Maurizio Cusmà-Piccione

Left Ventricular Function in Hypertension: New Insight by Speckle Tracking Echocardiography

Background: Conventional transthoracic echocardiography (TTE) and tissue Doppler imaging (TDI) are usually unable to reveal very early subtle abnormalities in left ventricular (LV) systolic function caused by hypertension, prior to manifestation of hypertrophy (LVH). This study was undertaken to assess whether speckle tracking echocardiography (STE) provides more insight into early hypertension‐induced LV systolic dysfunction, with the purpose of identifying patients at higher risk for heart failure (HF). Methods: Fifty‐one patients (56.5 ± 14 years) and 51 controls (52 ± 12.6 years) were enrolled. According to the presence or absence of LVH, patients were classified as LVH(+) and LVH(–), respectively. Global longitudinal function was calculated by TDI, global strains [longitudinal (LS), radial (RS), and circumferential (CS)] and twist were assessed by STE. Results: Conventional TTE showed a LV diastolic dysfunction with normal systolic function in all patients. TDI was able to detect a systolic dysfunction only in the LVH(+) group (P < 0.001) whereas STE revealed an impairment of systolic LS in all patients, including those without hypertrophy (P = 0.02). Furthermore, in the LVH(+) group, STE showed reduced RS and increased CS and twist. These last alterations were observed with respect to both controls (RS: P = 0.02; CS: P = 0.05; twist: P < 0.001) and LVH(–) patients (RS: P = 0.01; CS: P = 0.003; twist: P = 0.001). Conclusion: In hypertensive patients, STE provides more detailed information than conventional echocardiography and TDI, since it reveals a systolic dysfunction before hypertrophy occurs (Stage A of ACC/AHA classification of HF) and identifies some early LV mechanic changes that might improve the clinical management of these patients. (Echocardiography 2011;28:649‐657)

Prognostic Significance of Valvuloarterial Impedance and Left Ventricular Longitudinal Function in Asymptomatic Severe Aortic Stenosis Involving Three-Cuspid Valves

The purpose of the present study was to evaluate the role of left ventricular global afterload and various echocardiographic parameters of systolic function in a prospective cohort of 52 asymptomatic patients with severe aortic stenosis (indexed aortic valve area 0.4 ± 0.1 cm²/m²) and normal left ventricular ejection fraction (61 ± 5%). Using 2-dimensional speckle tracking echocardiography, myocardial strain, rotation, and twist were evaluated. The valvuloarterial impedance (Zva) was calculated as a measure of left ventricular global afterload. The predefined end points were the occurrence of symptoms (dyspnea, angina, syncope), aortic valve replacement, and death. At study entry, all patients had decreased longitudinal strain (LS) (-15 ± 4%) and increased circumferential strain (-22 ± 5%), twist (24 ± 7°), and Zva (5.8 ± 2 mm Hg/ml/m²). Increased Zva was closely associated with the circumferential strain increase (r = 0.59, p = 0.02) and LS decrease (r = -0.56, p = 0.016). In contrast, no relation was found between myocardial function and transaortic gradients. During follow-up (11 ± 7.5 months), on univariate Cox regression analysis, the predictors of events were the left ventricular ejection fraction (p = 0.02), mass index (p = 0.01), LS (p < 0.0001), radial strain (p = 0.04), and Zva (p = 0.0002). On multivariate Cox regression analysis, only the global LS (p = 0.03) and Zva (p = 0.03) were independently associated with the combined end point. Using receiver operating characteristic curve analysis, a LS of ≤-18% (sensitivity 96%, specificity 73%) and a Zva of ≥ 4.7 mm Hg/ml/m² (sensitivity 100%, specificity 91%) were identified as the best cutoff values to be associated with events. In conclusion, in asymptomatic patients with severe aortic stenosis, the degree of global afterload and its consequences on longitudinal function might play a role in clinical practice.

Interplay between arterial stiffness and diastolic function: a marker of ventricular-vascular coupling.

Aims We evaluated the interplay between left ventricular diastolic function and large-artery stiffness in asymptomatic patients at increased risk of heart failure and no structural heart disease (Stage A). Methods We divided 127 consecutive patients (mean age 49 ± 17 years) with risk factors for heart failure who were referred to our laboratory to rule out structural heart disease into two groups according to presence (Group 1, n = 35) or absence (Group 2, n = 92) of grade I left ventricular diastolic dysfunction. Doppler imaging with high-resolution echo-tracking software was used to measure intima-media thickness (IMT) and stiffness of carotid arteries. Results Group 1 had significantly higher mean age, blood pressure, left ventricular mass index, carotid IMT and arterial stiffness than Group 2 (P < 0.05). Overall, carotid stiffness indices (&bgr;-stiffness index, augmentation index and elastic modulus) and ‘one-point’ pulse wave velocity each showed inverse correlation with E-wave velocity, E′ velocity and E/A ratio, and direct correlation with A-wave velocity, E-wave deceleration time and E/E′ ratio (P < 0.05). Arterial compliance showed negative correlations with the echocardiographic indices of left ventricular diastolic function (P < 0.05). On logistic regression analysis, age, hypertension, SBP, pulse pressure, left ventricular mass index, carotid IMT and stiffness parameters were associated with grade I left ventricular diastolic dysfunction (P < 0.05 for each). However, on multivariate logistic analysis, only ‘one-point’ pulse wave velocity and age were independent predictors (P = 0.038 and P = 0.016, respectively). Conclusion An independent association between grade I left ventricular diastolic dysfunction and increased arterial stiffness is demonstrated at the earliest stage of heart failure. Hence, assessment of vascular function, beyond cardiac function, should be included in a comprehensive clinical evaluation of these patients.

Accessory mitral valve tissue: an updated review of the literature

Accessory mitral valve tissue (AMVT) is a rare congenital cardiac anomaly sometimes responsible for left ventricular outflow tract (LVOT) obstruction. It is diagnosed during both neonate-childhood and adult periods in patients usually symptomatic for dyspnoea, chest pain, palpitations, fatigue, or syncope. Nevertheless, AMVT is often an incidental finding. AMVT is most often associated with other cardiac and vascular congenital malformations, such as septal defects and transposition of the great arteries. Surgery is indicated only in cases of significant LVOT obstruction and in patients undergoing correction of other cardiac malformations or exploration of an intracardiac mass. Two-dimensional echocardiography, both transthoracic and transoesophageal, is considered the main imaging modality for AMVT diagnosis and patient follow-up. The recent introduction of three-dimensional echocardiography allows a more realistic characterization of this entity. We present three clinical cases in which AMVT was incidentally diagnosed during standard echocardiography and an updated review of the literature highlighting the usefulness of echocardiography for AMVT morphological and functional characterization as well as the most relevant clinical implications due to its discovery.

Myocardial deformation and rotational mechanics in revascularized single vessel disease patients 2 years after ST-elevation myocardial infarction.

Objective We sought to characterize the left ventricular strains and rotational mechanics in the infarct-related and remote regions of dilated heart following an ST-elevation myocardial infarction (STEMI) to understand the adaptive changes in global left ventricular function that develop several months after percutaneous coronary revascularization. Methods Forty-six patients with STEMI (66.6 ± 11 years, 29 men) 2 years after coronary revascularization were enrolled. Longitudinal, circumferential, radial and rotational mechanics of the left ventricle were evaluated by speckle tracking echocardiography in 39 (84.8%) of them, after excluding seven patients with multivessel coronary disease. Forty-one asymptomatic volunteers without a history of coronary artery disease (65 ± 9 years, 23 men) served as controls. Results There was no difference, between groups, regarding the prevalence of cardiovascular risk factors, whereas patients had significantly reduced left ventricular strains (P < 0.001), rotations (P < 0.001), twist (P < 0.001), torsion (P < 0.001) and untwisting rates (P < 0001) in comparison with controls. Furthermore, reduction in regional strains was observed both in infarct and remote regions of the left ventricle and correlated with the changes in ejection fraction. On logistic regression analysis, only global circumferential strain was independently related (odds ratio 4.28; 95% confidence interval 1.11–16.4; P = 0.034) with left ventricular dilation, defined as an indexed end-diastolic left ventricular volume more than 75 ml/m2. Conclusion Reduction in regional strains and rotational mechanics are detectable in both the infarct-related and remote regions of dilated left ventricle. Attenuation of global circumferential strain, rather than isolated changes in the mechanics of the infarct region might contribute to determine the extent of left ventricular dilation, independent of the presence of multiple risk factors for left ventricular dysfunction. These findings might have important clinical implications regarding novel therapeutic approaches for counteracting left ventricular remodeling.

In Patients with Post-Infarction Left Ventricular Dysfunction, How Does Impaired Basal Rotation Affect Chronic Ischemic Mitral Regurgitation?

BACKGROUND The aim of this study was to explore the contribution of left ventricular (LV) basal rotation to the mechanism of chronic ischemic mitral regurgitation (MR). METHODS Fifty-seven patients (52 men; mean age, 68.3 ± 11.8 years) with postinfarction LV dysfunction (defined as an ejection fraction ≤ 45%) were prospectively enrolled. Each invariably had functional MR. To assess MR degree, the effective regurgitant orifice area (EROA) was quantified by echocardiography using the proximal isovelocity surface area method. Furthermore, mitral valve deformation (valve tenting and annular function) and LV global (systolic and diastolic volumes, function, and sphericity) and local remodeling (displacement of papillary muscles, regional strain, and rotation by speckle-tracking) were assessed. The patients were subsequently subdivided into two groups according to the absence (group A) or presence (group B) on transthoracic echocardiography of infarct area in the inferior and/or posterior basal segments. RESULTS A larger EROA was found in group B than in group A (P = .034) and in subjects with asymmetric rather than symmetric tethering in either group (P = .036 and P = .040 for groups A and B, respectively). Basal radial (P = .009), circumferential (P = .042), and longitudinal (P = .005) strain and rotation (P = .021) were lower in group B than in group A. There was also a significant inverse correlation between EROA and basal rotation in group B (r = -0.75, P < .001). Furthermore, using multivariate linear regression analysis, we found that the independent determinants of EROA were end-diastolic volume (P < .001) and tenting area (P = .004) in group A and asymmetric tethering (P = .029) and basal rotation (P < .001) in group B. CONCLUSIONS Impaired basal rotational mechanics occurring after an inferior-posterior myocardial infarction is associated with increased MR.

Arterial stiffness changes in patients with cardiovascular risk factors but normal carotid intima-media thickness.

Aims We aimed to evaluate, through an Echotracking system, the functional changes of carotid arteries with relation to the amount of cardiovascular risk factors in patients without structural atherosclerotic damage. Methods From a series of 260 asymptomatic consecutive patients we selected 75 patients (mean age: 47 ± 8 years) with normal intima–media thickness (IMT) and without atherosclerotic plaques. In these patients, local arterial stiffness parameters were evaluated using a simple Echotracking system. Patients were divided in three groups: group 1 (n = 25 patients without risk factors), group 2 (n = 23 patients with one risk factor) and group 3 (n = 27 patients with two or more risk factors). Results Carotid IMT was similar in all groups (P = ns). On the contrary, stiffness parameters progressively increased according to the number of risk factors [pulse wave velocity (PWV) = 5.8 ± 1.1 m/s, 6.4 ± 1.2 m/s and 6.7 ± 1.4 m/s in Group 1, 2 and 3, respectively, P = 0.002; &bgr;-index = 7.5 ± 3.4, 8.5 ± 3.2 and 9.5 ± 4.7 in Group 1, 2 and 3, respectively, P = 0.047]. Furthermore, on multivariate linear regression analysis, PWV and &bgr;-index significantly correlated (P = 0.002 and P = 0.048, respectively) with the number of risk factors even when adjusted for age, gender and current therapy. Conclusion In a population with normal carotid IMT and without plaques, changes in arterial stiffness are significantly related to the number of risk factors. This information could be relevant for a more tailored primary prevention in patients with risk factors even in absence of structural atherosclerotic abnormalities.

Longitudinal Strain by Automated Function Imaging Detects Single-Vessel Coronary Artery Disease in Patients Undergoing Dipyridamole Stress Echocardiography

BACKGROUND The aim of this study was to investigate the incremental value of global longitudinal strain (GLS) by automated function imaging in respect to wall motion (WM) for the detection of coronary artery disease (CAD) during dipyridamole stress echocardiography. METHODS Fifty-two patients (mean age, 65.3 ± 8.7 years; 22 men) underwent dipyridamole stress echocardiography followed by coronary angiography within 1 week. Diagnostic accuracy for the identification of single-vessel CAD was evaluated for WM and GLS. The study population was divided into two groups according to coronary angiographic findings: those with CAD (n = 38; mean age, 67.2 ± 5.9 years; 19 men) and those without CAD (n = 14; mean age, 63.3 ± 6.4 years; three men). RESULTS A trend toward lower resting GLS values was found in patients with CAD than in those without (-18.7 ± 2.2% vs -20 ± 2.8%, P = .061). In patients without CAD, GLS progressively increased up to peak dose (from -20 ± 2.8% at rest to -20.7 ± 1.9% at low dose, P = .045; from -20.7 ± 1.9% at low dose to -21.5 ± 3.1% at peak dose, P = .032), whereas in patients with CAD, an increase of GLS from rest to low dose (from -18.7 ± 2.2% to -19.2 ± 3.9%, P = .046) followed by a decrease from low to peak dose (from -19.2 ± 3.9% to -17.5 ± 2.4%, P = .007) was observed. In addition, with regard to diagnostic accuracy in detecting CAD, WM yielded sensitivity of 44%, specificity of 55%, positive predictive value of 73%, and negative predictive value of 26%, whereas GLS, alternatively evaluated as the difference between peak dose and resting values or between peak and low-dose values, provided sensitivity of 61%, specificity of 90%, positive predictive value of 94%, and negative predictive value of 47% (respectively, P = .020, P = .001, P = .023, and P = .031, all vs WM) and sensitivity of 84%, specificity of 92%, positive predictive value of 96%, and negative predictive value of 68% (respectively, P < .001, P < .001, P = .001, P < .001, all vs WM). CONCLUSIONS GLS analysis, particularly performed by comparing peak-dose with low-dose values, improves the accuracy of dipyridamole stress echocardiography in the detection of single-vessel CAD compared with the sole assessment of WM changes.

New diagnostic perspectives on heart failure with preserved ejection fraction: systolic function beyond ejection fraction

Although preserved ejection fraction is found in more than 50% of patients with heart failure, its acceptance as a specific clinical entity is limited. More understanding of the physiopathology, early diagnosis and medical management is needed. With no existing systematic information in the literature, the aim of this review is to provide a comprehensive overview of the new imaging techniques for diagnosing heart failure with preserved ejection fraction, particularly in the early stages of the disease, underlying the pivotal role of new technologies such as two-dimensional speckle tracking echocardiography and vascular stiffness.

Takotsubo syndrome and estrogen receptor genes: partners in crime?

Aims We aimed to analyze genetic polymorphism of estrogen receptor (ESR) 1 and ESR2 in a series of postmenopausal women with Takotsubo syndrome (TS). Methods In total, 81 consecutive white women were prospectively enrolled: 22 with TS (TS group; mean age 71.2 ± 9.8 years), 22 with acute myocardial infarction (MI group; mean age 73.2 ± 8 years), and 37 asymptomatic healthy controls (CTRL group; mean age 69 ± 4.2 years). Genotyping of ESR1 −397C>T (rs2234693) and −351A>G (rs9340799) and ESR2 −1839G>T (rs 1271572) and 1082G>A (rs1256049) genetic variants was performed. We estimated the odds ratio (OR) between the genotype of each examined locus with the occurrence of TS or MI. Results The risk of experiencing TS was higher for those study participants carrying the T allele at the rs2234693 locus of the ESR1 gene [OR: 2.0, 95% confidence interval (CI): 0.973–4.11, P = 0.04, TS vs. MI + CTRL; OR: 2.79, 95% CI: 1.17–6.64, P = 0.016, TS vs. MI alone]. Women carrying a T allele at the rs1271572 locus of the ESR2 gene demonstrated an even higher risk (OR: 3.23, 95% CI: 1.55–6.73, P = 0.0019, TS vs. MI + CTRL; OR: 9.13, 95% CI: 2.78–29.9, P = 0.0001, TS vs. MI alone). Conclusion The study reports preliminary findings suggesting a possible link between ESR polymorphisms and the occurrence of TS. Larger studies are needed to confirm our results.