Sebastian I. Sarvari

Echocardiographic Evaluation of Hemodynamics in Patients With Decompensated Systolic Heart Failure

Background— Doppler echocardiography is currently applied for the assessment of left ventricular and right ventricular hemodynamics in patients with cardiovascular disease. However, there are conflicting reports about its accuracy in patients with unstable decompensated heart failure. The objective of this study was to evaluate the accuracy of the technique in patients with unstable heart failure. Methods and Results— Consecutive patients with decompensated heart failure had simultaneous assessment of left ventricular and right ventricular hemodynamics invasively and by Doppler echocardiography. In 79 patients, the noninvasive measurements of stroke volume (r=0.83, P<0.001), pulmonary artery systolic (r=0.83, P<0.001) and diastolic pressure (r=0.51, P=0.009), and mean right atrial pressure (r=0.85, P<0.001) all had significant correlations with invasively acquired measurements. Several Doppler indices had good accuracy in identifying patients with pulmonary capillary wedge pressure >15 mm Hg (area under the curve, 0.86 to 0.92). The recent American Society of Echocardiography/European Association of Echocardiography guidelines were highly accurate (sensitivity, 98%; specificity, 91%) in identifying patients with increased wedge pressure. In 12 repeat studies, Doppler echocardiography readily detected the changes in mean wedge pressure (r=0.75, P=0.005) as well as changes in pulmonary artery systolic pressure and mean right atrial pressure. Conclusions— Doppler echocardiography provides reliable assessment of right and left ventricular hemodynamics in patients with decompensated heart failure.

Right ventricular mechanical dispersion is related to malignant arrhythmias: a study of patients with arrhythmogenic right ventricular cardiomyopathy and subclinical right ventricular dysfunction.

AIMS We evaluated if right ventricular (RV) mechanical dispersion by strain was related to ventricular arrhythmias (VT/VF) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and if mechanical dispersion was increased in so far asymptomatic mutation carriers. METHODS AND RESULTS We included 69 patients, 42 had symptomatic ARVC and 27 were mutation positive asymptomatic family members. Forty healthy individuals served as controls. Myocardial strain was assessed in 6 RV and 16 left ventricular (LV) segments. Contraction duration (CD) in 6 RV and 16 LV segments were measured as the time from onset R on electrocardiogram to maximum myocardial shortening in each segment. The standard deviation of CD was defined as mechanical dispersion. Mechanical dispersion was more pronounced in ARVC patients with arrhythmias compared with asymptomatic mutation carriers and healthy individuals in RV [52(41,63) vs. 35(23,47) vs. 13(9,19)ms, P < 0.001]. Mechanical dispersion was more pronounced in asymptomatic mutation carriers compared with healthy individuals (P < 0.001). Right ventricular mechanical dispersion predicted VT/VF in a multivariate logistic regression analysis [odds ratio (OR), 1.66 (95% confidence interval (CI) 1.06-2.58), P < 0.03]. Right ventricular and LV function by strain were reduced in symptomatic ARVC patients and correlated significantly (R = 0.81, P < 0.001). Right ventricular and LV strain were reduced in asymptomatic mutation carriers compared with healthy individuals (P < 0.001). CONCLUSION Right ventricular mechanical dispersion was pronounced in patients with ARVC with VT/VF. Right ventricular mechanical dispersion was present in asymptomatic mutation carriers and may be helpful in risk stratification. Right ventricular and LV function correlated in ARVC patients implying that ARVC is a biventricular disease.

Vigorous physical activity impairs myocardial function in patients with arrhythmogenic right ventricular cardiomyopathy and in mutation positive family members

Exercise increases risk of ventricular arrhythmia in subjects with arrhythmogenic right ventricular cardiomyopathy (ARVC). We aimed to investigate the impact of exercise on myocardial function in ARVC subjects.

Layer-Specific Quantification of Myocardial Deformation by Strain Echocardiography May Reveal Significant CAD in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome

OBJECTIVES Our objective was to assess whether patients with significant coronary artery disease (CAD) had reduced endocardial function assessed by layer-specific strain compared with patients without significant CAD. BACKGROUND The left ventricular (LV) wall of the heart comprises 3 myocardial layers. The endocardial layer is most susceptible to ischemic injury. METHODS Seventy-seven patients referred to coronary angiography due to suspected non-ST-segment elevation-acute coronary syndromes (NSTE-ACS) were prospectively included. Coronary occlusion was found in 28, significant stenosis in 21, and no stenosis in 28 patients. Echocardiography was performed 1 to 2 h before angiography. Layer-specific longitudinal and circumferential strains were assessed from endocardium, mid-myocardium, and epicardium by 2-dimensional (2D) speckle-tracking echocardiography (STE). Territorial longitudinal strain (TLS) was calculated based on the perfusion territories of the 3 major coronary arteries in a 16-segment LV model, whereas global circumferential strain (GCS) was averaged from 6 circumferential LV segments in all 3 layers. RESULTS Patients with significant CAD had worse function in all 3 myocardial layers assessed by TLS and GCS compared with patients without significant CAD. Endocardial TLS (mean -14.0 ± 3.3% vs. -19.2 ± 2.2%; p < 0.001) and GCS (mean -19.3 ± 4.0% vs. -24.3 ± 3.4%; p < 0.001) were most affected. The absolute differences between endocardial and epicardial TLS and GCS were lower in patients with significant CAD (Δ2.4 ± 3.6% and Δ6.7 ± 3.8%, respectively) than in those without significant CAD (Δ5.3 ± 2.1% and Δ10.4 ± 3.0%; p < 0.001). This reflects a pronounced decrease in endocardial function in patients with significant CAD. A receiver-operating characteristic curve analysis showed that endocardial and mid-myocardial TLS were superior to identify significant CAD compared with epicardial TLS (p < 0.05), wall motion score index (p < 0.01), and ejection fraction (EF) (p < 0.001). CONCLUSIONS Assessment of layer-specific strain by 2D-STE might identify NSTE-ACS patients with significant CAD. Endocardial function was more affected in patients with significant CAD compared with epicardial function and EF.

Left ventricular global longitudinal strain is associated with exercise capacity in failing hearts with preserved and reduced ejection fraction

Aims Heart failure patients with reduced and preserved left ventricular (LV) ejection fraction (EF) show reduced exercise capacity. We explored the relationship between exercise capacity and systolic and diastolic myocardial function in heart failure patients. Methods and results Exercise capacity, by peak oxygen uptake (VO2), was assessed in 100 patients (56 ± 12 years, NYHA functional class: 2.5 ± 0.9, EF: 42 ± 19%). LV systolic function, as EF and global longitudinal strain (GLS), and right ventricular function were assessed by echocardiography. Left atrial volume index and the ratio of peak early diastolic filling velocity (E) to early diastolic mitral annular velocity (e′) were measures of diastolic function. Thirty-seven patients had heart failure with preserved EF (HFpEF), defined as EF ≥50% and echocardiographic diastolic dysfunction. LV GLS and peak pulmonary arterial systolic pressure were independently correlated to peak VO2 in the total study population and in HFpEF separately. LV GLS was superior to EF in identifying patients with impaired peak VO2 <20 mL/kg/min as shown by receiver operating characteristic analyses [areas under curves 0.93 (0.89–0.98) vs. 0.85 (0.77–0.93), P < 0.05]. In patients with HFpEF, GLS was reduced below normal (−17.5 ± 3.2%) and correlated to E/e′ (R = 0.45, P = 0.005) and left atrial volume index (R = 0.48, P = 0.003), while EF did not. Conclusion GLS correlated independently to peak VO2 in patients with reduced and preserved EF and was superior in identifying patients with reduced exercise capacity. In HFpEF, systolic function by GLS was impaired. There was a significant relationship between diastolic function and GLS, confirming a coupling between diastolic and longitudinal systolic function in HFpEF.

Early Postoperative Left Ventricular Function by Echocardiographic Strain is a Predictor of 1-Year Mortality in Heart Transplant Recipients

BACKGROUND Left ventricular (LV) function can be accurately assessed using two-dimensional speckle-tracking echocardiography. The association between reduced LV global longitudinal strain (LVGLS) magnitude and risk for mortality in heart transplant recipients is unclear. The aim of this study was to test the hypothesis that LVGLS could predict 1-year mortality in heart transplant recipients. METHODS A total of 176 consecutive adult primary single-organ orthotopic heart transplant recipients were retrospectively evaluated. Of these, 167 had acceptable echocardiographic image quality and were included in the study. N-terminal pro-B-type natriuretic peptide, creatinine, C-reactive protein, and invasive hemodynamic parameters were measured, and echocardiography was performed 1 to 3 weeks after heart transplantation. LVGLS was averaged from regional strain in 16 LV segments. RESULTS During the first year, 15 patients (9%) died 86 ± 72 days after heart transplantation. LVGLS and LV ejection fraction were decreased in magnitude in nonsurvivors (P < .05). They were older and had higher donor ages. Mean pulmonary capillary wedge pressures were similar in the two groups, while all other hemodynamic parameters were increased in nonsurvivors (P < .05). LVGLS was the only significant (P = .02) noninvasive independent predictor, with a hazard ratio of 1.42 (95% confidence interval, 1.07-1.88; P = .02) per 1% decrease in strain magnitude, while pulmonary vascular resistance was a significant (P < .001) invasive predictor, with a hazard ratio of 3.98 (95% confidence interval, 2.01-7.87) of 1-year mortality in multivariate Cox regression analysis. CONCLUSIONS Reduced LV function and increased pulmonary vascular resistance are related to poor prognosis in heart transplant recipients. Early assessment of LVGLS might be a noninvasive predictor of 1-year mortality in these patients.

Strain echocardiographic assessment of left atrial function predicts recurrence of atrial fibrillation

Aims We evaluated if a dispersed left atrial (LA) contraction pattern was related to atrial fibrillation (AF) in patients with normal left ventricular (LV) function, and normal or mildly enlarged left atrium. Methods and results We included 61 patients with paroxysmal AF (PAF). Of these, 30 had not while 31 had recurrence of AF after radiofrequency ablation (RFA). Twenty healthy individuals were included for comparison. Echocardiography was performed in patients in sinus rhythm the day before RFA. LA volume was calculated. Peak negative longitudinal strain was assessed in 18 LA segments during atrial systole. Contraction duration in 18 LA segments was measured as the time from peak of the P wave on electrocardiogram to maximum myocardial shortening in each segment. The standard deviation of contraction durations was defined as LA mechanical dispersion (LA MD). LA size was rather preserved in patients with PAF (LA volume 25 ± 10 mL/m2). LA MD was more pronounced in patients with recurrence of AF after RFA compared with those without recurrence and controls (38 ± 14 ms vs. 30 ± 12 ms vs. 16 ± 8 ms, both P < 0.001). LA MD was a predictor of PAF [OR 7.84 (95%CI 2.15–28.7), P < 0.01, per 10 ms increase] adjusted for age, LA volume, e’, and LA function. LA function by strain was reduced in both patients with and without recurrent AF after RFA compared with controls (−14 ± 4% vs. −16 ± 3% vs. −19 ± 2%, both P < 0.05). Conclusion LA MD was pronounced, and LA deformation was reduced in patients with PAF with apparently normal LV structure and function, and normal or mildly enlarged LA. LA MD may be useful as a predictor of AF recurrence after RFA.

Duration of Myocardial Early Systolic Lengthening Predicts the Presence of Significant Coronary Artery Disease

OBJECTIVES This study sought to investigate whether the duration of left ventricular (LV) early systolic lengthening could accurately identify patients with significant coronary artery disease (CAD). BACKGROUND Ischemic myocardium with reduced active force will lengthen when LV pressure rises during early systole before onset of systolic shortening. METHODS We included 88 patients with suspected CAD referred to elective diagnostic coronary angiography. Two of these patients were excluded from the study due to evidence of previous myocardial infarction on contrast-enhanced magnetic resonance imaging. Speckle tracking echocardiography was performed before coronary angiography and at follow-up scheduled 1 year after revascularization, and global longitudinal strain and duration of average LV early systolic lengthening were recorded. RESULTS Forty-three of 86 patients had significant CAD. The duration of early systolic lengthening was significantly prolonged in patients with significant CAD compared with patients without significant coronary artery stenoses (76 ± 37 ms vs. 38 ± 23 ms, p < 0.001). Correspondingly, global systolic strain was significantly lower in patients with CAD (-17.7 ± 3.0% vs. -19.5 ± 2.6%, p = 0.003). Prolonged duration of early systolic lengthening showed the best accuracy in detecting CAD, with an area under the receiver-operating characteristic curve of 0.83. The area under the curve for global strain was 0.68. At 1-year follow-up, the duration of early systolic lengthening was significantly reduced (64 ± 37 ms vs. 76 ± 37 ms, p = 0.041) in the patients treated with revascularization. CONCLUSIONS Duration of myocardial early systolic lengthening was prolonged in patients with significant CAD; this might be a useful parameter to identify patients who might benefit from reperfusion therapy.

Automatic segmentation of cardiac MRI cines validated for long axis views.

Segmentation of cardiac magnetic resonance imaging is considered an important application in clinical practice. An automatic algorithm is proposed for segmentation of both endocardial and epicardial boundaries, in long-axis views. The data consisted of 126 patients, yielding 1008 traces. Estimated clinical parameters were highly correlated to gold standard measurements. The error between the automatic tracing and the gold standard was not significantly different than the error between two manual observers. In conclusion, a tool for segmenting the myocardial boundaries in the long-axis views is proposed, which works well, as demonstrated by the validation performed using a clinical dataset.

Left-Atrial Segmentation From 3-D Ultrasound Using B-Spline Explicit Active Surfaces With Scale Uncoupling

Segmentation of the left atrium (LA) of the heart allows quantification of LA volume dynamics which can give insight into cardiac function. However, very little attention has been given to LA segmentation from three-dimensional (3-D) ultrasound (US), most efforts being focused on the segmentation of the left ventricle (LV). The B-spline explicit active surfaces (BEAS) framework has been shown to be a very robust and efficient methodology to perform LV segmentation. In this study, we propose an extension of the BEAS framework, introducing B-splines with uncoupled scaling. This formulation improves the shape support for less regular and more variable structures, by giving independent control over smoothness and number of control points. Semiautomatic segmentation of the LA endocardium using this framework was tested in a setup requiring little user input, on 20 volumetric sequences of echocardiographic data from healthy subjects. The segmentation results were evaluated against manual reference delineations of the LA. Relevant LA morphological and functional parameters were derived from the segmented surfaces, in order to assess the performance of the proposed method on its clinical usage. The results showed that the modified BEAS framework is capable of accurate semiautomatic LA segmentation in 3-D transthoracic US, providing reliable quantification of the LA morphology and function.