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Infiltrative Cardiomyopathies
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Arthur Qi, Quynh Nguyen, Haran Yogasundaram, Gavin Y. Oudit
A standard electrocardiogram may identify conduction abnormalities.42 Echocardiography can provide information on systolic and diastolic function, pericardial abnormalities, or valvular structure and function. Pseudo-normal or restrictive filling can be detected in early-stage IOC.43 Later, echocardiography can reveal dilated phenotypes, characterized by ventricular dilatation and reduced LVEF, or restrictive phenotypes, characterized by dilatation of the left atrium and RV with preserved LVEF. However, conventional measures of systolic and diastolic function such as end-systolic volume, end-diastolic volume, EF, or fractional shortening are not sufficiently sensitive to detect early myocardial iron overload.43 Strain and strain rate imaging allows for measurement of regional or global function of the myocardium and is more sensitive for evaluating subtle systolic and diastolic dysfunctions.65
Survivorship: Pediatric cancer survivors
Published in Susan F. Dent, Practical Cardio-Oncology, 2019
Shahnawaz Amdani, Neha Bansal, Emma Rachel Lipshultz, Michael Jacob Adams, Steven E. Lipshultz
The most common measures used in serial follow-up of patients with anthracycline-related cardiomyopathy are LVFS and LVEF (113). However, as mentioned previously, these measures may not detect subclinical cardiotoxicity, which may occur in up to 60% of treated patients (128). Moreover, LVFS and LVEF are load-dependent measures. Recently, strain and strain-rate imaging measured by speckle tracking echocardiography has been used. Among 56 asymptomatic patients evaluated 2–15 years after anthracycline treatment (doses <300 mg/m2), although traditional measures of ventricular function (LVFS and LVEF) did not differ, systolic myocardial deformation decreased, as did radial and longitudinal peak systolic strain (69). However, long-term evaluations of pediatric cancer survivors exposed to cancer chemotherapeutics using strain imaging have not been validated.
Left-ventricular dysfunction in mitral stenosis
Published in Neeraj Parakh, Ravi S. Math, Vivek Chaturvedi, Mitral Stenosis, 2018
Echocardiography enables noninvasive assessment of the LV geometry and contractility. Initial studies used M-mode echocardiography.19,20 They found that indices of LV performance such as cardiac output, ejection fraction, and Vcf were reduced in patients with severe MS. Mohan et al. noted21 that the LV tended to be more spherical than ellipsoid in patients with isolated MS. Measurement of EF and LV volumes is highly subjective and variable. Load-independent indices such as tissue Doppler imaging (TDI) and strain rate imaging have been studied. Using TDI, Ozdemir et al.22 demonstrated that myocardial velocities of the LV in the long axis were reduced even in patients with normal ejection fraction. Subsequently, Dogan et al.23 using Doppler-derived strain rate imaging demonstrated that in patients with mild to moderate MS with normal global systolic function, the peak-systolic strain rate and end-systolic strain was significantly reduced as compared to controls. The impaired long-axis function despite normal systolic function indicated subclinical LV dysfunction. Since Doppler-derived strain is angle-dependent, Aydan et al.24 used 2D strain and strain rate imaging with speckle tracking, which is angle-independent. Among patients with mild to moderate MS with normal LV systolic function, the mean global longitudinal strain (GLS) and global longitudinal strain rate (GLSR) were significantly reduced in patients with isolated MS. Regional analysis demonstrated significantly reduced longitudinal peak strain and strain rate in all the basal segments and in some of the mid-segments (inferior, anteroseptal, interventricular septum) of the LV. The authors felt that a possible extension of the rheumatic process from the mitral valve to the basal segments could explain the reduced strain and strain rate in these areas. Bilen et al.25 included cases of severe MS (in addition to mild and moderate MS) with normal LV function as well. They noted similar reduction in LV global strain and strain rate in MS patients and this was independent of the hemodynamic severity of the obstruction. They felt that the most probable reason for this was rheumatic myocardial involvement.
Adjuvant radiotherapy-induced cardiac changes among patients with early breast cancer: a three-year follow-up study*
Published in Acta Oncologica, 2019
Tanja Skyttä, Suvi Tuohinen, Tiina Luukkaala, Vesa Virtanen, Pekka Raatikainen, Pirkko-Liisa Kellokumpu-Lehtinen
GLS is shown to be superior to LVEF in detecting early LV systolic dysfunction [25,26]. In our patients, we observed changes in LV systolic function measurements immediately after RT in GLS. At 3 years, the systolic impairment had elaborated in GLS, LVEF and SV especially in left-sided patients. Similarly, Erven et al. [10] observed subclinical changes in LV systolic function measured with strain rate imaging immediately after RT as well as at 8 and 14 months after RT. However, all patients in their study had received prior chemotherapy. Lo et al. [12] reported similar strain imaging changes in chemo-naïve patients immediately and at 6 weeks after RT. The same group has later published a more detailed dose-related segmental strain correlation [27]. The long-term results of these patients are awaited. Heggemann et al. [11] reported echocardiography and cardiac MRI results from 49 left-sided breast cancer patients (20/49 with previous chemotherapy) at 6, 12 and 24 months after RT compared to baseline. They observed, similar to our findings, significant changes in longitudinal strain. These aforementioned studies did not report the correlations of other risk factors to the observed cardiac changes. In our patients, the concurrent use of AI during RT was associated with the GLS impairment.
Propulsion of blood through the right heart circulatory system
Published in Scandinavian Cardiovascular Journal, 2018
Torvind Næsheim, Ole-Jakob How, Truls Myrmel
A multitude of studies have described the right atrium in various manipulated and disease states (e.g. [21–24]). The overall conclusion has to be that more than anything, the observations of pressure [23,24] and deformation (contraction and stretch) [19,25] in the right atrium must be interpreted in the context of the function of the venous system, right ventricle and pulmonary circulation [22]. For instance, using modern echocardiography with sensitive strain and strain rate imaging, Saha and colleges [22] demonstrated how the strain of the right atrium directly reflect the pulmonary pressure and resistance in patients with idiopathic pulmonary hypertension. Likewise, opening the pericardium during cardiac surgery distort the tricuspid annular plane systolic excursion, results in a dilation of the right atrium and reduced respiratory variation of the inferior vena cava [19]. These alterations occur with no sign of reduced cardiac output and is even accompanied by an improved overall function after coronary surgery [19]. As this can be seen in direct relation to pericardial opening [25], these parameters probably reflect that the thin-walled right atrium is most sensitive to the altered constrain following pericardial incision [19,23].
Evaluation of the right ventricle by echocardiography: particularities and major challenges
Published in Expert Review of Cardiovascular Therapy, 2018
Compared to the LV, RV wall motion assessment by conventional 2D- and 3D-ECHO is more difficult because RV radial thickening and circumferential shortening, being less pronounced than longitudinal shortening, are often insufficient to generate good visible free wall inward movement, whereas longitudinal shortening is usually less visible with the naked eye. Additionally, wall motion measurements (displacement and velocity) by conventional ECHO-techniques cannot differentiate between active and passive movement of a myocardial segment, irrespective whether the evaluated chamber is the LV or RV [2,32]. To a great extent, these limitations can be overcome by strain imaging. Unlike wall motion displacement or velocity, strain (myocardial deformation) is unaffected by the motion of the entire heart and deformation analysis (strain and strain rate imaging) allows distinction between active and passive myocardial tissue movement [32,50]. Angle-independent speckle-tracking echocardiography (STE)-derived strain imaging parameters, which are also less sensitive to signal noise, are particularly useful for assessment of RV contractile function [50–55]. Especially the RV global and RV free wall peak systolic longitudinal strain (PSSL) and strain rate (PSSrL) appeared useful for evaluation of RV contractile function and showed also valuable prognostic value for cardiovascular morbidity and mortality [56–58]. Strain and strain-rate can also be used for the assessment of RV intraventricular dyssynchrony, a new promising approach to the evaluation of RV dysfunction in patients with different cardiac conditions. RV assessment by 3D-STE appeared particularly useful because 3D-STE can reveal also the relative contribution of segmental deformation heterogeneity to the global RV systolic function [3,59,60]. Main limitations of STE are dependency on image quality, relatively low temporal resolution, and segmental reproducibility of measurements (especially for 3D-STE), as well as the influence of RV loading conditions especially on myocardial strain values [32,50]. Both free wall and global RV longitudinal strain showed better correlation with MRI-derived RVEF measurements in comparison with the traditional FACRV, TAPSE, or TAPS’ measurements [34]. Global PSSL also showed good correlation with the right heart catheterization (RHC)-derived SWIRV and 6-min walk distance (6MWD) [51,52]. The longitudinal systolic strain of the RV free wall also showed high predicting value for RVF after LVAD implantation but the RV strain data show high heterogeneity [61]. For proper interpretation of STE data, it is mandatory to be aware of their load dependency [50,62]. In patients with pulmonary arterial hypertension (PAH) it was found that RV longitudinal strain and strain rate correlate not only with 6MWD, but also with invasive hemodynamic parameters, and decrease of both mPAP and PVR after treatment was associated with improvement of right ventricle longitudinal strain (RVLS)[63]. Overall, due to the lack of normative data and insufficient validation, STE is yet not recommended for routine clinical use in assessment of RV contractile function [7]. Table 1 shows an overview on the major limitations and challenges in ECHO-assessment of RV function.