Yen-Wen Liu

Evidence of Left Ventricular Systolic Dysfunction Detected by Automated Function Imaging in Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

BACKGROUND Left ventricular ejection fraction (LVEF) cannot reflect cardiac contractile function in patients with heart failure and preserved LVEF (HFPEF). LV systolic impairment is actually debated in HFPEF patients. Automated function imaging (AFI) is a novel algorithm of speckle-tracking echocardiography and efficiently to assess global LV peak systolic longitudinal strain (PSLS), an index for systolic function. The purpose of the study is to examine whether contractile function is impaired in HFPEF patients. METHODS AND RESULTS This study included 49 heart failure patients (23 with systolic dysfunction [SHF] and 26 with HFPEF), and 40 patients, matched for age, sex, as well as concomitant disease and without heart failure as controls. All patients underwent transthoracic echocardiography. LVEF was measured by Simpsons method. Two-dimensional speckle tracking imaging with AFI assessment was applied to measure longitudinal strain. LVEF was 66+/-5% in the controls, 63+/-8% in the HFPEF group (P=.14), and 34+/-10% in the SHF group (P < .001). The value of LV global PSLS (controls: -20%, HFPEF: -14%, SHF: -8%, P < .001) was significantly less negative in both heart failure groups. CONCLUSIONS Deteriorated LV systolic function is demonstrated by decreased global PSLS in HFPEF patients. AFI is an effective and facile method for assessing LV systolic abnormalities.

Left Ventricular Systolic Strain in Chronic Kidney Disease and Hemodialysis Patients

Background: The impact of chronic kidney disease (CKD) and hemodialysis on heart function is not fully understood. We aimed to investigate the influence of different stages of CKD and maintenance hemodialysis on heart function. Methods: One hundred fifty-three patients were categorized into 3 subgroups [56 without CKD as controls; 37 with moderate-advanced CKD, stages 3, 4 or 5, and 60 with end-stage renal disease (ESRD) undergoing maintenance hemodialysis]. Left ventricular (LV) function was assessed by conventional echocardiography and 2-dimensional speckle-tracking echocardiography with strain analysis (2D strain analysis). Results: There was no significant difference of gender, age and LV ejection fraction among groups. Compared with controls, global peak systolic longitudinal strain (GSl), circumferential strain and strain rate were decreased in the CKD group. Along with the decline of renal function, GSl deteriorated. Moreover, compared with moderate-advanced CKD patients, GSl, circumferential strain and strain rate were better in ESRD group receiving maintenance hemodialysis. Conclusions: Worsening renal function was associated with a reduction of systolic function, and could be quantified by 2D strain analysis. The hemodialysis patients have better LV systolic function than the moderate-advanced CKD patients.

Usefulness of real-time three-dimensional echocardiography for diagnosis of infective endocarditis.

Objectives. To compare transthoracic 2-dimentional echocardiography (2DE) and real-time three-dimensional echocardiography (RT-3DE) evaluation of clinically suspected infective endocarditis (IE) and to determine the feasibility of RT-3DE in vegetation detection. Designs. There were 46 patients (mean age 61±17 years, 54% male) enrolled. We acquired 2DE and RT-3DE with full volume images. RT-3DE images were analyzed by 3D QLAB software. Parameters suggestive of vegetation for RT-3DE assessment included mobile nodules, focal thickness, and uneven surface. The diagnosis of IE was made according to the Duke criteria. Results. The sensitivity and specificity were 91.6% and 88.2% for 2DE, and 91.6% and 100% for RT-3DE. Among three parameters of RT-3DE, presence of mobile nodule (83.3% vs. 0%, p < 0.001) were significantly higher in IE patients but not focal thickness (75% vs. 65%, p = 0.723), or uneven surface (33% vs. 10%, p = 0.064). Conclusion. The sensitivity of RT-3DE and 2DE was similar for endocarditis diagnosis, but the specificity of RT-3DE was higher. Mobile nodules viewed by RT-3DE might be a useful finding for vegetation detection.

Application of Speckle-Tracking Echocardiography in Detecting Coronary Artery Disease in Patients with Maintenance Hemodialysis

Background: Satisfactory and noninvasive diagnostic tools for coronary artery disease (CAD) are not available in hemodialysis patients. We aimed to elucidate a reliable tool to diagnose CAD in these patients. Methods: 102 hemodialysis patients received 2D speckle-tracking echocardiography with left ventricular (LV) strain analysis and blood tests for cardiac troponin T, high-sensitive C-reactive protein, interleukin (IL)-6, and IL-18. Results: The levels of biomarkers did not differ between patients with and without CAD. The factors associated with CAD were decreased circumferential strain, decreased global longitudinal strain, and the number of LV segments with decreased longitudinal strain. Logistic regression analyses showed that the number of LV segments with decreased longitudinal strain, over 6 segments, was strongly associated with CAD in hemodialysis patients (OR 12.08, 95% CI 3.724–39.209). Conclusions: The noninvasive modality of speckle-tracking echocardiography with strain analysis is efficient and objective for identifying CAD in hemodialysis patients.

Increased C-reactive protein is associated with future development of diabetes mellitus in essential hypertensive patients

Coexistence of hypertension and diabetes mellitus (DM) increases the risk of cardiovascular disease. However, factors associated with future development of DM have not been well elucidated in patients already having essential hypertension. This study prospectively included 168 patients (mean age 41 ± 7 years, 112 men) with essential hypertension. All patients did not have DM and vascular or renal complications initially. Baseline demographic data, blood pressure, body mass index, and antihypertensive agents were carefully evaluated and serum high-sensitivity C-reactive protein (hsCRP) was measured at the beginning of the study. All of the patients were followed for at least 6 months. The study endpoint was occurrence of new DM. After a mean follow-up period of 32 ± 10 months, 22 subjects (13.1%) developed new DM. Patients with new DM had higher baseline glucose (105.2 ± 11.8 vs 94.2 ± 8.0 mg/dl, P < 0.001), triglyceride level (213.7 ± 112.4 vs 155.6 ± 83.2 mg/dl, P = 0.04), log hsCRP (0.31 ± 0.44 vs 0.19 ± 0.25 mg/dl, P = 0.016), and lower high-density lipoprotein (40.2 ± 7.8 vs 46.6 ± 14.4 mg/dl, P = 0.045). Total cholesterol, low-density lipoprotein, homeostasis model assessment index, and adiponectin were not different in patients with or without new DM. Among antihypertensive agents, only use of β-blocker was significantly associated with new DM (P = 0.008). Multivariate Cox regression analysis showed log hsCRP (hazard ratio [HR] 9.77, 95% confidence interval [CI] 2.97-32.10, P < 0.001), age (HR 1.21, 95% CI 1.06–1.38, P = 0.004), and baseline glucose level (HR 1.11, 95% CI 1.06–1.15, P < 0.001) to be independent predictors for occurrence of new DM. High-sensitivity CRP was an independent factor for future development of DM in essential hypertensive patients. Increased inflammation might have a key role in the pathogenesis of DM in hypertension.

Tuberculous constrictive pericarditis with concurrent active pulmonary tuberculous infection: a case report

IntroductionIn some particular endemic area, it is not uncommon to see patients with tuberculosis pericarditis. However, it takes a period of time from tuberculous pericarditis to constrictive pericarditis. There is still no report of tuberculous constrictive pericarditis concurrent with active pulmonary TB infection in a patient without previous pulmonary TB infection history. Therefore, we reported a TB constrictive pericarditis with rare disease progress.Case presentationWe report the case of a 63-year-old Taiwanese man with tuberculous constrictive pericarditis concurrent with active pulmonary tuberculous infection presenting with progressive extremities edema, puffy face, abdominal distension and dyspnea on exertion found to be caused by right heart failure. The patient was cured by pericardial stripping and anti-tuberculosis chemotherapy. We reviewed other cases of tuberculous constrictive pericarditis from the literature and described the peculiarities of this case.ConclusionsRapid diagnosis and treatment of constrictive pericarditis are crucial to reduce mortality. In some endemic areas, Mycobacterium tuberculosis infection should be taken into consideration during diagnostic evaluations for constrictive pericarditis. Surgical intervention is still the treatment of choice when the patient has the symptoms or signs of pericardial constriction and right heart failure. Our case is a constant reminder that active Mycobacterium tuberculosis infection does present itself with uncommon presentations.

Arrhythmogenesis: a Roadblock to Cardiac Stem Cell Therapy.

Opinion statementDespite significant advances in the treatment of ischemic heart disease (IHD), it remains the leading cause of mortality worldwide. Undoubtedly, methods for regenerating the injured human heart are urgently needed, and whilst exciting progress has been made from utilizing stem cell therapy for cardiac regeneration, several major challenges still remain. In particular, one major safety issue is the occurrence of potentially life-threatening ventricular arrhythmias after cell therapy. Several drivers may be responsible for this, ranging from the potential inherent arrhythmogenicity of delivered stem cells to that of the underlying IHD. Therefore, it is imperative to thoroughly assess the risk-to-benefit ratio of such treatments prior to the clinical application. As such, despite the considerable progress made in stem cell therapy over the past decades, many obstacles still lie ahead.

P1270Effects of blood pressure variability on layer-specific longitudinal strain in hypertension

Background Our previous study showed sub-epicardial longitudinal strain (EpiLS) was an independent prognostic factor for worse outcome in regular treated hypertension but not global longitudinal strain (GLS) and sub-endocardial longitudinal strain (EndLS). Increased blood pressure variability (BPV) has been found associated with target organ damage in hypertension. However, effects of BPV on layer-specific longitudinal strain have not been well studied. Purpose The aim of this study was to investigate the effects of different blood pressure parameters on layer-specific longitudinal strain in hypertension. Methods This study included 95 patients (57 men, age 65 ± 12 years) with uncomplicated hypertension who have been regularly treated for more than 1 year. Speckle tracking echocardiography was used for measurement of longitudinal deformation from 3 apical views of left ventricle. GLS was measured by automated function imaging (AFI). We further divided into sub-endocardial and sub-epicardial myocardium and measured their longitudinal strain by manual click-and-draw method and averaged from 3 apical views. Blood pressure parameters included office systolic blood pressure (SBP), office diastolic blood pressure (DBP), central SBP and DBP by tonometry, average 24-hour SBP and DBP, and BPV parameters by ambulatory blood pressure monitor. BPV parameters included standard deviation of daytime SBP (DSSD), standard deviation of nighttime SBP (NSSD), standard deviation of daytime DBP (DDSD), and standard deviation of nighttime DBP (NDSD). Results We divided subjects into low and high group according to median level of each strain. No blood pressure parameters were different between low and high EndLS group except week difference in NDSD (9.0 ± 3.4 vs. 7.8 ± 2.0 mmHg, p = 0.051). NSSD (11.2 ± 4.6 vs. 9.3 ± 2.9 mmHg, p = 0.027) and NDSD (9.1 ± 3.4 vs. 7.7 ± 2.0 mmHg, p = 0.031) were significant increased in low GLS group but not other parameters. DDSD (10.3 ± 3.0 vs. 9.0 ± 2.5 mmHg, p = 0.034), NSSD (11.4 ± 4.4 vs. 9.1 ± 3.1 mmHg, p = 0.006), and NDSD (9.2 ± 3.2 vs. 7.6 ± 2.2 mmHg, p = 0.012) were significantly increased in low EpiLS group. Conclusions Only BPV parameters were associated with decreased longitudinal strain in hypertension. Effects of BPV were majorly noted in EpiLS.

891 Effects of Hypertension on Left Ventricular Area Strain Assessed by Three-dimensional Speckle Tracking Echocardiography

Background: Area strain (AS) is a new index for left ventricular (LV) deformation measured from 3-dimensional speckle tracking echocardiography (3D STE). We studied effects of hypertension on AS of LV and the relationship between AS and exercise capacity. Methods: This study included 40 normal subjects who undergoing regular health examination. All of the subjects did not have coronary artery disease or any structure heart disease and were free of symptoms. Global AS (GAS) was measured from 3D STE. GAS represents changes of area deformation after LV contraction. Symptom-limited treadmill exercise test using Bruces protocol was performed immediately after echocardiography. Results: GAS was significantly lower in subjects with hypertension (-23.3 ± 9.4 vs. -29.8 ± 6.0 %, p = 0.016), with diabetes (-22.1 ± 14.2 vs. -29.2 ± 5.1 %, p = 0.030), and female subjects (-24.5 ± 9.6 vs. -29.7 ± 5.8 %, p = 0.041). GAS was significantly correlated with diastolic blood pressure (r = 0.433, p = 0.006) and body weight (r = 0.343, p = 0.035). After multivariate analysis controlling gender, diabetes, body weight, GAS was still significantly lower in subjects with hypertension (p = 0.23). Diastolic blood pressure was independently correlated with GAS (B = 0.349, p = 0.022). GAS was significantly correlated with exercise time (r = -0.502, p = 0.001) but not LV ejection fraction, and average early diastolic mitral filling velocity to annulus velocity ratio. Conclusions: Hypertension decreased GAS of LV in healthy subjects. GAS was significantly correlated with exercise capacity.

CORRELATION OF SMALL ARTERIAL STIFFNESS WITH TARGET ORGAN DAMAGE IN HYPERTENSION: PP.11.443

Background: We have developed a novel Compliance Index (CI) as a marker for small artery stiffness. This study tried to study the correlation of CI with target organ damage (TOD) in hypertension. Methods: This study recruited 59 consecutive patients (mean age 66 ± 10 years, 39 men) with essential hypertension regularly treated with anti-hypertensive agents for at least for 1 year in a hypertensive clinic. All of the patients did not have diabetes mellitus and vascular complications. CI was measured by our new developed photoplethysmography system as the area under the curve of digital volume pulse divided by pulse pressure. Pulse wave velocity (PWV) measured by applanation tonometry was used for large arterial stiffness. Clearance of creatinine (Ccr) calculated from 24 urine was used for renal function and echocardiography was used for assessment of left ventricular function. TOD was defined as renal insufficiency (Ccr <60 ml/min) or presence of diastolic dysfunction by echocardiography. Results: There were 8 (14%) patients with renal insufficiency. CI was significantly lower in patients with renal insufficiency but not PWV. There were 16 (27%) patients with diastolic dysfunction. CI was lower and left ventricular mass index was higher in patients with diastolic dysfunction. Antihypertensive agents were not different between patients with or without TOD. CI was gradually decreased from patients without TOD, with one TOD, to patients with two TOD (3.18 ± 1.19 U, 2.04 ± 0.78 U, 1.49 ± 0.44 U; p < 0.001) but not PWV. Conclusion: Small but not large arterial stiffness was significant correlated with TOD. CI could be a marker for degree of TOD in regular treated hypertensive patients.