sensitivity and 70% and 91% specificity to detect high and low syntax score, respectively. CONCLUSION: 2D longitudinal strain analysis has incremental diagnostic value over visual assessment during echocardiography in predicting significant coronary artery disease; GLS may offer a potential sensitive tool to detect significant CAD.

Revisiting the pathogenic role of insulin resistance in Duchenne muscular dystrophy cardiomyopathy subphenotypes.

INTRODUCTION: Duchenne muscular dystrophy (DMD) is known to impact the subepicardial layer of the myocardium through chronic inflammation. Recent animal studies have shown predominant subendocardial involvement in rats with DMD. The primary outcome parameter was to determine by cardiovascular MRI (CMR) if two differential patterns of myocardial involvements exist in DMD; the secondary outcome parameters were to correlate the observed pattern with metabolic markers such as insulin resistance measures. METHODS: Forty patients with DMD were screened using CMR to determine which of them had predominantly subendocardial dysfunction (SENDO group), or subepicardial/midmyocardial involvement (SEPMI group). Patients were subjected to body mass index measurement, serum creatinine kinase, serum lactate dehydrogenase enzyme, fasting glucose-insulin ratio (FGIR), full lipid profile, left ventricular ejection fraction (LVEF), left ventricle E/E´ ratio (the ratio of early mitral inflow velocity to average early diastolic velocities of the basal septum and mitral annulus) for left ventricle diastolic function, and myocardial layer strain discriminating echocardiography (MLSD-STE). Results: 26 patients displayed SENDO while 34 displayed SEPMI. SENDO group displayed overt insulin resistance; (FGIR (SENDO: 7 ± 1 vs. SEPMI: 5 ± 1, P < 0.001). FGIR was negatively correlated with Subendocardial Global Longitudinal Strain (ENDO-LS) with r = -0.75. CONCLUSION: DMD does not seem to influence the heart uniformly; DMD cardiomyopathy probably has two separate phenotypes with different mechanisms. Insulin resistance might be implicated in its pathogenesis and its reversal may help to slow disease progression.

Left ventricular mass index and subendocardial myocardial function in children with chronic kidney disease, a transmural strain and three-dimensional echocardiographic study.

Introduction: Left ventricular hypertrophy (LVH) is the commonest myocardial response to chronic kidney disease (CKD); this response has been regarded detrimental as it impairs the blood flow to the deepest layers of the myocardium causing progressive myocardial dysfunction. The aim of these series is to assess the determinants of LVH in CKD patients and its impact on subendocardial function in such patients. Methods: This study has been conducted on 40 CKD patients (Group 1) and 40 age-matched controls, both groups were assessed by transmural echocardiography to determine the subepicardial and subendocardial global longitudinal strain (GLS) as an expression of the systolic function of each of those layers. LVH was assessed by calculation of left ventricle mass index (LVMI). Both groups underwent ambulatory blood pressure monitoring. Group 1 was assessed as regards lipid profile and insulin resistance by homeostasis model assessment of insulin resistance (HOMA-IR). Results: HOMA-IR proved to be a more important determinant of LV hypertrophy than SBP and DBP with a P of 0.01. Moreover subendocardial GLS was negatively correlated with LVMI with r = 0.69 and P < 0.01 denoting the negative effect. LVH plays on subendocardial function probably by impairing myocardial perfusion. Conclusion: This study points toward the importance of insulin resistance in aggravation of myocardial remodeling in CKD patients; more studies are warranted to examine the role of insulin Sensitizers in reversing such remodeling and restoring subendocardial function in such important systemic disorder.