Impact of left ventricular hemodynamic forces in adult patients with treated aortic coarctation and preserved left ventricular systolic function.

BACKGROUND: The LV myocardial strain and hemodynamic forces (HDFs) are innovative markers of LV function. Aortic coarctation is safely repaired in infancy; however, mortality and morbidity remain increased in later life. The study investigated the role of left ventricular myocardial deformation and HDFs in asymptomatic patients who underwent successful aortic coarctation repair. METHODS: Clinical and echocardiographic data were analyzed from 42 repaired CoA, 32 ± 20 years after surgery, 2D echocardiographic global longitudinal strain (GLS), circumferential strain (GCS) and HDFs were determined. CoA patients were compared with 42 patients affected by blood hypertension and 84 healthy controls; all matched for age and gender. RESULTS: All groups had normal LV ejection fraction (LVEF), dimensions, and volumes. CoA patients showed a significantly higher rate of LV mass indexed (p < .001) and left atrial volumes indexed (p < .001). LV myocardial and endocardial global longitudinal and circumferential strain were decreased in CoA patients (p < .001, p < .001; p = .032 and p < .001, respectively). HDF parameters such as LV longitudinal force, LV systolic longitudinal force and LV impulse (LVim) were uniformly reduced (p = .006, p = .001, and p = .001, respectively). LV myocardial strain and HDF parameter values were independently associated with hospitalization for heart failure on univariable Cox regression analysis. CONCLUSION: Despite preserved LVEF, patients with CoA had lower LV myocardial strain and HDF parameters values, independently associated with hospitalization for heart failure.

Neuromuscular diseases and their cardiac manifestations under the spectrum of cardiovascular imaging.

Neuromuscular diseases (NMDs) include a broad spectrum of disorders that affect motor unit in every possible site, extending from the cell body of peripheral nerves to the muscle. The different lesion sites make this group of inherited disorders difficult to diagnose. Many NMDs, especially those involving skeletal muscles, can present significant cardiovascular complications, ranging from rhythm disturbances to the development of dilated or hypertrophic cardiomyopathy. Heart disease represents a major cause of morbidity and mortality among NMD patients, underlining the vital need for further familiarization with the pathogenesis and assessment of cardiac involvement. Cardiovascular imaging is the cornerstone for the evaluation of heart disorders in NMDs, with conventional echocardiography still offering a portable, affordable, and easily accessible solution. Meanwhile, newer echocardiographic techniques such as speckle tracking imaging in combination with cardiac magnetic resonance add new insights into further substrate characterization. The purpose of this review is to offer a brief presentation of the main NMDs and their cardiovascular complications, as well as the presentation of data that highlight the importance of cardiovascular imaging in early diagnosis, monitoring, and prognosis of these patients. Lastly, the authors provide a simple guide about which clinical features, imaging findings, and follow-up plan to adopt in each myopathic disorder.

Initial Derivation of a Predictive Model for Left Ventricular Longitudinal Strain (LS) in Early Sepsis.

Septic shock is a common deadly disease often associated with cardiovascular dysfunction. Left ventricular longitudinal strain (LV LS) has been proposed as a sensitive marker to measure cardiovascular function; however, it is not available universally in standard clinical echocardiograms. We sought to derive a predictive model for LV LS, using machine learning techniques with the hope that we may uncover surrogates for LV LS. We found that left ventricular ejection fraction, tricuspid annular plane systolic excursion, sepsis source, height, mitral valve Tei index, LV systolic dimension, aortic valve ejection time, and peak acceleration rate were all predictive of LV LS in this initial exploratory model. Future modeling work may uncover combinations of these variables which may be powerful surrogates for LV LS and cardiovascular function.

Right ventricular peak systolic free wall longitudinal strain as a practical tool to detect right ventricular dysfunction in acute myocarditis.

INTRODUCTION: Acute myocarditis is one of the etiologies of acute heart failure, chronic dilated cardiomyopathy, and cardiac mortality. The extent of right ventricular (RV) involvement and its impact on the course of the disease have been scarcely studied. This study aimed to evaluate both the prevalence of RV dysfunction in acute myocarditis and echocardiographic measures as a diagnostic tool for RV dysfunction compared with cardiac magnetic resonance imaging (CMR) findings. METHODS: This retrospective study enrolled patients with a definite or probable acute myocarditis diagnosis based on the Lake Louise criteria in CMR and evaluated the diagnostic accuracy of echocardiographic measures in predicting RV dysfunction in CMR. RESULTS: The study population consisted of 71 patients, including 54 men (76%), at a median (Q1-Q3) age of 33 (26-46) years. CMR detected RV dysfunction in 53.5% of the patients. The RV free wall peak systolic longitudinal strain showed the highest correlation (r = -.786, p < .001) and area under the curve (.919) with the RV ejection fraction in CMR, followed by the RV global peak systolic longitudinal strain and the RV fractional area change. The RV-free wall peak systolic longitudinal strain had a sensitivity of 92% and a specificity of 73% for the diagnosis of RV dysfunction in myocarditis. A cutoff value of -17.9% was 100% specific for RV systolic dysfunction. CONCLUSIONS: Echocardiography, as a readily available tool, was predictive of and had acceptable accuracy for RV dysfunction in acute myocarditis compared with CMR.

Echocardiographic Differentiation of Pericardial Constriction and Left Ventricular Restriction.

PURPOSE OF REVIEW: Overlapping hemodynamics in constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM) often pose difficulties in establishing accurate diagnosis. Echocardiography is the first-line imaging modality used for this purpose, but no single echocardiographic parameter is sufficiently robust for distinguishing between the two conditions. The newer developments may improve the diagnostic accuracy of echocardiography in this setting. RECENT FINDINGS: Recent studies have validated multiparametric algorithms, based on conventional echocardiographic parameters, which enable high sensitivity and specificity for distinguishing between CP and RCM. In addition, myocardial deformation analysis using speckle-tracking echocardiography has revealed distinct pattern of abnormalities in the two conditions. CP is characterized by impaired left ventricular apical rotation with relatively preserved longitudinal strain, esp. of ventricular and atrial septum. In contrast, RCM results in global and marked impairment of left ventricular longitudinal strain with initially preserved circumferential mechanics. Combining multiple echocardiographic parameters into step-wise algorithms and incorporation of myocardial deformation analysis help improve the diagnostic accuracy of echocardiography for distinguishing between CP and RCM. The use of machine-learning may allow easy integration of a wide range of echocardiographic and clinical parameters to permit accurate, automated diagnosis, with less dependence on the user expertise.

Multimodality imaging for the management of patients with primary mitral regurgitation.

Advanced cardiac imaging (ACI), including myocardial deformation imaging, 3D echocardiography and cardiac magnetic resonance, overcomes the limitations of conventional echocardiography in the assessment of patients with primary mitral regurgitation (MR). They enable a more precise MR quantification and reveal early changes before advanced and irreversible remodeling with depressed heart function occurs. ACI permits a thorough analysis of mitral valvular anatomy and MR mechanisms (important for planning and guiding percutaneous and surgical procedures) and helps to identify structural and functional changes coupled with a high arrhythmogenic potential, especially the occurrence of atrial fibrillation and heart failure development. The key question is how the data provided by ACI can improve the current management of primary MR.

Head-to-head comparison of cardiovascular MR feature tracking cine versus acquisition-based deformation strain imaging using myocardial tagging and strain encoding.

PURPOSE: Myocardial feature-tracking (FT) deformation imaging is superior for risk stratification compared with volumetric approaches. Because there is no clear recommendation regarding FT postprocessing, we compared different FT-strain analyses with reference standard techniques, including tagging and strain-encoded (SENC) MRI. METHODS: Feature-tracking software from four different vendors (TomTec, Medis, Circle [CVI], and Neosoft), tagging (Segment), and fastSENC (MyoStrain) were used to determine left ventricular global circumferential strains (GCS) and longitudinal strains (GLS) in 12 healthy volunteers and 12 patients with heart failure. Variability and agreements were assessed using intraclass correlation coefficients for absolute agreement (ICCa) and consistency (ICCc) as well as Pearson correlation coefficients. RESULTS: For FT-GCS, consistency was excellent comparing different FT vendors (ICCc = 0.84-0.97, r = 0.86-0.95) and in comparison to fast SENC (ICCc = 0.78-0.89, r = 0.73-0.81). FT-GCS consistency was excellent compared with tagging (ICCc = 0.79-0.85, r = 0.74-0.77) except for TomTec (ICCc = 0.68, r = 0.72). Absolute FT-GCS agreements among FT vendors were highest for CVI and Medis (ICCa = 0.96) and lowest for TomTec and Neosoft (ICCa = 0.32). Similarly, absolute FT-GCS agreements were excellent for CVI and Medis compared with both tagging and fast SENC (ICCa = 0.84-0.88), good to excellent for Neosoft (ICCa = 0.77 and 0.64), and lowest for TomTec (ICCa = 0.41 and 0.47). For FT-GLS, consistency was excellent (ICCc ≥ 0.86, r ≥ 0.76). Absolute agreements among FT vendors were excellent (ICCa = 0.91-0.93) or good to excellent for TomTec (ICCa = 0.69-0.85). Absolute agreements (ICCa) were good (CVI 0.70, Medis 0.60) and fair (TomTec 0.41, Neosoft 0.59) compared with tagging, but excellent compared with fast SENC (ICCa = 0.77-0.90). CONCLUSION: Although absolute agreements differ depending on deformation assessment approaches, consistency and correlation are consistently high regardless of the method chosen, thus indicating reliable strain assessment. Further standardisation and introduction of uniform references is warranted for routine clinical implementation.

Fibrosis in hypertrophic cardiomyopathy: role of novel echo techniques and multi-modality imaging assessment.

Hypertrophic cardiomyopathy (HCM) represents one of the primary cardiomyopathies and may lead to heart failure and sudden cardiac death. Among various histologic features of the disease examined, assessment of myocardial fibrosis may offer valuable information, since it may be considered the common nominator for all HCM connected complications. Late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) has emerged as the reference noninvasive method for visualizing and quantifying myocardial fibrosis in patients with HCM. T1 mapping, a promising new CMR technique, may provide an advantage over conventional LGE-CMR, by permitting a more valid quantification of diffuse fibrosis. On the other hand, echocardiography offers a significantly more portable, affordable, and easily accessible solution for the study of fibrosis. Various echocardiographic techniques ranging from integrated backscatter and contrast-enhanced ultrasound to two- (2D) or three-dimensional (3D) deformation and shear wave imaging may offer new insights into substrate characterization in HCM. The aim of this review is to describe thoroughly all different modalities that may be used in everyday clinical practice for HCM fibrosis evaluation (with special focus on echocardiographic techniques), to concisely present available evidence and to argue in favor of multi-modality imaging application. It is essential to understand that the role of various imaging modalities is not competitive but complementary, since the information provided by each one is necessary to illuminate the complex pathophysiologic pathways of HCM, offering a personalized approach and treatment in every patient.

Myocardial Strain Imaging in Resistant Hypertension.

PURPOSE OF REVIEW: Resistant hypertension (RH) is a major contributor to cardiovascular diseases and is associated with increased all-cause and cardiovascular mortality. Cardiac changes such as impaired left ventricular (LV) function, left ventricular hypertrophy (LVH), myocardial fibrosis, and enlarged left atrium (LA) are consequences of chronic exposure to an elevated blood pressure. The purpose of this review article is to demonstrate the potential benefits of using STE as a non-invasive imaging technique in the assessment of cardiac remodeling in patients with hypertension and specifically in uncontrolled and RH population. RECENT FINDINGS: It is well-recognized that conventional transthoracic echocardiography is a useful analytic imaging modality to evaluate hypertension-mediated organ damage (HMOD) and in a resistant hypertensive population. More recently two-dimensional speckle tracking echocardiography (STE) has been utilized to provide further risk assessment to this population. Recent data has shown that STE is a new promising echocardiographic marker to evaluate early stage LV dysfunction and myocardial fibrosis over conventional 2D parameters in patients with cardiovascular diseases.

Electromechanical substrate characterization in arrhythmogenic cardiomyopathy using imaging-based patient-specific computer simulations.

AIMS: Arrhythmogenic cardiomyopathy (AC) is an inherited cardiac disease, characterized by life-threatening ventricular arrhythmias and progressive cardiac dysfunction. The aim of this study is to use computer simulations to non-invasively estimate the individual patient's myocardial tissue substrates underlying regional right ventricular (RV) deformation abnormalities in a cohort of AC mutation carriers. METHODS AND RESULTS: In 68 AC mutation carriers and 20 control subjects, regional longitudinal deformation patterns of the RV free wall (RVfw), interventricular septum (IVS), and left ventricular free wall (LVfw) were obtained using speckle-tracking echocardiography. We developed and used a patient-specific parameter estimation protocol based on the multi-scale CircAdapt cardiovascular system model to create virtual AC subjects. Using the individual's deformation data as model input, this protocol automatically estimated regional RVfw and global IVS and LVfw tissue properties. The computational model was able to reproduce clinically measured regional deformation patterns for all subjects, with highly reproducible parameter estimations. Simulations revealed that regional RVfw heterogeneity of both contractile function and compliance were increased in subjects with clinically advanced disease compared to mutation carriers without clinically established disease (17 ± 13% vs. 8 ± 4%, P = 0.01 and 18 ± 11% vs. 10 ± 7%, P < 0.01, respectively). No significant difference in activation delay was found. CONCLUSION: Regional RV deformation abnormalities in AC mutation carriers were related to reduced regional contractile function and tissue compliance. In clinically advanced disease stages, a characteristic apex-to-base heterogeneity of tissue abnormalities was present in the majority of the subjects, with most pronounced disease in the basal region of the RVfw.

Comparative analysis of phasic left atrial strain and left ventricular posterolateral strain pattern to discriminate Fabry cardiomyopathy from other forms of left ventricular hypertrophy.

BACKGROUND: "Classical" echocardiographic signs of Fabry cardiomyopathy (FC), such as left ventricular hypertrophy (LVH), posterolateral strain impairment (PLSI), and papillary muscle hypertrophy may be of limited diagnostic accuracy in clinical practice. Our aim was to evaluate the diagnostic value of left atrial (LA) strain impairment compared to "classical" echocardiographic findings to discriminate FC. METHODS: In standard echocardiographic assessments, we retrospectively analyzed the diagnostic value of the "classical" red flags of FC as well as LA strain in 20 FC patients and in 20 subjects with other causes of LVH. Receiver operating characteristic (ROC) curve analysis was performed to assess the respective diagnostic accuracy. RESULTS: FC was confirmed in 20 patients by genetic testing. In the LVH group, 12 patients were classified by biopsy to have hypertrophic cardiomyopathy, two had hypertensive heart disease, and six LVH combined with borderline myocarditis. Global and regional left ventricular (LV) strain was not significantly different between groups while LA strain was significantly impaired in FC (Left atrial reservoir strain (LASr) 19.1%±8.4 in FC and 25.6%±8.9 in LVH, p = 0.009; left atrial conduction strain (LAScd) -8.4%±4.9 in FC and -15.9%±8.4 in LVH, p < 0.01). LAScd, with an area under the curve (AUC) of .81 (95% confidence interval [CI] .66-.96) showed the highest diagnostic accuracy to discriminate FC. The PLSI pattern showed an AUC of .49, quantification of papillary muscle hypertrophy an AUC of .47. CONCLUSION: Adding LA strain analysis to a comprehensive echocardiographic work-up of unclear LVH may be helpful to identify FC as a possible cause.

Subclinical myocardial disease in patients with primary hyperoxaluria and preserved left ventricular ejection fraction: a two-dimensional speckle-tracking imaging study.

BACKGROUND: Primary hyperoxaluria (PH) is characterized by progressive chronic kidney disease (CKD) and systemic oxalate deposition. Myocardial dysfunction might be present early in the course of the disease. However, this hypothesis has not yet been tested in the PH population. Therefore, we aimed to determine whether strain imaging using two-dimensional speckle tracking echocardiography (2D-STE) might detect subclinical myocardial disease in otherwise asymptomatic PH patients. METHODS: Prospective study of pediatric and adolescent PH patients with preserved LV ejection fraction (LV EF) and without renal replacement therapy. Subjects underwent conventional echocardiography and 2D-STE. Global (GLS) and segmental peak systolic LV longitudinal strain (LS) measurements were obtained. Data were compared with age- and gender-matched controls, and Z-scores were calculated as appropriate. RESULTS: Fifteen PH patients (age 14.1 ± 5.9 years; 13/15 in CKD stages 1-2) were studied. Although LV EF was preserved (63 ± 6%) in patients, GLS was significantly impaired (GLS - 17.1 ± 2.2% vs - 22.4 ± 1.9%, p < 0.001). This was mainly due to decreased LS values in the apical segments (p < 0.05). Echocardiographic indices of ventricular wall thickness were significantly increased in patients compared to controls (all p < 0.03). GLS correlated significantly with Z-scores of diastolic interventricular wall thickness (r = - 0.57, p = 0.025) and moderately with serum creatinine levels (r = 0.53, p = 0.044). No correlation was found between GLS and blood pressure measurements. CONCLUSIONS: Subclinical myocardial disease is already present early in the course of disease in PH patients with preserved LV EF and some degree of renal dysfunction, but without overt systemic oxalosis. Current recommendations to screen only PH patients with advanced CKD for cardiac disease should be revised accordingly.

Correlation and agreement between 2D and 3D speckle-tracking echocardiography for left ventricular volumetric, strain, and rotational parameters in healthy volunteers and in patients with mild mitral stenosis.

BACKGROUND: Recent advances had allowed measurement of myocardial deformation parameters using 3D speckle-tracking echocardiography (STE). Agreement between these two modalities and interchangeability of findings remain as an issue since 2DSTE is more widely available than 3DSTE. The aim of this study was to investigate the correlation and agreement between 2DSTE and 3DSTE in healthy volunteers and in patients with mild mitral stenosis (MS). METHODS: Data from 31 patients with mild MS and 27 healthy volunteers were included in this study. Data were analyzed for the correlation and agreement between 2DSTE and 3DSTE for volumetric, strain, and rotational parameters. RESULTS: There were no significant differences between 2DSTE and 3DSTE in both control and MS groups for left ventricular volumetric and rotational parameters. 3D global longitudinal strain (GLS) and global circumferential strain (GCS) were significantly higher in healthy volunteers (P < 0.001 for both), while only 3DGCS was significantly higher than 2DGCS in MS group (P < 0.001). The correlation between 3DSTE and 2DSTE was weak-to-moderate in both groups for strain and rotational parameters, and overall, correlation coefficients were higher in MS group. An exception was GLS in MS group, where coefficient of correlation was excellent (r = 0.907). Agreement between two modalities was poor for strain and rotational parameters, and the average bias was high. CONCLUSIONS: Overall, the agreement between 2DSTE and 3DSTE for strain and rotational measures was poor with a high average bias. The agreement between 2DSTE and 3DSTE is affected by the presence of underlying MS and the direction of strain.

Independent parameters of left atrium function in hypertensive heart disease.

BACKGROUND: The left atrium reservoir function has an important role in the global cardiac performance and is determined by multiple cardiac and extra-cardiac factors. A new parameter is introduced, the independent strain, which quantifies left atrium reservoir phase deformation during isovolumetric relaxation. AIMS: Is evaluated whether independent strain can identify intrinsic atrial myocardial damage in hypertension. MATERIAL AND METHODS: Prospective observational study in which echocardiography was done to 50 hypertensive patients and 80 healthy volunteers. Myocardial deformation was evaluated with two-dimensional speckle tracking and left atrium volumes were calculated whit 3D-echocardiography. RESULTS: In hypertensive patients, the indexed left atrium volume was greater than in the control group (34 ± 7.8 vs 24 ± 4.9 mL/m2 ); strain of pump (-5.7 ± 2.4% vs -17±3.5%) and reservoir phases (34 ± 9% vs 48 ± 10%) were worst. The minimum left atrium volume was higher (26 ± 10 vs 15 ± 8 mL) and left atrium independent strain was lower in hypertensive patients (4.0% vs 6.5%, P = .001). Left atrium independent strain only correlated with minimum left atrium volume (r = -.31, P = .048). DISCUSSION: The left ventricle longitudinal performance has an important contributing role in the left atrium reservoir function; despite this finding, the independent strain was unrelated to left ventricle longitudinal function. CONCLUSION: Independent strain can identify atrial myocyte contractile dysfunction in hypertension given the relative absence of hemodynamic loads during this period. Additionally, quantification of left atrium minimum volume suggests indirectly the presence of atrial myocyte contractile dysfunction.

Biatrial and right ventricular deformation imaging: Implications of the recent EACVI consensus document in the clinics and beyond.

In this review, right ventricular (RV), right atrial (RA), and left atrial (LA) strain in some selected clinical situations has been discussed in light of the current literature. To exemplify the significance of the use of multichamber strain, we have provided some illustrations of common cardiac problems. The recently published European Association of Cardiovascular Imaging (EACVI) consensus document for standardization of RV, RA, and LA strain, using the currently available software, has fulfilled the aspirations of investigators world over who have been studying atrial strain using a bailed-out algorithm designed principally to quantify left ventricular deformation. The purpose of this review was to reiterate the value of the application of RV and biatrial strain imaging in research and day-to-day clinical practice, using the 2-dimensional speckle tracking echocardiography (2D-STE). Also, we present a short report on how RA strain may remain coupled to pulmonary hemodynamics. Besides, we have highlighted the technical challenges of atrial strain quantification. We have not used the nomenclature of chamber deformation proposed by the EACVI document as the publications cited in this review have used different sets of nomenclature.

A Comparison of Global Longitudinal, Circumferential, and Radial Strain to Predict Outcomes After Cardiac Surgery.

OBJECTIVE: Myocardial strain measured by speckle-tracking echocardiography detects subtle regional and global left ventricular dysfunction. Myocardial strain is measured in the longitudinal, circumferential, and radial dimensions; however, it is unclear which dimension of strain is the best predictor of postoperative outcomes. DESIGN: A secondary analysis of prospectively collected data from a clinical trial (NCT01187329). SETTING: The cardiothoracic surgical operating rooms of an academic tertiary-care center. PARTICIPANTS: Cardiothoracic surgery patients with aortic stenosis having aortic valve replacement (AVR) with or without coronary artery bypass grafting enrolled in a clinical trial. INTERVENTIONS: Myocardial deformation analysis from standardized investigative transesophageal echocardiographic examinations performed after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: The authors compared the ability of intraoperative global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) strain to predict adverse postoperative outcomes, including prolonged hospitalization and the need for pharmacologic hemodynamic support after cardiac surgery. The association of GLS, GCS, and GRS with prolonged hospitalization (>7 days) and the need for pharmacologic hemodynamic support, with epinephrine or norepinephrine after cardiopulmonary bypass, were assessed using separate multivariable logistic regression models with adjustment for multiple comparisons. Of 100 patients, 86 had acceptable measurements for GLS analysis, 73 for GCS, and 72 for GRS. Worse GLS was associated with prolonged hospitalization [odds ratio [OR] (98.3% confidence interval [CI]) of 1.21 (1.01-1.46) per-unit worsening in strain (p = 0.01, significance criterion <0.0167)] and the need for inotropic support with epinephrine [OR (99.2% CI) of 1.81 (1.10-2.97) per-unit worsening in strain (p = 0.002, significance criterion <0.0083)], but not norepinephrine. GCS and GRS were not associated with adverse outcomes. CONCLUSION: GLS, but not GCS or GRS, predicts prolonged hospitalization and the requirement for inotropic support with epinephrine after AVR.

Evaluation of Left Ventricular Function Long Term After Arterial Switch Operation for Transposition of the Great Arteries.

Long-term after arterial switch operation for transposition of the great arteries, abnormal coronary anatomy and altered loading conditions could compromise ventricular function. The current study investigates whether left ventricular function, measured with echocardiographic bi-plane ejection fraction and deformation imaging, in patients long term after arterial switch operation for transposition of the great arteries differs from healthy peers. A cross-sectional cohort study of patients at least 12 years after arterial switch operation was analyzed with bi-plane Simpson's left ventricular ejection fraction (LVEF) and deformation (speckle tracking) echocardiography. 81 patients, median age 20.6 (interquartile range 13.5-28.4) years, were included. LVEF was normal on average at 55.5 ± 6.1%. Global longitudinal strain (GLS) was lower in patients compared to healthy peers throughout all age groups and on pooled average (- 15.4 ± 1.1% vs. - 23.2 ± 0.9%). Although LVEF is normal on average in patients after arterial switch operation for transposition of the great arteries, GLS is impaired compared to healthy peers. The reduced GLS could indicate sub-clinical myocardial dysfunction.

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction.

Echocardiography, given its safety, easy availability, and the ability to permit a comprehensive assessment of cardiac structure and function, is an indispensable tool in the evaluation and management of patients with heart failure (HF). From initial phenotyping and risk stratification to providing vital data for guiding therapeutic decision-making and monitoring, echocardiography plays a pivotal role in the care of HF patients. The recent advent of multiparametric approaches for myocardial deformation imaging has provided valuable insights in the pathogenesis of HF, elucidating distinct patterns of myocardial dysfunction and events that are associated with progression from subclinical stage to overt HF. At the same time, miniaturization of echocardiography has further expanded clinical application of echocardiography, with the use of pocket cardiac ultrasound as an adjunct to physical examination demonstrated to improve diagnostic accuracy and risk stratification. Furthermore, ongoing advances in the field of big data analytics promise to create an exciting opportunity to operationalize precision medicine as the new approach to healthcare delivery that aims to individualize patient care by integrating data extracted from clinical, laboratory, echocardiographic, and genetic assessments. The present review summarizes the recent advances in the field of echocardiography, with emphasis on their role in HF phenotyping, risk stratification, and optimizing clinical outcomes.

Comprehensive assessment of left ventricular myocardial function by two-dimensional speckle-tracking echocardiography.

BACKGROUND: Left ventricular ejection fraction (LVEF) results from the combined action of longitudinal and circumferential contraction, radial thickening, and basal and apical rotation. The study of these parameters together may lead to an accurate assessment of the cardiac function. METHODS: Ninety healthy volunteers, categorized by gender and age (≤ 55 and >  55 years), were evaluated using two-dimensional speckle tracking echocardiography. Transversal views of the left ventricle (LV) were obtained to calculate circumferential strain and left ventricular twist, while three apical views were obtained to determine longitudinal strain (LS) and mitral annular plane systolic excursion (MAPSE). We established the integral myocardial function of the LV according to: 1. The Combined Deformation Parameter (CDP), which includes Deformation Product (DP) - Twist x LS (° x %) - and Deformation Index (DefI) -Twist / LS (° / %)-; and 2. the Torsion Index (TorI): Twist / MAPSE (° / cm). RESULTS: The mean age of our patients was 50.3 ± 11.1 years. CDP did not vary with gender or age. The average DP was - 432 ± 172 ° x %, and the average DefI was - 0.96 ± 0.36 ° / %. DP provides information about myocardial function (normal, pseudonormal, depressed), and the DefI quotient indicates which component (s) is/are affected in cases of abnormality. TorI was higher in volunteers over 55 years (16.5 ± 15.2 vs 13.1 ± 5.0 °/cm, p = 0.003), but did not vary with gender. CONCLUSIONS: The proposed parameters integrate values of twisting and longitudinal shortening. They allow a complete physiological assessment of cardiac systolic function, and could be used for the early detection and characterization of its alteration.

Cardiac fluid dynamics meets deformation imaging.

Cardiac function is about creating and sustaining blood in motion. This is achieved through a proper sequence of myocardial deformation whose final goal is that of creating flow. Deformation imaging provided valuable contributions to understanding cardiac mechanics; more recently, several studies evidenced the existence of an intimate relationship between cardiac function and intra-ventricular fluid dynamics. This paper summarizes the recent advances in cardiac flow evaluations, highlighting its relationship with heart wall mechanics assessed through the newest techniques of deformation imaging and finally providing an opinion of the most promising clinical perspectives of this emerging field. It will be shown how fluid dynamics can integrate volumetric and deformation assessments to provide a further level of knowledge of cardiac mechanics.