[Show abstract][Hide abstract] ABSTRACT: Background
Left ventricular (LV) radial tissue Doppler imaging (TDI) strain increases gradually from the subepicardial to the subendocardial layer in healthy individuals. A speckle tracking echocardiography study suggested this gradient to be reduced in parallel with increasing aortic stenosis (AS) severity.
We used TDI strain in 84 patients with AS (mean age 73 ± 10 years, 56% hypertensive) for superior assessment of layer strain. 38 patients had non-severe and 46 severe AS by aortic valve area corrected for pressure recovery. Peak systolic radial TDI strain was measured in the subendocardial, mid-myocardial and subepicardial layers of the basal inferior LV wall, each within a region of interest of 2 × 6 mm (strain length 2 mm).
Radial strain was lower in the subepicardial layer (33.4 ± 38.6%) compared to the mid-myocardial and subendocardial layers (50.3 ± 37.3% and 53.0 ± 40.0%, respectively, both p < 0.001 vs. subepicardial). In the subendo- and midmyocardium, radial strain was lower in patients with severe AS compared to those with non-severe AS (p < 0.05). In multivariate regression analyses including age, heart rate, inferior wall thickness, hypertension, and AS severity, radial strain in the mid-myocardium was primarily attenuated by presence of hypertension (β = −0.23) and AS severity (β = −0.26, both p < 0.05), while radial strain in the subendocardium was significantly influenced by AS severity only (β = −0.35, p < 0.01).
In AS, both the AS severity and concomitant hypertension attenuate radial TDI strain in the inferior LV wall. The subendocardial radial strain is mainly influenced by AS severity, while midmyocardial radial strain is attenuated by both hypertension and AS severity.
[Show abstract][Hide abstract] ABSTRACT: Increased left ventricular (LV) wall thickness/internal diameter ratio (relative wall thickness) was recently reported in RA patients. The aim of this study was to assess the association between LV relative wall thickness and RA disease activity.
[Show abstract][Hide abstract] ABSTRACT: Background
In normal subjects, left ventricular (LV) dimensions have been shown to decrease over time, while wall thickness is increasing. The aim of this study was to investigate LV remodeling in a cohort of patients with type 2 diabetes mellitus during a 3-year follow-up period and its potential association with decreased longitudinal systolic strain (εL).
One hundred seventy-two patients with type 2 diabetes without overt heart disease were prospectively enrolled and underwent echocardiography with speckle-tracking imaging to assess global LV εL at baseline and at 3 years. The associations between alteration in εL (defined as |εL| < 18%), LV geometry at baseline, and LV remodeling over time were evaluated.
Among the 172 enrolled patients, 154 completed 3-year follow-up. At baseline, patients with εL alteration had higher LV end-systolic volumes (28 ± 11 vs 23 ± 9 mL, P < .001) and relative wall thicknesses (RWT; 0.44 ± 0.06 vs 0.40 ± 0.07, P = .008) compared with those with normal εL. At 3-year follow-up, RWTs remained stable in both groups. LV volumes significantly decreased in patients with normal εL but not in patients with εL alteration. Multivariate analysis showed that εL alteration was independently associated with LV end-systolic volume (β = 5.0, P = .006) and RWT (β = 0.03, P = .03) at baseline and with changes in both LV end-diastolic volume (β = 19.1, P = .001) and LV end-systolic volume (β = 2.6, P = .047) over 3 years.
In patients with type 2 diabetes, εL alteration was associated with higher RWT and LV volumes and with the absence of decreases in LV volumes over time, which might be an early sign of adverse LV remodeling.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 05/2014; 27(5). DOI:10.1016/j.echo.2014.01.001 · 3.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Left ventricular (LV) geometry is a strong predictor of cardiovascular death. Less is known about the relation between LV geometry and RA.
Objectives Our objective was to study if RA or RA disease activity was associated with abnormal LV geometry measured as increased LV relative wall thickness (RWT) or mass (LVM).
Methods Echocardiography, clinical and laboratory assessment was performed in 137 RA patients without prior myocardial infarction or valvular disease and 50 healthy controls. Age-adjusted RWT and LVM were calculated by validated equations.
Results The RA group was older, had higher blood pressure (BP) and included more women compared to controls (all p<0.01). Among RA patients, higher RWT correlated with higher systolic BP, wall stress, and RA disease activity measured by modified health assessment questionnaire (MHAQ), Clinical Disease Activity Index (CDAI), simple DAI (SDAI) and Disease Activity Score in 28 joints (DAS-28) in univariate analyses (all p<0.05). Wall stress and systolic BP were the main covariates of higher RWT in multivariate analyses both among RA patients and controls (all p<0.01). However, the analyses showed that among RA patients, RWT was associated with 4 different disease activity measures independently of gender, systolic BP and wall stress (Table). Higher LVM was independently associated with higher systolic BP, age and body weight, male gender and lower LV ejection fraction (all p<0.05), but was not associated with markers of RA disease activity.
Conclusions Abnormal LV geometry is associated with markers of increased disease activity in RA, independent of systolic BP and wall stress, pointing to the importance of disease activity control in RA patients.
Disclosure of Interest None Declared
Annals of the Rheumatic Diseases 01/2014; 72(Suppl 3):A415-A415. DOI:10.1136/annrheumdis-2013-eular.1260 · 10.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute dysfunction of mechanical aortic valve prostheses is a life-threatening adverse event. Pannus overgrowth, which is fibroelastic hyperplasia originating from the periannular area, is one cause of dysfunction. The aim of this study was to determine the annual incidence of readmittance resulting from acute obstruction caused by pannus during 30 years of observation in patients with Medtronic-Hall aortic valve prostheses and to analyze the risk factors associated with pannus development.
From 1982 to 2004, 1,187 patients in our department underwent aortic valve replacement with Medtronic-Hall mechanical monoleaflet valve prostheses. As of December 31, 2012, 27 of these patients (2.3%) had presented with acute valve dysfunction caused by pannus obstruction.
The annual incidence of pannus was 0.7 per 1,000. The median time from the primary operation to prosthetic dysfunction was 11.1 years (range, 1.2 to 26.8 years). Of the 20 patients who underwent reoperation, 2 died. Seven patients died before reoperation. Women had a higher risk for the development of obstructing pannus, and patients with pannus obstruction were younger. Valve size was not an independent risk factor.
Women and younger patients are at higher risk for pannus development. When acute dysfunction by pannus is suspected in a mechanical aortic valve, an immediate echocardiogram and an emergency aortic valve replacement should be carried out because of the potential of a fatal outcome.
The Annals of thoracic surgery 09/2013; 96(6). DOI:10.1016/j.athoracsur.2013.07.019 · 3.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Deformation imaging is undergoing continuous development with the emergence of new technologies allowing the evaluation of the different components of strain simultaneously in three dimensions. Assessment of all global strain parameters in 2D and 3D modes and comparison with LVEF have been the focus of our study.
Out of 166 patients, 147 were evaluated with the use of both 2D and 3D speckle-tracking echocardiography (STE). Global strain parameters including longitudinal (GLS), circumferential (GCS), radial (GRS) and area strain (AS), as well as left ventricular volumes and ejection fraction were examined. Analysis of strain with 3D STE was faster than with 2D STE (7 ± 2 vs. 24 ± 4 min, P < 0.05). GLS values were similar between 2D and 3D modes (-14 ± 4 vs. -13 ± 3, NS), while slight differences were observed for GCS (-24 ± 7 vs. -27 ± 7, P < 0.05) and GRS (27 ± 9 vs. 24 ± 9, P < 0.05). All 2D and 3D strain parameters showed good accuracy in the identification of 2D-LVEF <55% with AS demonstrating superiority over GCS and GRS but not GLS.
Three-dimensional STE allows accurate and faster analysis of deformation when compared with 2D STE and might represent a viable alternative in the evaluation of global LV function.
[Show abstract][Hide abstract] ABSTRACT: Background and Aims: In patients with chronic pressure overload due to hypertension or aortic valve stenosis (AS), higher left atrial systolic force (LASF) is associated with a high-risk cardiovascular (CV) phenotype. We tested LASF as prognostic marker in patients with AS. Methods: We used baseline and outcome data from 1,566 patients recruited in the Simvastatin and Ezetimibe in AS (SEAS) study evaluating the effect of placebo-controlled simvastatin and ezetimibe treatment on CV events. The primary outcome was a composite of major CV events, including CV death, aortic valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure caused by progression of AS, coronary artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. LASF was calculated by Manning's method. High LASF was defined as >95th percentile (50 Kdynes/cm(2) ) of the distribution within the study population. Results: During 4.3 years of follow-up, a major CV event occurred in 38 of 78 patients with high LASF (49%) and in 513 of 1,488 (34%) with normal LASF (P = 0.01). In multivariate Cox regression analysis, high LASF predicted higher rate of major CV events (Hazard ratio 1.43 [95% confidence interval 1.01-2.03] independent of aortic valve area and LV mass index. A simple risk score including absence or presence of these three variables allowed risk stratification into low, intermediate, high and very high risk for major CV events during follow-up (22%, 28%, 38%, and 53%, respectively). Conclusions: Higher LASF provides additional prognostic information in patients with asymptomatic mild-to-moderate AS.
[Show abstract][Hide abstract] ABSTRACT: There is a limited knowledge about left atrial (LA) systolic force (LASF) and its key determinants in patients with asymptomatic mild-moderate aortic stenosis (AS).
We used baseline clinic and echocardiographic data from 1,566 patients recruited in the simvastatin ezetimibe in aortic stenosis study evaluating the effect of placebo-controlled combined simvastatin and ezetimibe treatment in asymptomatic AS. The LASF was calculated by Manning's method. Low and high LASF were defined as <5th and >95th percentile of the distribution within the study population, respectively.
Mean LASF in the total study population was 21±14 kdynes/cm2. The determinants of LASF were higher age, heart rate, body mass index, systolic blood pressure, left ventricular (LV) mass, mitral peak early velocity, maximal LA volume, and longer mitral deceleration time (multiple R2=0.37, P<0.01). High LASF (78 patients) was characterized by abnormal LV relaxation in 90% of the cases. Low LASF (82 patients) was associated with restrictive LV filling pattern, absence of abnormal relaxation pattern, smaller maximal LA volume, and lower body mass index. In 40% of the patients with low LASF, estimated LV filling pressures were normal and the reduced LA force was explainable by an intrinsic systolic LA dysfunction.
In patients with asymptomatic AS, LASF was closely related to filling pressure. Higher LASF invariably signifies the maximal LA effort to keep near normal LV filling pressure; lower LASF belongs to a heterogeneous group of patients in which it is much more difficult to depict who have low LA preload or who have intrinsic systolic LA dysfunction.
[Show abstract][Hide abstract] ABSTRACT: To report aortic root geometry by echocardiography in a large population of healthy, asymptomatic aortic stenosis (AS) patients in relation to current vendor-specified requirements for transcatheter aortic valve implantation (TAVI).
Baseline data in 1481 patients with asymptomatic AS (mean age 67 years, 39% women) in the Simvastatin Ezetimibe in AS study were used. The inner aortic diameter was measured at four levels: annulus, sinus of Valsalva, sinotubular junction and supracoronary, and sinus height as the annulo-junctional distance. Analyses were based on vendor-specified requirements for the aortic root geometry for current available prostheses, CoreValve and Edwards-Sapien. The ratio of sinus of Valsalva height to sinus width was 1:2. In multivariate linear regression analysis, larger sinus of Valsalva height was associated with older age, larger sinus of Valsalva diameter, lower ejection fraction and smaller supracoronary diameter (multiple R(2) = 0.19, P< 0.01). The required annulus diameter for implantation of CoreValve was met in 61.9%, and for the Edwards-Sapien prosthesis in 66.9%. Overall, annular dimension feasible for TAVI using any available prosthesis was found in 78.2% of patients and in 77.7% of patients also the required minimum sinus of Valsalva height was found. Comparing the group of patients who met TAVI requirements to those who did not, the latter included more women and patients with lower body height and weight and significantly smaller aortic root diameters (all P < 0.05).
Among AS patients in the SEAS study, 27% of women and 19% of men did not have aortic root geometry fulfilling current requirements for TAVI.
[Show abstract][Hide abstract] ABSTRACT: A 72-year-old woman was hospitalized with recurrent acute coronary syndrome after initial successful treatment of acute ST-elevation myocardial infarction with percutaneous coronary intervention. Echocardiography demonstrated unexpectedly a 9 x 8 mm pendulating structure attached to the anterior, proximal interventricular septum in the left ventricular outflow tract 6 mm beneath the aortic valve annulus. Magnetic resonance imaging of the heart yielded the same findings. The patient underwent coronary artery bypass grafting and tumour excision. The histopathological findings were typical for papillary fibroelastoma (PFE) with a central zone of connective tissue and some elastic fibres without blood vessels and covered by endocardium. PFE is the third most common type of primary cardiac tumours, second to myxoma and lipoma. PFEs are avascular papillomas that predominantly occur on the aortic and mitral valves (90%). However, the present case demonstrates that PFE occasionally can be attached to the ventricular wall endocardium.
[Show abstract][Hide abstract] ABSTRACT: To assess left ventricular (LV) strain and displacement and their relations to LV geometry in patients with aortic stenosis (AS).
Cross-sectional echocardiographic study in patients with AS. Peak circumferential, radial and longitudinal strain, and radial, longitudinal and transverse displacement were measured by 2D speckle tracking. Severity of AS was assessed from energy loss index (ELI). LV hypertrophy was present if LV mass/height(2.7) > or =46.7/49.2 g/m(2.7) in women/men and concentric LV geometry if relative wall thickness > or =0.43. LV geometry was assessed from LV mass/height(2.7) and relative wall thickness in combination. Setting Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
70 patients with AS (mean age 73+/-10 years, 54% women).
None. Main outcome measures Association of regional and average LV myocardial strain and displacement with LV geometric pattern and degree of AS.
Average longitudinal strain was lower in the hypertrophy groups and correlated with higher LV mass index and relative wall thickness, lower stress-corrected mid-wall shortening and smaller ELI (all p<0.05). Average strain and displacement in other directions did not differ between geometric groups. In multivariate regression analysis, lower average longitudinal strain was associated with higher relative wall thickness (beta=0.15), lower ejection fraction (beta=-0.16), systolic blood pressure (beta=-0.16) and energy loss index (beta=-0.20) (all p<0.05) (R(2)=0.72). When relative wall thickness was replaced with LV mass, lower longitudinal strain was also associated with higher LV mass (beta=0.21, p<0.05) (R(2)=0.73).
In patients with AS, lower average longitudinal strain is related to higher LV mass, concentric geometry and more severe AS.
[Show abstract][Hide abstract] ABSTRACT: Measuring strain in multiple myocardial layers using 2-dimensional tissue Doppler imaging may provide valuable diagnostic information about non-transmural disease. However, its feasibility in humans has not been demonstrated previously, and optimal machine settings not defined.
From parasternal short axis, zoomed tissue Doppler imaging of the left ventricular inferior wall was obtained in 23 young, healthy humans. Images were recorded with six different machine settings. Velocity, strain rate and strain were measured in two and three layers across the wall.
For two-layer-measurements, all subendocardial values were significantly higher than the subepicardial ones (p<0.003 for all data sets). Minimal radial and maximal lateral averaging resulted in largest strain differences: 106.4+/-32.6% (mean+/-SD) subendocardially versus 54.2+/-20.1% subepicardially. By similar settings in three layers, strain was 105.7+/-34.5% subendocardially, 81.2+/-26.9% midmyocardially and 48.3+/-26.9% subepicardially (p <0.05).
We have demonstrated that it is feasible to measure radial velocity, strain rate and strain in up to three individual layers in young healthy humans, and the diagnostic potentials should be tested on patient groups.
[Show abstract][Hide abstract] ABSTRACT: Myasthenia gravis (MG) primarily affects skeletal muscles, but influence on cardiac function has been suggested. The aim of this study was to assess left ventricular long-axis function in MG patients compared to healthy controls, and to examine whether any MG-related heart involvement was influenced by the acetylcholine-esterase inhibitor pyridostigmine. We found that early diastolic atrioventricular-plane velocity and tissue Doppler peak systolic strain was lower in MG patients than in controls before pyridostigmine. The differences disappeared following administration of pyridostigmine. Also, tissue velocities at systole and early diastole tended to be lower in patients before pyridostigmine. In multivariate analyses adjusting for between-group differences in blood pressure, MG was no longer associated with lower longaxis function. Conventional echocardiographic measures of left ventricular diastolic and systolic function did not differ between groups. In conclusion, this study, using modern tissue Doppler imaging as well as conventional echocardiography, could not demonstrate definite MG-related cardiac involvement in a group of MG patients without known cardiac disease, but indicates that pyridostigmine-responsive MG-related alterations in cardiac muscle function exist in MG patients.
Journal of Neurology 12/2008; 255(11):1777-84. DOI:10.1007/s00415-008-0049-x · 3.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We recently demonstrated reduced exercise capacity in treated genetic haemochromatosis, in spite of normal radial left ventricular (LV) systolic function assessed by 2-dimensional echocardiography at rest. It remains unknown if haemochromatosis-related impairment of LV long-axis function can be demonstrated also at rest. LV long-axis function was assessed by echocardiography including spectral tissue Doppler of systolic (S') and early (E') diastolic velocities in 105 treated haemochromatosis patients and 50 controls. Patients had higher body mass index, systolic atrioventricular excursion, and smaller LV end-systolic diameter (all P < 0.05). Other conventional echocardiographic variables did not differ. S' was normal in both groups, though significantly higher among the patients (11.1 vs. 9.9 cm/s, P < 0.001). In multiple regression analysis, higher S' was associated with having haemochromatosis, independently of significant contributions from higher atrioventricular excursion and LV length, and lower body mass index and E/E'-ratio (multiple R(2) = 0.44, P < 0.001). E' did not differ between patients and controls. However, in multivariate analysis lower E' was associated with having haemochromatosis independently of significant contributions from higher age and diastolic blood pressure, and lower transmitral E and end-diastolic LV length (multiple R(2) = 0.57, P < 0.001). The long-axis function in the haemochromatosis group was normal. Still haemochromatosis, even in this group of patients treated with regular phlebotomy, influenced both systolic and early diastolic long-axis function, and was associated with higher atrioventricular excursion and S', and with lower E'.
The international journal of cardiovascular imaging 12/2008; 25(3):237-47. DOI:10.1007/s10554-008-9383-4 · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We recently demonstrated reduced exercise capacity in phlebotomy treated genetic haemochromatosis in spite of normal systolic function. The present objective was to investigate diastolic function at rest.
Diastolic function was echocardiographically assessed in 132 phlebotomy treated genetic haemochromatosis patients and 50 controls.
Patients had higher body mass index and heart rate, higher transmitral early (E) (11.2+/-2.6 versus 10.4+/-2.2 cm) and atrial (A) (5.7+/-1.6 versus 5.0+/-1.6) velocity time integrals, pulmonary venous systolic peak velocity (0.58+/-0.12 versus 0.54+/-0.13 m/s) and ratio of E to spectral tissue Doppler E' velocity (6.3+/-1.6 versus 5.6+/-1.4, all p <0.05). Independently of age, heart rate, systolic blood pressure and body weight, having haemochromatosis remained statistically significantly associated with higher E (beta=0.27) and A (beta =0.18) velocity time integrals, pulmonary venous systolic peak velocity (beta =0.21), and E/E'-ratio (beta=0.25) in separate multivariate analyses (all p <0.05). In the youngest age tertile, patients had longer isovolumic relaxation time and lower E' than controls.
Our findings are compatible with mildly impaired diastolic function in treated haemochromatosis, with delayed relaxation in the younger tertile, and an elevated filling pressure and pseudonormalisation with increasing age.
[Show abstract][Hide abstract] ABSTRACT: Many patients with genetic haemochromatosis complain about fatigue and reduced physical capacity. Exercise capacity, however, has not been evaluated in larger series of haemochromatosis patients treated with repeated phlebotomy.
We performed exercise echocardiography in 152 treated haemochromatosis patients (48+/-13 years, 26% women) and 50 healthy blood donors (49+/-13 years, 30% women), who served as controls. Echocardiography was performed at rest and during exercise in a semiupright position on a chair bicycle, starting from 20 W, increasing by 20 W/min. Transmitral early and atrial velocity and isovolumic relaxation time were measured at each step. Ventilatory gas exchange was measured by the breath-to-breath-technique.
Compared with healthy controls, haemochromatosis patients were more obese and less trained. More of them smoked, and 17% had a history of cardiovascular or pulmonary disease. Adjusted for training, the left ventricular function and dimensions at rest did not differ between the groups. During exercise the haemochromatosis patients obtained a significantly lower peak oxygen (O2) uptake (28.1 vs. 34.4 ml/kg per min, P<0.001). In a multiple regression analysis haemochromatosis predicted lower peak O2 uptake independently of significant contributions of sex, age, and height, as well as of systolic blood pressure and log-transformed isovolumic relaxation time at peak exercise, whereas no independent association was found with weight or physical activity (multiple R=0.74, P<0.001). Adding genotype, s-ferritin, prevalence of smoking, or history of cardiopulmonary disease among the covariates in subsequent models did not change the results.
Genetic haemochromatosis, even when treated with regular phlebotomy, is associated with lower exercise capacity independently of other covariates of exercise capacity.
European Journal of Cardiovascular Prevention and Rehabilitation 06/2007; 14(3):470-5. DOI:10.1097/HJR.0b013e3280ac151c · 3.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to assess the influence of left ventricular (LV) hypertrophy regression on exercise capacity in hypertensive patients. Doppler echocardiography was performed at rest and during exercise in 51 patients with electrocardiographic LV hypertrophy before and after 1 year of randomized blinded losartan- or atenolol-based antihypertensive treatment. After 1 year, blood pressure was comparably reduced by 32/14 and 27/13 mmHg, respectively, in the losartan and atenolol groups, but the atenolol group had higher mean LV mass index (118 vs 103 g/m2) and lower LV ejection fraction (61% vs 67%) and midwall shortening (15.8% vs 16.8%) (all p<0.05). Resting diastolic Doppler indices remained unchanged and did not differ between the groups. Peak oxygen uptake during exercise was virtually unchanged after 1 year and did not differ between the groups in spite of a lower peak exercise heart rate in atenolol-treated patients. In multivariate analysis, higher peak oxygen uptake at 1 year was associated with lower body mass index, and higher systolic blood pressure and shorter isovolumic relaxation time at peak exercise (multiple R2 = 0.51, p<0.01), while age, gender, heart rate increase during exercise, reduction in LV mass and study treatment did not enter. In conclusion, reduction in blood pressure and LV mass induced by losartan or atenolol treatment was not accompanied by improved exercise capacity after 1 year. The results may be explained by persistent impairment of myocardial relaxation influencing exercise capacity.