Einar Skulstad Davidsen

Myocardial deformation in aortic valve stenosis: relation to left ventricular geometry.

Objective To assess left ventricular (LV) strain and displacement and their relations to LV geometry in patients with aortic stenosis (AS). Design Cross-sectional echocardiographic study in patients with AS. Peak circumferential, radial and longitudinal strain, and radial, longitudinal and transverse displacement were measured by 2D speckle tracking. Severity of AS was assessed from energy loss index (ELI). LV hypertrophy was present if LV mass/height2.7 ≥46.7/49.2 g/m2.7 in women/men and concentric LV geometry if relative wall thickness ≥0.43. LV geometry was assessed from LV mass/height2.7 and relative wall thickness in combination. Setting Department of Heart Disease, Haukeland University Hospital, Bergen, Norway. Patients 70 patients with AS (mean age 73±10 years, 54% women). Interventions None. Main outcome measures Association of regional and average LV myocardial strain and displacement with LV geometric pattern and degree of AS. Results Average longitudinal strain was lower in the hypertrophy groups and correlated with higher LV mass index and relative wall thickness, lower stress-corrected mid-wall shortening and smaller ELI (all p<0.05). Average strain and displacement in other directions did not differ between geometric groups. In multivariate regression analysis, lower average longitudinal strain was associated with higher relative wall thickness (β=0.15), lower ejection fraction (β=−0.16), systolic blood pressure (β=−0.16) and energy loss index (β=−0.20) (all p<0.05) (R2=0.72). When relative wall thickness was replaced with LV mass, lower longitudinal strain was also associated with higher LV mass (β=0.21, p<0.05) (R2=0.73). Conclusions In patients with AS, lower average longitudinal strain is related to higher LV mass, concentric geometry and more severe AS.

Assessment of left ventricular systolic function by deformation imaging derived from speckle tracking: a comparison between 2D and 3D echo modalities.

AIMS Deformation imaging is undergoing continuous development with the emergence of new technologies allowing the evaluation of the different components of strain simultaneously in three dimensions. Assessment of all global strain parameters in 2D and 3D modes and comparison with LVEF have been the focus of our study. METHODS AND RESULTS Out of 166 patients, 147 were evaluated with the use of both 2D and 3D speckle-tracking echocardiography (STE). Global strain parameters including longitudinal (GLS), circumferential (GCS), radial (GRS) and area strain (AS), as well as left ventricular volumes and ejection fraction were examined. Analysis of strain with 3D STE was faster than with 2D STE (7 ± 2 vs. 24 ± 4 min, P < 0.05). GLS values were similar between 2D and 3D modes (-14 ± 4 vs. -13 ± 3, NS), while slight differences were observed for GCS (-24 ± 7 vs. -27 ± 7, P < 0.05) and GRS (27 ± 9 vs. 24 ± 9, P < 0.05). All 2D and 3D strain parameters showed good accuracy in the identification of 2D-LVEF <55% with AS demonstrating superiority over GCS and GRS but not GLS. CONCLUSION Three-dimensional STE allows accurate and faster analysis of deformation when compared with 2D STE and might represent a viable alternative in the evaluation of global LV function.

Longitudinal Myocardial Strain Alteration Is Associated with Left Ventricular Remodeling in Asymptomatic Patients with Type 2 Diabetes Mellitus

BACKGROUND In normal subjects, left ventricular (LV) dimensions have been shown to decrease over time, while wall thickness is increasing. The aim of this study was to investigate LV remodeling in a cohort of patients with type 2 diabetes mellitus during a 3-year follow-up period and its potential association with decreased longitudinal systolic strain (εL). METHODS One hundred seventy-two patients with type 2 diabetes without overt heart disease were prospectively enrolled and underwent echocardiography with speckle-tracking imaging to assess global LV εL at baseline and at 3 years. The associations between alteration in εL (defined as |εL| < 18%), LV geometry at baseline, and LV remodeling over time were evaluated. RESULTS Among the 172 enrolled patients, 154 completed 3-year follow-up. At baseline, patients with εL alteration had higher LV end-systolic volumes (28 ± 11 vs 23 ± 9 mL, P < .001) and relative wall thicknesses (RWT; 0.44 ± 0.06 vs 0.40 ± 0.07, P = .008) compared with those with normal εL. At 3-year follow-up, RWTs remained stable in both groups. LV volumes significantly decreased in patients with normal εL but not in patients with εL alteration. Multivariate analysis showed that εL alteration was independently associated with LV end-systolic volume (β = 5.0, P = .006) and RWT (β = 0.03, P = .03) at baseline and with changes in both LV end-diastolic volume (β = 19.1, P = .001) and LV end-systolic volume (β = 2.6, P = .047) over 3 years. CONCLUSIONS In patients with type 2 diabetes, εL alteration was associated with higher RWT and LV volumes and with the absence of decreases in LV volumes over time, which might be an early sign of adverse LV remodeling.

Disease activity and left ventricular structure in patients with rheumatoid arthritis

OBJECTIVE Increased left ventricular (LV) wall thickness/internal diameter ratio (relative wall thickness) was recently reported in RA patients. The aim of this study was to assess the association between LV relative wall thickness and RA disease activity. METHODS Clinical and echocardiographic data from 129 RA patients without established cardiovascular disease and 102 controls were used. RA disease activity was assessed by different composite scores and active RA defined by the Simplified Disease Activity Index (SDAI) level exceeding the cut-off for remission (SDAI >3.3). RESULTS The RA patients were on average 61.3 years old, 77% were women and 67% had active RA (SDAI >3.3). Patients with active RA had greater LV relative wall thickness and included more patients with treated hypertension (all P < 0.05), but had LV mass index and blood pressure comparable to patients in remission. Having active RA by the SDAI score (β = 0.20, P = 0.008) was also independently associated with greater LV relative wall thickness after adjusting for systolic blood pressure, wall stress, age and sex in a multivariate model. This association was robust also in secondary models including other disease activity composite scores such as the Clinical Disease Activity Index and 28-joint DAS. CONCLUSION Among RA patients, higher disease activity was independently associated with greater LV relative wall thickness, reflecting subclinical heart disease. The findings point to the importance of disease activity control in RA patients to prevent progression to clinical heart disease.

Left ventricular long-axis function in myasthenia gravis

Myasthenia gravis (MG) primarily affects skeletal muscles, but influence on cardiac function has been suggested. The aim of this study was to assess left ventricular long-axis function in MG patients compared to healthy controls, and to examine whether any MG-related heart involvement was influenced by the acetylcholine-esterase inhibitor pyridostigmine. We found that early diastolic atrioventricular-plane velocity and tissue Doppler peak systolic strain was lower in MG patients than in controls before pyridostigmine. The differences disappeared following administration of pyridostigmine. Also, tissue velocities at systole and early diastole tended to be lower in patients before pyridostigmine. In multivariate analyses adjusting for between-group differences in blood pressure, MG was no longer associated with lower longaxis function. Conventional echocardiographic measures of left ventricular diastolic and systolic function did not differ between groups. In conclusion, this study, using modern tissue Doppler imaging as well as conventional echocardiography, could not demonstrate definite MG-related cardiac involvement in a group of MG patients without known cardiac disease, but indicates that pyridostigmine-responsive MG-related alterations in cardiac muscle function exist in MG patients.

Left Atrial Systolic Force and Outcome in Asymptomatic Mild to Moderate Aortic Stenosis

Background and Aims: In patients with chronic pressure overload due to hypertension or aortic valve stenosis (AS), higher left atrial systolic force (LASF) is associated with a high‐risk cardiovascular (CV) phenotype. We tested LASF as prognostic marker in patients with AS. Methods: We used baseline and outcome data from 1,566 patients recruited in the Simvastatin and Ezetimibe in AS (SEAS) study evaluating the effect of placebo‐controlled simvastatin and ezetimibe treatment on CV events. The primary outcome was a composite of major CV events, including CV death, aortic valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure caused by progression of AS, coronary artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. LASF was calculated by Mannings method. High LASF was defined as >95th percentile (50 Kdynes/cm2) of the distribution within the study population. Results: During 4.3 years of follow‐up, a major CV event occurred in 38 of 78 patients with high LASF (49%) and in 513 of 1,488 (34%) with normal LASF (P = 0.01). In multivariate Cox regression analysis, high LASF predicted higher rate of major CV events (Hazard ratio 1.43 [95% confidence interval 1.01–2.03] independent of aortic valve area and LV mass index. A simple risk score including absence or presence of these three variables allowed risk stratification into low, intermediate, high and very high risk for major CV events during follow‐up (22%, 28%, 38%, and 53%, respectively). Conclusions: Higher LASF provides additional prognostic information in patients with asymptomatic mild‐to‐moderate AS.

Reduced exercise capacity in genetic haemochromatosis

Background Many patients with genetic haemochromatosis complain about fatigue and reduced physical capacity. Exercise capacity, however, has not been evaluated in larger series of haemochromatosis patients treated with repeated phlebotomy. Design and methods We performed exercise echocardiography in 152 treated haemochromatosis patients (48 ± 13 years, 26% women) and 50 healthy blood donors (49 ± 13 years, 30% women), who served as controls. Echocardiography was performed at rest and during exercise in a semiupright position on a chair bicycle, starting from 20 W, increasing by 20 W/min. Transmitral early and atrial velocity and isovolumic relaxation time were measured at each step. Ventilatory gas exchange was measured by the breath-to-breath-technique. Results Compared with healthy controls, haemochromatosis patients were more obese and less trained. More of them smoked, and 17% had a history of cardiovascular or pulmonary disease. Adjusted for training, the left ventricular function and dimensions at rest did not differ between the groups. During exercise the haemochromatosis patients obtained a significantly lower peak oxygen (O2) uptake (28.1 vs. 34.4 ml/kg per min, P < 0.001). In a multiple regression analysis haemochromatosis predicted lower peak O2 uptake independently of significant contributions of sex, age, and height, as well as of systolic blood pressure and log-transformed isovolumic relaxation time at peak exercise, whereas no independent association was found with weight or physical activity (multiple R 2 = 0.74, P < 0.001). Adding genotype, s-ferritin, prevalence of smoking, or history of cardiopulmonary disease among the covariates in subsequent models did not change the results. Conclusion Genetic haemochromatosis, even when treated with regular phlebotomy, is associated with lower exercise capacity independently of other covariates of exercise capacity.

Aortic root geometry in aortic stenosis patients (a SEAS substudy)

AIMS To report aortic root geometry by echocardiography in a large population of healthy, asymptomatic aortic stenosis (AS) patients in relation to current vendor-specified requirements for transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS Baseline data in 1481 patients with asymptomatic AS (mean age 67 years, 39% women) in the Simvastatin Ezetimibe in AS study were used. The inner aortic diameter was measured at four levels: annulus, sinus of Valsalva, sinotubular junction and supracoronary, and sinus height as the annulo-junctional distance. Analyses were based on vendor-specified requirements for the aortic root geometry for current available prostheses, CoreValve and Edwards-Sapien. The ratio of sinus of Valsalva height to sinus width was 1:2. In multivariate linear regression analysis, larger sinus of Valsalva height was associated with older age, larger sinus of Valsalva diameter, lower ejection fraction and smaller supracoronary diameter (multiple R(2) = 0.19, P< 0.01). The required annulus diameter for implantation of CoreValve was met in 61.9%, and for the Edwards-Sapien prosthesis in 66.9%. Overall, annular dimension feasible for TAVI using any available prosthesis was found in 78.2% of patients and in 77.7% of patients also the required minimum sinus of Valsalva height was found. Comparing the group of patients who met TAVI requirements to those who did not, the latter included more women and patients with lower body height and weight and significantly smaller aortic root diameters (all P < 0.05). CONCLUSION Among AS patients in the SEAS study, 27% of women and 19% of men did not have aortic root geometry fulfilling current requirements for TAVI.

The association of hypertension with asymptomatic cardiovascular organ damage in rheumatoid arthritis

Abstract Background: The association of hypertension with asymptomatic cardiovascular organ damage in patients with rheumatoid arthritis (RA) has been little studied by echocardiography. Methods: Echocardiography was done in 134 RA patients and 102 healthy controls. Left ventricular (LV) geometry was considered abnormal if LV mass index or relative wall thickness was increased. LV diastolic dysfunction was considered present if septal early diastolic tissue velocity <8 cm/s. Systemic arterial compliance (SAC) was assessed from stroke volume index/pulse pressure ratio. Results: The hypertensive RA patients (n = 72) had higher inflammatory activity, older age and more diabetes than the normotensive RA patients (n = 62) (all p < 0.05). Rates of abnormal LV geometry, LV diastolic dysfunction and lower SAC were higher among the hypertensive RA patients (p < 0.05), but similar between normotensive RA patients and controls. Hypertension was associated with a 3-fold higher prevalence both for abnormal LV geometry (odds ratio 2.89 [95% confidence interval 1.09–7.63], p = 0.03) and for diastolic LV dysfunction (odds ratio 2.92 [95% confidence interval 1.14–7.46], p = 0.03) as well as lower SAC (β = 0.31, p = 0.001) independent of age, gender, diabetes and inflammatory activity measured by erythrocyte sedimentation rate. Conclusion: The presence of asymptomatic cardiovascular organ damage in RA patients is closely associated with hypertension independent of inflammatory activity.

Left ventricular diastolic function in patients with treated haemochromatosis

Objectives. We recently demonstrated reduced exercise capacity in phlebotomy treated genetic haemochromatosis in spite of normal systolic function. The present objective was to investigate diastolic function at rest. Design. Diastolic function was echocardiographically assessed in 132 phlebotomy treated genetic haemochromatosis patients and 50 controls. Results. Patients had higher body mass index and heart rate, higher transmitral early (E) (11.2±2.6 versus 10.4±2.2 cm) and atrial (A) (5.7±1.6 versus 5.0±1.6) velocity time integrals, pulmonary venous systolic peak velocity (0.58±0.12 versus 0.54±0.13 m/s) and ratio of E to spectral tissue Doppler E′ velocity (6.3±1.6 versus 5.6±1.4, all p <0.05). Independently of age, heart rate, systolic blood pressure and body weight, having haemochromatosis remained statistically significantly associated with higher E (β =0.27) and A (β =0.18) velocity time integrals, pulmonary venous systolic peak velocity (β =0.21), and E/E′-ratio (β =0.25) in separate multivariate analyses (all p <0.05). In the youngest age tertile, patients had longer isovolumic relaxation time and lower E′ than controls. Conclusion. Our findings are compatible with mildly impaired diastolic function in treated haemochromatosis, with delayed relaxation in the younger tertile, and an elevated filling pressure and pseudonormalisation with increasing age.