H. Pavlopoulos

The association of clinical outcome with right atrial and ventricular remodelling in patients with pulmonary arterial hypertension: study with real-time three-dimensional echocardiography

AIMSnRight atrial (RA) dilatation may be important for patients outcome in pulmonary arterial hypertension (PAH). The aim of this study was to examine the longitudinal RA and right ventricular (RV) remodelling in PAH patients using real-time three-dimensional echocardiography (3DE) and their relation to clinical outcome.nnnMETHODS AND RESULTSnSixty-two consecutive PAH patients were studied and compared with a control group of 30 healthy volunteers. RA and RV sphericity indices were measured with 3DE. RV ejection fraction (RVEF), RA volume (RAvol), and the quantification of jet area of tricuspid regurgitation (TR) were measured. Two observers were used for reproducibility assessment. The geometrical change of RA and RV was assessed in relation to clinical outcome, as defined by the increase of functional class or admission to the hospital due to right heart failure. Over 1 year of follow-up, there was significant increase of RA sphericity index (0.85±0.16 vs. 1.2±0.24, P<0.01), RV dilatation (RV sphericity index 0.71±0.07 vs. 0.98±0.04, P<0.01), as well as deterioration of RV systolic function (RVEF 33±8.2 vs. 28±7.6%, P<0.01). Twenty-three patients (37%) had a clinical deterioration within 1 year. An increase of RA sphericity index>0.24 predicted clinical deterioration with a sensitivity of 96% and a specificity of 90% [area under the curve (AUC) 0.97]. RV sphericity index was less sensitive (70%) and specific (62%) in predicting clinical deterioration (AUC 0.649). The deterioration in RVEF had a sensitivity of 91.1% and a specificity of 35.3% (AUC 0.479) in predicting clinical deterioration. The dilatation of RA>14 mL over 1 year had high sensitivity at 82.6% but low specificity at 30.8% in predicting clinical deterioration.nnnCONCLUSIONnPAH leads to RA and RV dilatation and functional deterioration which are linked to an adverse clinical outcome. 3DE measurement of RA sphericity index may be a suitable index in predicting clinical deterioration of PAH patients.

Recent advances in cardiac resynchronization therapy: echocardiographic modalities, patient selection, optimization, non-responders—all you need to know for more efficient CRT

Cardiac Resynchronization Therapy (CRT) constitutes an established way of treatment for patients suffering from severe heart failure. However, this technologically based and expensive mode of therapy may not be effective for a substantial number of individuals. Recent research and advanced echocardiographic modalities have provided new insight on the proper patient selection, lead implantation, optimization and reasons for non-response. Based on this evidence, an overall assessment of parameters that appear to contribute significantly to the outcome of CRT in addition to electrical or mechanical dyssynchrony, seems to be a reasonable approach for more effective resynchronization therapy.

Abnormal Segmental Relaxation Patterns in Hypertensive Disease and Symptomatic Diastolic Dysfunction Detected by Strain Echocardiography

BACKGROUNDnAn abnormal segmental relaxation pattern exists as an early sign of diastolic dysfunction (DD), detectable by strain (S) echocardiography.nnnOBJECTIVEnThe objective of this study was to investigate the relation of segmental relaxation patterns with longitudinal systolic function and symptomatic DD in patients with hypertension (HTN).nnnMETHODSnWe evaluated 30 healthy volunteers and 78 volunteers with HTN, divided as follows: (1) patients without DD (n: 28); (2) patients with asymptomatic DD (n: 25); and (3) patients with symptomatic DD (n: 25). All groups had normal ejection fraction greater than or equal to 55%. The symptomatic group had mild exertional dyspnea. All participants underwent 2-dimensional and color Doppler myocardial imaging, and the mean longitudinal strain (S) and S rate (SR) were estimated. Early and late diastolic SR parameters (SR(E) and SR(A)) were also recorded from the basal, mid, and apical segments for each wall. Altered segmental relaxation (SR(E)/SR(A) < 1.1) was regarded as an index of segmental DD.nnnRESULTSnPatients who were symptomatic with DD were found to have more segments with an abnormal relaxation pattern (segmental DD) and more deteriorated longitudinal systolic function based on S and SR, compared with patients with asymptomatic HTN and control subjects. Segmental DD was correlated with structural changes of left ventricular (LV) remodeling such as wall thickness (r: 0.64), relative wall thickness (r: 0.58), and LV mass index (r: 0.59), as well as mean S (r: -0.61), SR (r: -0.62), systolic blood pressure (r: 0.44), age (r: 0.49), and filling pressures (r: 0.50), all P less than .01. In multiple regression analysis, segmental DD and systolic blood pressure were independently related to symptomatic status (segmental DD: beta = 0.33, P = .003; systolic blood pressure: beta = 0.24, P = .009, R(2): 0.33). Compared with conventional indices of DD (deceleration time of the E wave, isovolumic relaxation time, E, A, and E/A), segmental DD was the only parameter that predicted symptomatic status (coefficient: 0.3817, SE: 0.1101, P = .0005, odds ratio: 1.4648, 95% confidence interval: 1.1761-1.7485).nnnCONCLUSIONnLV segmental relaxation demonstrates progressive deterioration in HTN disease, which is more pronounced in patients with symptomatic DD. Altered segmental relaxation is related to structural changes of LV remodeling and constitutes an independent predictor for the presence of a symptomatic status.

Regional left ventricular distribution of abnormal segmental relaxation evaluated by strain echocardiography and the incremental value over annular diastolic velocities in hypertensive patients with normal global diastolic function.

AIMSnDiastolic dysfunction (DD) identifies patients with increased cardiovascular risk. The aim of this study was to investigate the regional distribution of abnormal segmental relaxation in hypertensives with normal global DD and to demonstrate the incremental value of strain echocardiography over annular diastolic velocities and global indices of DD derived by conventional echocardiography.nnnMETHODS AND RESULTSnWe evaluated 70 individuals, consisting of 35 hypertensives and 35 middle-aged volunteers as a control. None had DD based on global indices (deceleration time, isovolumic relaxation time, and E/A). Segmental early and late diastolic Doppler-derived strain rates (SRs) were recorded from 18 segments in the longitudinal axis. The number of segments with SR(E)/SR(A)<1.1 was represented as segmental DD. Mean relaxation of the basal, mid, and apical regions was also calculated. Septal and mean mitral annular Ea velocities were also recorded. Non-hypertensive, middle-aged individuals had evidence of segmental DD that was mostly distributed at the basal parts of the heart, and in particular at the septal wall. Hypertensive patients had a lower mean relaxation based on SR(E) and SR(E/A) at the basal, mid, and apical regions, with the basal parts appearing more compromised and with higher segmental DD compared with controls. Segmental DD in that group was more extensive towards the mid and even apical regions, with the septal and basal inferior walls being the most heavily affected areas. The lateral wall appeared to be the region that was most resistant to diastolic abnormalities in both groups. Even individuals with normal septal and mean Ea had evidence of segmental DD. However, contrary to global indices of DD, septal Ea could predict the presence of segmental DD.nnnCONCLUSIONnAbnormal relaxation appears to have a particular distribution over the myocardial walls. Basal parts are generally more heavily affected, particularly the septal and inferior walls. The lateral wall and apical regions are more resistant to diastolic abnormalities. In subjects with normal global DD, strain echocardiography has an incremental value over mitral annular diastolic velocities and global indices of DD for early detection of diastolic abnormalities.

239 Early diastolic velocity of the mitral annulus in relation with segmental diastolic dysfunction and remodelling in hypertension

had lower Ea (5.5±1.7 vs 8.4±2.0 cm/s, p 8 cm/s. Ea was correlated with LVMI (r: -0.34, p<0.05), WT (r: -0.58, p<0.001), systolic BP (r: -0.62, p<0.001), mean S (r: 0.44, p<0.05), mean SR (r: 0.63, p<0.001) E/A (r: 0.62, p<0.001). Conclusion: Global diastolic and longitudinal systolic dysfunction are inter- related. Depressed early relaxation velocity of mitral annulus is accompa- nied with decreased systolic longitudinal function, estimated by deforma- tion parameters, in hypertension. mental diastolic dysfunction was correlated with systolic BP (r: 0.59, p<0.001), wall thickness (r: 0.618, p<0.001), RWT (r: 0.54, p<0.001), LVMI (r: 0.36, p<0.05), E/A (r: -0.59, p<0.001) DT ( r: 0.32, p<0.05), E (r: -043, p<0.05),

947 Mean longitudinal strain and strain rate: an index of assessing subclinical left ventricular dysfunction in hypertension

Eur J Echocardiography Abstracts Supplement, December 2006 Aim: Aim of the present study was to analyze heart function in Subclinical Hyperthyroidism (sHT) in otherwise cardiological healthy subjects both by conventional and by new methods using intramyocardial ultrasonic techniques. Material and methods: Twenty-four newly diagnosed and untreated sHT patients (20 women, mean age: 46 years) and 24 sexand age-matched healthy volunteers were studied. All subjects were submitted to conventional 2D Color-doppler echocardiography, to Pulsed Wave tissue Doppler Imaging (PWTDI) for the analysis of diastolic function, to Color Doppler Myocardial Imaging (CDMI) for the analysis of regional strain ad strain rate (SR) expression of regional myocardial deformability, and to Integrated Backscatter (IBS) for the evaluation of intrinsic contractility and tissue characterization. Results: Regional myocardial systolic strain findings were significantly higher in sHT patients when compared with controls (p<0.001). Considering diastolic SR, the early phase of diastolic SR was compromised in sHT subjects as compared with controls (p<0.001). Cyclic Variation Index (CVI), expression of intrinsic contractility, was significantly higher in sHT subjects in comparison with controls (p<0.0001). IBS values, were comparable between the 2 study groups. Conclusions: In conclusion, data of present study suggest that in young patients with sHT are present early left ventricular systolic hyperdeformability and hypercontractility and impairment of both active and passive phases of diastole but not ventricular hypertrophy or other structural alterations. To our knowledge, it is the first evidence that in sHT patients these functional modifications are present at the same time both in systolic and diastolic phase of the cardiac cycle. The intramyocardial ultrasonic techniques CDMI and IBS revealed an higher sensitivity in order to detect early functional cardiac abnormalities in sHT patients in comparison with conventional 2D-Doppler Echocardiography.