Maria Caputo

Feasibility and reference values of left atrial longitudinal strain imaging by two-dimensional speckle tracking

BackgroundThe role of speckle tracking in the assessment of left atrial (LA) deformation dynamics is not established. We sought to determine the feasibility and reference ranges of LA longitudinal strain indices measured by speckle tracking in a population of normal subjects.MethodsIn 60 healthy individuals, peak atrial longitudinal strain (PALS) and time to peak longitudinal strain (TPLS) were measured using a 12-segment model for the left atrium. Values were obtained by averaging all segments (global PALS and TPLS) and by separately averaging segments measured in the two apical views (4- and 2-chamber average PALS and TPLS).ResultsAdequate tracking quality was achieved in 97% of segments analyzed. Inter and intra-observer variability coefficients of measurements ranged between 2.9% and 5.4%. Global PALS was 42.2 ± 6.1% (5–95° percentile range 32.2–53.2%), and global TPLS was 368 ± 30 ms (5–95° percentile range 323–430 ms). The 2-chamber average PALS was slightly higher than the 4-chamber average PALS (44.3 ± 6.0% vs 40.1 ± 7.9%, p < 0.0001), whereas no differences in TPLS were found (p = 0.93).ConclusionSpeckle tracking is a feasible technique for the assessment of longitudinal myocardial LA deformation. Reference ranges of strain indices were reported.

Chronic Mitral Regurgitation: Left Atrial Deformation Analysis by Two‐Dimensional Speckle Tracking Echocardiography

Background: Speckle tracking echocardiography (STE) is a novel method for the angle‐independent and objective quantification of myocardial deformation; it has recently evolved, enabling the quantification of longitudinal myocardial left atrial (LA) deformation dynamics. To investigate the effects of chronic mitral regurgitation (MR) on these functional atrial indices, we analyzed LA function by STE in a group of asymptomatic patients with chronic degenerative MR. Methods: The study population included 36 patients with mild MR, 38 with moderate MR, and 42 with severe MR. 52 age‐matched controls were also recruited. Global peak atrial longitudinal strain (global PALS) was measured in all subjects by averaging all atrial segments. Results: Age, gender, and LV ejection fraction in all pathological groups were comparable to those in the controls. Global PALS was higher in the mild MR group (46.7 ± 9.1%) in comparison with the controls (40.5 ± 6.2%; P < 0.001); instead global PALS was lower in the moderate MR group (25.7 ± 7.1%) and further reduced in the severe MR group (13.2 ± 5.2%) in comparison with the controls (40.5 ± 6.2%; overall P < 0.0001 by ANOVA, P < 0.05 for all pairwise comparisons). In multivariate analysis, E/Em ratio emerged as the principal independent determinant of global PALS. Conclusions: Our study provides new insight for the LA function analysis in response to different degrees of MR, showing that STE measurements of LA longitudinal strain may be considered a promising tool for the early detection of impairment of LA compliance in patients with asymptomatic chronic MR. (Echocardiography 2011;28:327‐334)

Physiologic determinants of left ventricular systolic torsion assessed by speckle tracking echocardiography in healthy subjects.

Background: The associations of left ventricular (LV) systolic torsion with clinical and echocardiographic variables in physiological conditions have not been fully investigated. We explored the independent determinants of LV systolic torsion in a population of normal subjects. Methods: In 119 healthy subjects, peak twist angle (LVtw) and torsion (LVtor) during ejection, and the QRS‐LVtw interval (time‐to‐peak LVtw) were measured by speckle tracking. LV twisting rate and rotational deformation delay were also determined. Results: Stepwise multiple regression showed that LVtw was independently associated with indexed end‐systolic volume (β=–0.200, P < 0.0001), peak early diastolic mitral annulus velocity (β=–0.186, P = 0.0001), heart rate (β= 0.178, P = 0.0003), and male gender (β=–0.174, P = 0.0004). Similar results were found for LVtor. Age was the only parameter, which has demonstrated an independent correlation with time‐to‐peak LVtw (β= 0.329, P < 0.0001). Despite significance of these associations, the proportions of variability explained by regression models were relatively low (range 11–26%), and no accurate predictive models were identifiable for LV twisting rate and rotational deformation delay. Conclusion: In normal individuals, indexed end‐systolic LV volume, LV relaxation, heart rate, gender, and age correlate independently with LV torsion mechanics. However, conventional echocardiographic and clinical variables are not able to predict LV torsion mechanics. (Echocardiography 2011;28:641‐648)

Left ventricular twisting as determinant of diastolic function: a speckle tracking study in patients with cardiac hypertrophy.

Purpose: Left ventricular hypertrophy (LVH) can develop in response to training with morphological changes in the heart and to pathological increase in afterload such as in essential hypertension. Deformation analysis using two‐dimensional (2D) strain echocardiography can detect early systolic function abnormalities in patients with LVH. The aim of this study was to characterize left ventricular twisting (LVT) modifications, in professional athletes, compared with control subjects and with patients with hypertensive cardiopathy. Methods: Seventy‐six patients were enrolled: 37 professional athletes with cardiac hypertrophy (group A), 22 patients with early hypertensive cardiopathy (group B) cross‐matched for LV mass index, and 17 healthy controls (group C), with no evidence of cardiac hypertrophy. All patients had no concomitant cardiac disease. All patients were investigated at rest using transthoracic echocardiography. LVT was obtained with speckle tracking analysis, using dedicated software. Results: LVT was reduced in group A compared to group B and C (group A: 8.0°± 2.4°; group C: 10.3°± 2.3°; group B: 16.0°± 4.2°; P < 0.01). In overall population, LVT showed a significant correlation with transmitral flow pattern (r =–0.58, P < 0.01) and with age (r =–0.57, P < 0.01). LVT showed the best predictive value to diagnose diastolic dysfunction (AUC: 0.86, P < 0.0001). Conclusions: 2D strain can identify specific patterns of myocardial deformation in professional athletes, controls, and patients with early hypertensive cardiopathy. In our study LVT showed a parallel trend with modifications of diastolic function and could represent a promising tool to differentiate functional cardiac hypertrophy from hypertensive cardiac hypertrophy. (Echocardiography 2011;28:892‐898)

Usefulness of Left Ventricular Diastolic Dysfunction Assessed by Pulsed Tissue Doppler Imaging as a Predictor of Atrial Fibrillation Recurrence After Successful Electrical Cardioversion

The impact of left ventricular (LV) diastolic dysfunction on risk of atrial fibrillation (AF) recurrence is still unknown. The aim of this study was to assess the role of LV diastolic dysfunction in predicting AF recurrence after successful electrical cardioversion in patients with nonvalvular AF. In 51 patients with a first episode of nonvalvular AF undergoing successful electrical cardioversion, tissue Doppler echocardiography was performed to measure peak early diastolic mitral annulus velocity (E(m)) and the ratio of mitral inflow to mitral annulus velocity at end-diastole (E/E(m)). Clinical end points were recurrent persistent AF at 2-week follow-up (early AF recurrence [ERAF]) and at 1-year follow-up (including ERAF and late AF recurrence). Seventeen patients showed evidence of ERAF, whereas late AF recurrence occurred in another 5 patients. In time-independent analysis E/E(m) (odds ratio [OR] 1.746, p = 0.0084) and indexed LV end-systolic volume (OR 1.083, p = 0.040) were independent predictors of ERAF. Based on a logistic model risk of ERAF was 25% for an E/E(m) of 5.6 but increased to 50% for an E/E(m) of 8.1 and to 75% for an E/E(m) of 10.5. In time-dependent analysis E/E(m) emerged as the only predictor of ERAF (OR 1.757, p = 0.0078). E/E(m) also independently predicted risk of recurrence at 1 year in time-independent (OR 1.757, p = 0.0078) and time-dependent (OR 1.319, p = 0.0003) analyses. In conclusion LV diastolic dysfunction independently predicts AF recurrence in patients with nonvalvular AF undergoing successful electrical cardioversion.

Left atrial dysfunction detected by speckle tracking in patients with systemic sclerosis.

BackgroundCardiac involvement is a relevant clinical finding in systemic sclerosis (SSc) and is associated with poor prognosis. Left atrial (LA) remodeling and/or dysfunction can be an early sign of diastolic dysfunction. Two-dimensional speckle tracking echocardiography (STE) is a novel and promising tool for detecting very early changes in LA myocardial performance.AimTo assess whether STE strain parameters may detect early alterations in LA function in SSc patients.MethodsForty-two SSc patients (Group 1, age 50u2009±u200914xa0years, 95% females) without clinical evidence for cardiac involvement and 42 age- and gender-matched control subjects (Group 2, age 49u2009±u200913xa0years, 95% females) were evaluated with comprehensive 2D and Doppler echocardiography, including tissue Doppler imaging analysis. Positive peak left atrial longitudinal strain (ϵ pos peak), second positive left atrial longitudinal strain (sec ϵ pos peak), and negative left atrial longitudinal strain (ϵ neg peak) were measured using a 12-segment model for the LA, by commercially available semi-automated 2D speckle-tracking software (EchoPac PC version 108.1.4, GE Healthcare, Horten, Norway).ResultsAll SSc patients had a normal left ventricular ejection fraction (63.1u2009±u20094%). SSc patients did not differ from controls in E/A (Group 1u2009=u20091.1u2009±u20090.4 vs Group 2u2009=u20091.3u2009±u20090.4, pu2009=u2009.14) or pulmonary arterial systolic pressure (Group 1u2009=u200924.1u2009±u20098xa0mmHg vs Group 2u2009=u200921u2009±u20097xa0mmHg, pu2009=u2009.17). SSc patients did not show significantly different indexed LA volumes (Group 1u2009=u200924.9u2009±u20095.3xa0ml/m2 vs Group 2u2009=u200924.7u2009±u20094.4xa0ml/m2, pu2009=u2009.8), whereas E/e’ ratio was significantly higher in SSc (Group 1u2009=u20097.6u2009±u20092.4 vs Group 2u2009=u20096.5u2009±u20091.7, p<0.05), although still within normal values. LA strain values were significantly different between the two groups (ϵ pos peak Group 1u2009=u200931.3u2009±u20094.2% vs Group 2u2009=u200935.0u2009±u20097.6%, pu2009<u2009.01, sec ϵ pos peak Group 1u2009=u200918.4u2009±u20094 vs Group 2u2009=u200921.4u2009±u20097.6, pu2009<u20090.05).Conclusion2D speckle-tracking echocardiography is a sensitive tool to assess impairment of LA mechanics, which is detectable in absence of changes in LA size and volume, and may represent an early sign of cardiac involvement in patients with SSc.

Anemia correction by erythropoietin reduces BNP levels, hospitalization rate, and NYHA class in patients with cardio-renal anemia syndrome

Little is known about the effect of anemia correction with erythropoietin (EPO) on B-type natriuretic peptide (BNP) levels, NYHA class, and hospitalization rate. The aim of the study was to investigate, in patients with cardio-renal anemia syndrome, the effects of EPO on hemochrome and renal function parameters and BNP levels. We also analyzed the effect of EPO therapy on hospitalization rate and NYHA class after 12xa0months in comparison with a population undergoing to standard therapy. We performed a randomized double-blind controlled study of correction of the anemia with subcutaneous α (group A nxa0=xa013) or β (group B nxa0=xa014) EPO for 12xa0months in addition to standard therapy with oral iron in 27 subjects. Control group (nxa0=xa025 patients) received only oral iron. Significant increase in hemoglobin (Hb), hematocrit (Hct), and red blood cells (RBC) were revealed in EPO groups at 12xa0months; Hb, group A 12.3xa0±xa00.6; group B 11.7xa0±xa00.8; control group 10.6xa0±xa00.5xa0g/dl Pxa0<xa00.0001; Hct group A 34.2xa0±xa02.3, group B 34xa0±xa02, control group 32.3xa0±xa01.8% Pxa0<xa00.01; RBC, group A 3.9xa0±xa00.2, group B 3.8xa0±xa00.2, control group 3.3xa0±xa00.2, (Pxa0<xa00.0001). Plasma BNP levels in EPO groups were significantly reduced after 12xa0months (group A: 335xa0±xa0138 vs. group B: 449xa0±xa0274xa0pg/ml control group 582xa0±xa0209xa0pg/ml (Pxa0<xa00.01). After 12xa0months of treatment, hospitalization rate and NYHA class were reduced in EPO groups with respect to control group (Pxa0<xa00.05). Finally, an inverse correlation was observed between BNP and Hb levels in EPO Groups (rxa0=xa0−0.70 Pxa0<xa00.001). EPO treatment reduces BNP levels and hospitalization rate in patients with cardio-renal anemia syndrome. The correction of anemia by EPO treatment appears able to improve clinical outcome in this subset of patients with heart failure.

B-type natriuretic peptide as an independent predictor of coronary disease extension in non-ST elevation coronary syndromes with preserved systolic function

Objective: B-type natriuretic peptide (BNP) has been employed as a risk marker in patients with coronary artery disease (CAD) with ST elevation and non-ST elevation. It is not yet established if early BNP measurements provide additional information to troponin and electrocardiographic analysis in patients without ventricular enlargement and systolic dysfunction. Design: This study compared BNP levels in patients with stable angina (SA) and acute coronary syndromes with non-ST elevation in relation to angiographic lesions (NSTEMI-ACS). Moreover, the diagnostic utility of BNP was determined using the receiver operating characteristic curve. Patients: 280 patients with CAD without ST elevation and preserved systolic function were studied. BNP samples were measured in all recruited patients within 24 hours of hospitalization. Results: BNP values increased progressively with the severity of diagnosis: SA (nu2009=u200985; 50.4u2009±u200950u2009pg/ml) NSTEMI-ACS (nu2009=u2009195; 283u2009±u2009269u2009pg/ml; pu2009<u20090.0001). The analysis of BNP in relation to the number of involved vessels demonstrated significantly increased levels in patients with multivessel disease compared to patients with 1- or 2-vessel disease (pu2009<u20090.001 and pu2009<u20090.003). Values of BNP >80u2009pg/ml were shown to be able to predict CAD severity and coronary vessel involvement (AUCu2009=u20090.80; pu2009=u20090.0001) with a sensitivity of 78% and a specificity of 72%. In multivariate analysis, BNP levels >80u2009pg/ml, CAD history, and ST deviation >2u2009mm were confirmed as independent predictors of CAD severity. Conclusions: Circulating BNP levels appear elevated in NSTEMI-ACS, without left ventricular systolic dysfunction. A BNP cut-off value of 80u2009pg/ml is a good predictor of CAD extension.

B-type natriuretic peptide levels predict extent and severity of coronary disease in non-ST elevation coronary syndromes and normal left ventricular systolic function.

BACKGROUNDnB-type natriuretic peptide (BNP) has been used recently as a biological marker in patients with coronary artery disease (CAD) with ST-elevation, as well as without ST-elevation. BNP is able to predict systolic dysfunction, adding new prognostic information to existing traditional markers. However is not known if there is a relation between the quantity of BNP levels and the severity of coronary artery disease.nnnMETHODSnThis study compared B-type natriuretic peptide (BNP) levels in patients with stable angina (SA) and acute coronary syndromes (ACS) without ST-elevation in relation to angiographic lesions using TIMI and Gensini Scores. We studied 282 patients with CAD without ST elevation and preserved systolic function. BNP samples were measured in all recruited patients within 24 hours of hospitalization.nnnRESULTSnBNP values were progressively increased in relation to the severity of diagnosis: SA (52.6±49.4 pg/mL ) UA (243.3±212 pg/mL) NSTE-ACS (421.7±334 pg/mL) (p<0.0001 and p<0.007 respectively). No statistically significant difference was observed between patients with SA and controls (21.2±6.8 pg/mL). The analysis of BNP levels in relation to the number of involved vessels demonstrated significantly increased levels in patients with multivessel disease compared to patients with 1 or 2 vessel disease (1-86.2±46.3 pg/mL; 2-127±297 pg/mL; 3-295±318 pg/mL; 4-297±347 pg/mL p<0.001 and p<0.003). Evaluation of BNP using Gensini Score showed a strong relation between BNP and coronary disease extension (r=0.38 p<0.0001).This trend was maintained in all CAD groups (SA=r 0.54; UA r=0.36 NSTE-ACS r=0.28).nnnCONCLUSIONSnCirculating BNP levels appear elevated in ACS with diffuse coronary involvement, even in the absence of systolic dysfunction. BNP is also associated with multi-vessel disease and the extension of coronary disease.

Detection of Early Left Ventricular and Atrial Dysfunction in Overweight Patients with Preserved Ejection Fraction: A Speckle Tracking Analysis

Little remains known about the role of overweight to promote progressive atrial and ventricular myocardial dysfunction. Aim of this study was to investigate the potential influence of overweight on left ventricular (LV) and atrial (LA) function, as assessed by speckle tracking strain analysis, in patients at low‐to‐moderate global cardiovascular risk.