Influence of hypertension on systolic and diastolic left ventricular function including segmental strain and strain rate

Background - Left ventricular (LV) systolic and diastolic functions are important cardiovascular risk predictors in patients with hypertension. However, data on segmental, layer-specific strain, and diastolic strain rates in these patients are limited. The aim of this study was to investigate segmental two-dimensional strain rate imaging (SRI)-derived parameters to characterize LV systolic and diastolic function in hypertensive individuals compared with that in normotensive individuals. Methods - The study sample comprised 1194 participants from the population-based Know Your Heart study in Arkhangelsk and Novosibirsk, Russia, and 1013 individuals from the Seventh Tromsø Study in Norway. The study population was divided into four subgroups: (A) healthy individuals with normal blood pressure (BP), (B) individuals on antihypertensive medication with normal BP, (C) individuals with systolic BP 140–159 mmHg and/or diastolic BP > 90 mm HG, and (D) individuals with systolic BP ≥160 mmHg. In addition to conventional echocardiographic parameters, global and segmental layer-specific strains and strain rates in early diastole and atrial contraction (SR E, SR A) were extracted. The strain and SR (S/SR) analysis included only segments without strain curve artifacts. Results - With increasing BP, the systolic and diastolic global and segmental S/SR gradually decreased. SR E, a marker of impaired relaxation, showed the most distinctive differences between the groups. In normotensive controls and the three hypertension groups, all segmental parameters displayed apico-basal gradients, with the lowest S/SR in the basal septal and highest in apical segments. Only SR A did not differ between the segmental groups but increased gradually with increasing BP. End-systolic strain showed incremental epi-towards endocardial gradients, irrespective of the study group. Conclusion - Arterial hypertension reduces global and segmental systolic and diastolic left ventricular S/SR parameters. Impaired relaxation determined by SR E is the dominant factor of diastolic dysfunction, whereas end-diastolic compliance (by SR A) does not seem to be influenced by different degrees of hypertension. Segmental strain, SR E and SR A provide new insights into the LV cardio mechanics in hypertensive hearts

Insomnia and sleep-disordered breathing in FKRP-related limb-girdle muscular dystrophy R9. The Norwegian LGMDR9 cohort study (2020)

Limb-girdle muscular dystrophy R9 (LGMDR9) is a progressive and disabling genetic muscle disease. Sleep is relevant in the patient care as it impacts on health, functioning, and well-being. LGMDR9 may potentially afect sleep by physical or emotional symptoms, myalgia, or sleep-disordered breathing (SDB) through cardiorespiratory involvement. The objective was to investigate the occurrence of insomnia and unrecognized or untreated SDB in LGMDR9, associated factors, and relationships with fatigue and health-related quality of life (HRQoL). All 90 adults in a Norwegian LGMDR9 cohort received questionnaires on sleep, fatigue, and HRQoL. Forty-nine of them underwent clinical assessments and 26 without mask-based therapy for respiration disorders additionally underwent polysomnography (PSG) and capnometry. Among 77 questionnaire respondents, 31% received mask-based therapy. The prevalence of insomnia was 32% of both those with and without such therapy but was signifcantly increased in fatigued respondents (54% vs 21%). Insomnia levels correlated inversely with mental HRQoL. Among 26 PSG candidates, an apnea–hypopnea index (AHI)≥5/h was observed in 16/26 subjects (≥15/h in 8/26) with median 6.8 obstructive apneas and 0.2 central apneas per hour of sleep. The AHI was related to advancing age and an ejection fraction<50%. Sleep-related hypoventilation was detected in one subject. Fatigue severity did not correlate with motor function or nocturnal metrics of respiration or sleep but with Maximal Inspiratory Pressure (r=− 0.46). The results indicate that insomnia and SDB are underrecognized comorbidities in LGMDR9 and associated with HRQoL impairment and heart failure, respectively. We propose an increased attention to insomnia and SDB in the interdisciplinary care of LGMDR9. Insomnia and pulmonary function should be examined in fatigued patients

Virtual dissection of cardiac motion : what do we measure by strain and strain rate imaging?

The papers of the thesis are not available in Munin: 1. Assami Rösner, Bart Bijnens, Magna Hansen, Ole Jakob How, Erling Aarsæther, Stig Müller, George R. Sutherland, and Truls Myrmel: "Left ventricular size determines tissue Doppler derived longitudinal strain and strain rate", European Journal of Echocardiography (2009) 10, 271–277 (Oxford University Press - publisher's restrictions). Available at http://dx.doi.org/10.1111/10.1093/ejechocard/jen230 2. Assami Rösner, Ole Jakob How, Erling Aarsæther, Thor Allan Stenberg; Thomas Andreasen; Timofei V. Kondratiev, Terje S. Larsen, and Truls Myrmel: "High resolution speckle tracking dobutamine stress echocardiography reveals heterogeneous responses in different myocardial layers: implication for viability assessments", Journal of the American Society of Echocardiogrphy (2010) in print (Elsevier - publisher's restrictions). Check availability 3. Assami Rösner, Derk Avenarius, Siri Malm, Aigul Baltabaeva, Amjid Iqbal, George R. Sutherland, Bart Bijnens, and Truls Myrmel: "Longitudinal strain in patients with coronary artery disease and preserved ejection fraction. Implications for dobutamine stress echocardiography and tissue Doppler derived strain and strain rate" (manuscript)Since the introduction of strain and strain rate measurements in echocardiography of the heart, many studies have demonstrated that these parameters quantify effectively and precisely regional myocardial deformation. The method allows to measure and quantify regional myocardial function. Different cardiac diseases might be detected at an earlier stage. However, there are many factors influencing strain measurements without indicating changes in myocardial function. For the understanding of normal and pathological results it is important to gain more knowledge about factors with influence on strain measurements. Pigs with differing body size were investigated by ultrasound measuring strain. The result was that pigs had reduced strain with increasing body size. Furthermore, we could show that strain and strain rate, both changed in dependency on loading. In the other experimental study with pigs, we investigated myocardial motion with high resolution ultrasound. The aim was to investigate strain in the different myocardial layers, during reduced flow and the application of dobutamine stress. The result showed that strain was differently activated in the different myocardial layers. In a clinical study investigating patients with coronary artery bypass grafting, myocardial function was investigated before and after operation. The result showed strain as a sensitive method to detect reduced segmental myocardial function. Dobutamine stress and positive resting strain were good indicators for functional improvement. Taking the different strain-influencing factors into account, strain can be used as a sensitive method for changes in myocardial function.Virtuell disseksjon av hjertets bevegelser Nye ultralydmetoder kan måle ”strain” som uttykker regional funksjon av hjertemuskelen. Flere faktorer influerer disse målingene og noen av de ble belyst i avhandlingen. Siden ”strain” og ”strain rate” målinger har blitt innført i ultralyd av hjerte, mange studier har vist at det dreier seg om god reproduserbare parametere som kvantifiserer regional hjertemuskelbevegelse. Hjertets funksjon kan dermed måles på en helt ny måte og forskjellige hjertesykdommer kan muligens oppdages tidligere. Likevel er det mange faktorer som har innflytelse på ”strain” målinger uten å uttrykke forandring i hjertemuskelfunksjon. For å kunne tolke målingene riktig og for å forstå hva som er normalt og hva som er sykdomsrelatert, er det viktig å vite mer om influerende faktorer. Gris på forskjellige kroppsstørrelser ble undersøkt med ultralyd og ”strain” ble målt. Funnet var at grisene hadde minkende strain-verdier med økende kroppsstørrelse. Videre kunne vises at økende blodvolum øker og høy blodtrykk minsker både strain og strain rate. I den andre eksperimentelle studien på gris, ultralyd med høy opplyslighet ble gjennomført direkte på hjertemuskelen. Målet var å undersøke strain i forskjellige lag av hjertemuskelen ved forminsket ”flow” i vevet og samtidig påført medikamentell stress. Funnet var at strain aktiveres ved stress men er forskjellig i de ulike lag. I en klinisk studie hos hjerte-bypass pasienter hjertets funksjon ble undersøkt før og etter operasjon. Resultatet var at strain var en følsom metode for å oppdage mindre hjertemuskelskader og at strain økning ved en medikamentell stress test var en god indikator for funksjonsforbedring. Hvis man tar hensyn til de forskjellige faktorene som influerer strain målinger kan strain brukes som en følsom metode for å vise tidlige forandringer i hjertemuskelfunksjo

Transcatheter aortic valve implantation (from inception to standard treatment): a single-center observational study

Background: Treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) was introduced in 2002. Since then, TAVI has become the primary treatment approach worldwide for advanced-age patients and younger patients with severe comorbidities. We aimed to evaluate the changes in patient demographics, complications, and mortality rates within 13 years. Methods: This retrospective observational study included 867 patients who underwent TAVI at the University Hospital of North Norway in Tromsø from 2008 to 2021. The 13-year period was divided into period 1 (2008–2012), period 2 (2013–2017), and period 3 (2018–2021). The primary objective was to evaluate the changes in periprocedural (30 days), early (30–365 days), and late mortality rates (>365 days) between the periods. The secondary objective was to evaluate late mortality rates by sex and age groups: Results: The periprocedural mortality rates for periods 1, 2, and 3 were 10.3%, 2.9%, and 1.2%, respectively (P  Conclusion: Our findings indicate that most patients are octogenarians, and the burden of their comorbidities should be highly considered compared to their age when evaluating the procedural outcomes. As the incidence of most complications related to TAVI has decreased, the rates of permanent pacemaker implantation remain high. Important advancements in diagnostics, valve technology, and procedural techniques have improved the periprocedural mortality rates; however, early mortality remains unchanged and poses a clinical challenge that needs to be addressed in the future

Peak longitudinal strain most accurately reflects myocardial segmental viability following acute myocardial infarction - an experimental study in open-chest pigs

BACKGROUND: The extension and the transmurality of the myocardial infarction are of high predictive value for clinical outcome. The aim of the study was to characterize the ability of longitudinal, circumferential and radial strain measured by 2-dimensional speckle tracking echocardiography (2D-STE) to predict the extent of necrosis in myocardial segments following acute myocardial infarction and to separate transmural necrotic segments from non-transmural necrotic segments in a full 18-segment porcine model. METHODS: 2D-STE strain was assessed in long- and short-axis following myocardial infarction in ten open-chest anesthetized pigs. Strain was defined according to systolic peak values. In segments displaying both negative and positive peaks, only the peak with the highest absolute value was utilized. Necrosis was measured by 2,3,5-triphenyltetrazolium chloride (TTC) staining and expressed as percent of each myocardial segment. RESULTS: Significant correlations were found between the extension of necrosis and all measured parameters of myocardial deformation (p < 0.001), but was stronger for longitudinal strain (r(2) = 0.52) than circumferential strain (r(2) = 0.38) and radial strain (r(2) = 0.23). The area under the receiver operator characteristic curve (AUC) for separating transmural necrotic segments (>50% necrosis) from predominantly viable segments (0–50% necrosis) was significantly larger for longitudinal strain (AUC = 0.98, CI = 0.97–1.00) when compared with circumferential strain (AUC = 0.91, CI = 0.84–0.97, p < 0.05) and radial strain (AUC = 0.90, CI = 0.83 – 0.96, p < 0.01), indicating a stronger ability of longitudinal strain to identify segments with transmural necrosis. CONCLUSION: Peak strain values derived from 2D-STE correlate well with the extent of necrosis in myocardial segments following acute myocardial infarction. Longitudinal strain most accurately reflects myocardial segmental viability in this setting

Impact of Right Ventricular Geometry and Left Ventricular Hypertrophy on Right Ventricular Mechanics and Clinical Outcomes in Hypoplastic Left Heart Syndrome

Background - Right ventricular (RV) function is a major determinant of survival in hypoplastic left heart syndrome (HLHS). However, the relation of RV geometry to myocardial mechanics and their relation to transplant-free survival are incompletely characterized. Methods - We retrospectively studied 48 HLHS patients from the Hospital for Sick Children, Toronto, (median age, 2.2; interquartile range, 3.62 years) at different surgical stages. Patients were grouped by the presence (n = 23) or absence (n = 25) of RV “apical bulging” defined as a sigmoid-shaped septum with the RV leftward apical segment contiguous with the left ventricular (LV) lateral wall. Regional and global RV strain were measured using speckle-tracking echocardiography, and regional strains were analyzed for patterns and peak values. These were compared between HLHS anatomical subtypes and between patients with versus without apical bulging. We further investigated the association between RV geometry and dysfunction with the outcomes of heart failure, death, or transplant. Results - RV global (–7.3% ± 2.8% vs –11.2% ± 4.4%; P = .001), basal septal (–3.8% ± 3.2% vs –11.4% ± 5.8%; P = .0001) and apicolateral (–5.1% ± 3.5% vs –8.0% ± 5.8%, P = .001) longitudinal strain were lower in patients with versus without apical bulging, respectively. Apical bulging was equally prevalent in all HLHS anatomical variants. Twenty of 22 (91%) patients with apical bulging displayed hypertrophy of the LV apical and lateral segments. Death or transplantation were approximately equal in both groups but related to reduced RV global strain in patients with (seven of seven) and not in those without apical bulging (two of eight; P = .022). Conclusions - These results suggest that the finding of apical bulging is related to the presence of a hypertrophied hypoplastic LV, with a negative impact on regional and global RV function. Therefore, analysis of RV and LV geometry and mechanics may aid in the assessment and prognostication of this high-risk population

Echocardiographic assessment of diastolic dysfunction in elderly patients with severe aortic stenosis before and after aortic valve replacement

Background The 2016 guidelines of the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) for evaluation of left ventricular (LV) diastolic dysfunction by Doppler flow and tissue Doppler- echocardiography do not adjust assessment of high filling pressures for patients with aortic stenosis (AS). However, most of the studies on this patient group indicate age independent specific diastolic features in AS. The aim of this study is to identify disease-specific range and distribution of diastolic functional parameters and their ability to identify high N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels as a marker for high filling pressures. Methods In this study, 169 patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Resting echocardiography was performed including Doppler of the mitral inflow, pulmonary venous flow, tricuspid regurgitant flow and tissue Doppler in the mitral ring and indexed volume-estimates of the left atrium (LAVI). Echocardiography, and NT-proBNP levels were assessed before TAVR/SAVR and at two postoperative visits at 6 and 12 months. Results Pre- and postoperative values were septal e′; 5.1 ± 3.9, 5.2 ± 1.6 cm/s; lateral e′ 6.3 ± 2.1; 7.7 ± 2.7 cm/s; E/e′19 ± 8; 16 ± 7 cm/s; E velocity 96 ± 32; 95 ± 32 cm/s; LAVI 39 ± 8; 36 ± 8 ml/m2, pulmonary artery pressure (PAP) 39 ± 8; 36 ± 8 mmHg, respectively. The scoring recommended by ASE/EACVI detected elevated NT pro-BNP with a specificity of 25%. Adjusting thresholds towards PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E deceleration time  85%). Conclusion Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and NT-proBNP indicate elevated filling pressures in most of the patients, improving only modestly 6–12 months after TAVR and SAVR. Applying the 2016 ASE/EACVI recommendations for detection of elevated filling pressures to patients with AS, elevated NT pro-BNP levels could not be reliably detected. However, adjusting thresholds of the echocardiographic parameters increased specificities to useful diagnostic levels. Trial registration The study was prospectively approved by the regional ethical committee, REK North with the registration number: REK 2010/397-10

Predictors of early mortality after transcatheter aortic valve implantation

To investigate whether preoperative echocardiographic evaluation of ventricular function, especially right ventricular systolic and diastolic parameters including speckle-tracking analysis, could aid in the prediction of 30-day mortality after transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis.This is a prospective observational cohort study including 227 patients accepted for TAVI at the University Hospital of North Norway and Oslo University Hospital from February 2010 through June 2013. All patients underwent preoperative transthoracic echocardiography with retrospective speckle-tracking analysis. Primary endpoint was all-cause 30-day mortality.All-cause 30-day mortality was 8.7 % (n = 19). Independent predictors of 30-day mortality were systolic pulmonary arterial pressure (SPAP) &gt; 60 mm Hg (HR: 7.7, 95% CI: 1.90 to 31.3), heart failure (HR: 2.9, 95% CI: 1.1 to 7.78), transapical access (HR: 3.8, 95% CI: 1.3 to 11.2), peripheral artery disease (HR: 6.0, 95% CI: 2.0 to 18.0) and body mass index (HR: 0.73, 95% CI: 0.61 to 0.87). C-statistic for the model generated was 0.91 (95% CI: 0.85 to 0.98). Besides elevated SPAP, no other echocardiographic measurements were found to be an independent predictor of early mortality.Except for elevated systolic pulmonary artery pressure, our data suggests that clinical rather than echocardiographic parameters are useful predictors of 30-day mortality after TAVI

Predictors of early mortality after transcatheter aortic valve implantation

Objectives To investigate whether preoperative echocardiographic evaluation of ventricular function, especially right ventricular systolic and diastolic parameters including speckle-tracking analysis, could aid in the prediction of 30-day mortality after transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis. Methods This is a prospective observational cohort study including 227 patients accepted for TAVI at the University Hospital of North Norway and Oslo University Hospital from February 2010 through June 2013. All patients underwent preoperative transthoracic echocardiography with retrospective speckle-tracking analysis. Primary endpoint was all-cause 30-day mortality. Results All-cause 30-day mortality was 8.7 % (n = 19). Independent predictors of 30-day mortality were systolic pulmonary arterial pressure (SPAP) > 60 mm Hg (HR: 7.7, 95% CI: 1.90 to 31.3), heart failure (HR: 2.9, 95% CI: 1.1 to 7.78), transapical access (HR: 3.8, 95% CI: 1.3 to 11.2), peripheral artery disease (HR: 6.0, 95% CI: 2.0 to 18.0) and body mass index (HR: 0.73, 95% CI: 0.61 to 0.87). C-statistic for the model generated was 0.91 (95% CI: 0.85 to 0.98). Besides elevated SPAP, no other echocardiographic measurements were found to be an independent predictor of early mortality. Conclusion Except for elevated systolic pulmonary artery pressure, our data suggests that clinical rather than echocardiographic parameters are useful predictors of 30-day mortality after TAVI

Automatic measurements of left ventricular volumes and ejection fraction by artificial intelligence: clinical validation in real time and large databases

Aims - Echocardiography is a cornerstone in cardiac imaging, and left ventricular (LV) ejection fraction (EF) is a key parameter for patient management. Recent advances in artificial intelligence (AI) have enabled fully automatic measurements of LV volumes and EF both during scanning and in stored recordings. The aim of this study was to evaluate the impact of implementing AI measurements on acquisition and processing time and test–retest reproducibility compared with standard clinical workflow, as well as to study the agreement with reference in large internal and external databases. Methods and results - Fully automatic measurements of LV volumes and EF by a novel AI software were compared with manual measurements in the following clinical scenarios: (i) in real time use during scanning of 50 consecutive patients, (ii) in 40 subjects with repeated echocardiographic examinations and manual measurements by 4 readers, and (iii) in large internal and external research databases of 1881 and 849 subjects, respectively. Real-time AI measurements significantly reduced the total acquisition and processing time by 77% (median 5.3 min, P Conclusion - The software reduced the time taken to perform and volumetrically analyse routine echocardiograms without a decrease in accuracy compared with experts