Role of global longitudinal strain in discriminating variant forms of left ventricular hypertrophy and predicting mortality.

OBJECTIVE: In this study, we aimed to compare the functional adaptations of the left ventricle in variant forms of left ventricular hypertrophy (LVH) and to evaluate the use of two-dimensional speckle tracking echocardiography (2D-STE) in differential diagnosis and prognosis. METHODS: This was a prospective cohort study of 68 patients with LVH, including 20 patients with non-obstructive hypertrophic cardiomyopathy (HCM), 23 competitive top-level athletes free of cardiovascular disease, and 25 patients with hypertensive heart disease (HHD). All the subjects underwent 2D transthoracic echocardiography (TTE) and 2D-STE. The primary endpoint was all-cause mortality. Global longitudinal strain (GLS) below -12.5% was defined as severely reduced strain, -12.5% to -17.9% as mildly reduced strain, and above -18% as normal strain. RESULTS: The mean LV-GLS value was higher in athletes than in patients with HCM and HHD with the lowest value being in the HCM group (HCM: -11.4±2.2%; HHD: -13.6±2.6%; and athletes: -15.5±2.1%; p<0.001 among groups). LV-GLS below -12.5% distinguished HCM from others with 65% sensitivity and 77% specificity [area under curve (AUC)=0.808, 95% confidence interval (CI): 0.699-0.917, p<0.001]. The median follow-up duration was 6.4±1.1 years. Overall, 11 patients (16%) died. Seven of these were in the HHD group, and four were in the HCM group. The mean GLS value in patients who died was -11.8±1.5%. LV-GLS was significantly associated with mortality after adjusting age and sex via multiple analysis (RR=0.723, 95% CI: 0.537-0.974, p=0.033). Patients with GLS below -12.5% had a higher risk of all-cause mortality compared with that of patients with GLS above -12.5% according to Kaplan-Meier survival analysis for 7 years (29% vs. 9%; p=0.032). The LV-GLS value predicts mortality with 64% sensitivity and 70% specificity with a cut-off value of -12.5 (AUC=0.740, 95% CI: 0.617-0.863, p=0.012). CONCLUSION: The 2D-STE provides important information about the longitudinal systolic function of the myocardium. It may enable differentiation variable forms of LVH and predict prognosis.

Laparoscopic Sleeve Gastrectomy Outcomes of 750 Patients: A 2.5-Year Experience at a Bariatric Center of Excellence.

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide. This retrospective cohort study evaluated the outcomes of a large cohort of patients with obesity who underwent LSG in a Bariatric Center of Excellence. All consecutive patients who underwent LSG between July 2013 and April 2016 were identified retrospectively. Preoperative and postoperative variables and comorbidities were recorded. The study consisted of 750 patients. Their mean age was 37.4 years; 72% were women, and the mean body mass index was 42.8 kg/m. The most common preoperative comorbidities were diabetes (23.3%), hyperlipidemia (21.9%), hypertension (21.1%), and obstructive sleep apnea (21.1%). The rates of comorbidity resolution during follow-up were 80.6%, 74.4%, 82.9%, and 94.3%, respectively. The percentage average excess weight loss 1, 3, and 6 months and 1 and 2 years after surgery was 29.4%±11.3%, 54.4%±17.7%, 76.9%±20.9%, 85.5%±23.6%, and 89.7%±27.6%, respectively. There was no mortality. LSG effectively and safely induced weight loss and comorbidity resolution.

The evaluation of mitral valve stenosis: comparison of transthoracic echocardiography and cardiac magnetic resonance.

AIMS: Echocardiographic assessment of patients with mitral valve stenosis (MS) requires a detailed evaluation of mitral valve anatomy, mitral valve area (MVA), and pressure gradient and presence concomitant valve diseases. Our aim was to evaluate planimetric MVA and transmitral flow velocities using cardiac magnetic resonance (CMR) in patients with isolated MS and to compare with transthoracic echocardiography (TTE) to determine the reliability. METHODS AND RESULTS: Thirty-one patients (mean age 50.4 ± 10.2, 90.3% women) with isolated MS who were in a normal sinus rhythm were included in the study. Patients with ejection fraction <50%, atrial fibrillation, moderate-to-severe mitral valve insufficiency, moderate-to-severe stenosis and insufficiency of other valves, and previous commissurotomy and valvulotomy were excluded. Planimetric MVA and diastolic velocities were measured with TTE and CMR. There were strong correlations between measurements of planimetric MVA and transmitral diastolic velocities (P < 0.0001). Assessment of Bland-Altman analysis revealed strong agreement on measuring planimetric MVA with values -0.018 cm(2) (SD = 0.98 cm(2)) and the limits of agreement were -0.131 to 0.094. CONCLUSION: CMR is a reliable method in patients with MS for diagnosis and follow-up.

Association of mitral annular calcification with endothelial dysfunction, carotid intima-media thickness and serum fetuin-A: an observational study.

OBJECTIVE: Mitral annular calcification (MAC) is characterized by degenerative calcification of the mitral valve annulus. Atherosclerosis plays role in progression of MAC. Fetuin A is the inhibitor of pathological calcification. In the present study, we investigated the relationship between MAC and fetuin A with carotid intima media thickness (CIMT) and endothelial dysfunction. METHODS: In this observational cross-sectional study, 40 patients with documented MAC on transthoracic echocardiography and 40 without MAC were included. All patients had coronary artery disease (CAD). Endothelial functions were assessed by brachial artery Doppler ultrasound (USG) and carotid artery Doppler USG. Serum fetuin-A level was also measured. Linear regression analysis and receiver operator curve analysis were performed. RESULTS: Endothelial derived vasodilatory response (EDVR) was significantly decreased and CIMT value was increased in MAC group. There was a strong positive correlation between EDVR and serum fetuin-A value. There was a strong negative correlation between CIMT and EDVR, moderately negative correlation between CIMT and serum fetuin-A level. Simple linear regression analysis revealed that CIMT (ß=0.367, p=0.001) and serum fetuin-A level (ß=-0.291, p=0.009) were independent factors associated with MAC. The area under the curve (AUC) for serum fetuin-A level was 0.731 (95% 0.620-0.824) and AUC for CIMT was 0.724 (95% CI 0.613-0.818). CONCLUSION: We observed that MAC is closely related with CIMT and serum fetuin-A level. Serum fetuin-A and CIMT can be used as independent markers in the diagnosis of MAC. We suggest that MAC can be used as an early determinant of CAD.

Subclinical left ventricular systolic dysfunction in patients with mild-to-moderate rheumatic mitral stenosis and normal left ventricular ejection fraction: an observational study.

OBJECTIVE: Mitral valve stenosis (MS) remains as an important cause of morbidity despite evolution in diagnosis and treatment. Generally, left ventricular (LV) systolic functions are well preserved in patients with MS. However, there are some studies showing impaired LV systolic functions in patients with pure MS. The purpose of this study was to evaluate subclinical LV systolic dysfunction in a cohort of isolated mild-to-moderate MS patients with normal LV ejection fraction (EF) by using tissue Doppler imaging (TDI) and velocity vector imaging (VVI) techniques. METHODS: Fifty patients with isolated mild-to-moderate MS (84% female, mean age 49.1±10.0 years) and 60 healthy subjects (76.7% female, mean age 49.1±10.5) were included in this cross-sectional observational study. Conventional echocardiography, TDI, strain (S) and strain rate (SRs) analysis were performed in all patients. RESULTS: Transmitral mean pressure gradient was 6.4±3.0 mmHg and mean mitral valve area was 1.45±0.36 cm² in patients with MS. Both longitudinal and circumferential S and SRs were significantly reduced in patients with MS (p<0.001). TDI-derived parameters myocardial acceleration during isovolumic contraction (IVA) and peak velocity during systolic ejection (Sa) were also significantly decreased in patients with isolated MS (p<0.001). LV ejection fraction (EF) was not correlated with deformation indices. Deformation parameters were not correlated with transmitral gradient or mitral valve area. CONCLUSION: VVI-derived deformation parameters may identify subclinical systolic dysfunction in patients with isolated MS with normal EF. These findings may give way to optimal timing for mitral valve surgery.

Subclinical left and right ventricular systolic dysfunction in Behcet's disease: a combined tissue doppler and velocity vector imaging study.

BACKGROUND: Behcet's disease (BD) is a chronic inflammatory disease characterized by recurrent oral and genital ulcerations and ocular lesions. Subclinical cardiac involvement may develop in BD patients. We aimed to evaluate subclinical left ventricular (LV) and right ventricular (RV) systolic dysfunction in BD patients without any apparent cardiovascular disease. METHODS: We studied 50 BD patients (43.8 ± 9.7 years, 59% men) and 30 healthy controls (45.4 ± 8.2 years, 60% men). Conventional echocardiography, tissue Doppler imaging, and velocity vector imaging-based strain measurements were performed to analyze LV and RV systolic functions. RESULTS: LV isovolumic myocardial acceleration, peak systolic velocity during isovolumic contraction (isovolumic contraction velocity), were significantly lower, while myocardial performance index was increased in BD patients. RV peak systolic velocity, isovolumic myocardial acceleration, and isovolumic contraction velocity were also markedly lower in BD patients. LV and RV longitudinal peak systolic strain and strain rate were significantly lower in patients than in controls, demonstrating subclinical ventricular systolic dysfunction. CONCLUSIONS: Ventricular long-axis functions are important markers of myocardial contractility. Novel echocardiographic techniques may provide additional data for detecting early deterioration in ventricular systolic function in patients with BD.

Assessment of right ventricular endocardial dysfunction in mild-to-moderate mitral stenosis patients using velocity vector imaging.

PURPOSE: Right ventricular (RV) function plays an important role in the development of clinical symptoms, exercise capacity, prognosis, and survival in patients with mitral stenosis (MS). The purpose of this study was to evaluate global and regional RV systolic functions using a novel technique, VVI, in mild-to-moderate MS patients without clinical symptoms of heart failure. METHODS: The study population consisted of 60 patients (mean age 51.7 ± 11.6 years; 85% female) with isolated rheumatic mitral valve stenosis and 40 age- and sex-matched control subjects (mean age 49.1 ± 10.5 years; 76.7% female). Conventional echocardiography, tissue Doppler imaging (TDI), strain (S), and strain rate (SRs) analysis were performed in all patients. RESULTS: Transmitral mean pressure gradient was 6.1 ± 3.0 mmHg and mean mitral valve area was 1.41 ± 0.31 cm(2) in patients with MS. TDI systolic velocity was significantly lower in MS patients compared to control subjects (0.13 ± 0.03 m/sec vs. 0.17 ± 0.03 m/sec; P < 0.0001). RV-isovolumic acceleration was reduced in MS patients (3.75 ± 1.09 m/sec(2) vs. 4.62 ± 1.0 m/sec(2) ; P = 0.006). RV-myocardial performance index was significantly increased in patients with MS (0.75 ± 0.05 in MS and 0.29 ± 0.04 in controls; P < 0.0001) revealing impaired RV systolic and diastolic function. The mean longitudinal peak systolic S and SR were significantly reduced in patients with MS (P < 0.0001). CONCLUSION: Our data revealed that RV systolic performance is reduced in patients with mild-to-moderate MS.

Subclinical left ventricular dysfunction in asymptomatic chronic mitral regurgitation patients with normal ejection fraction: a combined tissue Doppler and velocity vector imaging-based study.

BACKGROUND: The optimal timing of the surgery in asymptomatic severe mitral regurgitation (MR) remains a challenge. The aim of the study is to evaluate the subclinical changes in LV longitudinal functions by using a novel strain imaging technique; velocity vector imaging (VVI); in patients with chronic MR. METHODS AND RESULTS: We studied 54 patients with asymptomatic, nonischemic, chronic MR (56.8 ± 9 years and 56% male) and 30 healthy controls (55 ± 6.5 years and 55% male) with normal ejection fraction. Patients with MR were analyzed in tertiles according to their regurgitant volumes (RV) and regurgitant fractions (RF): mild MR (RV < 30 mL, RF < 30% n = 7), moderate MR (RV: 30-59 mL, RF = 30-50%; n = 29), and severe MR (RV > 60 mL, RF ≥ 50%; n = 18). Conventional echocardiography and VVI-based strain imaging were performed to analyze LV functions. LV longitudinal peak systolic strain and strain rate (SRs) were significantly impaired in moderate and severe MR patients. Changes in LV longitudinal deformation were more significant in patients with severe MR. All deformation parameters showed a marked negative correlation with RV (LV Strain r =-0.583, P = 0.0001; LV SR r =-0.408, P = 0.002, respectively). CONCLUSIONS: LV long-axis functions are important markers of LV contractility in MR patients. Novel echocardiographic techniques may provide additional data on subclinical changes in the LV and give way to the optimal timing for the surgery in severe MR patients.

Progressive subclinical left ventricular systolic dysfunction in severe aortic regurgitation patients with normal ejection fraction: a 24 months follow-up velocity vector imaging study.

OBJECTIVES: We aimed to evaluate long-term changes in left ventricular (LV) longitudinal systolic functions in patients with asymptomatic, severe aortic regurgitation (AR) by using novel 2D strain imaging. METHODS AND RESULTS: Thirty severe AR patients with normal ejection fraction (EF) and 30 healthy controls were evaluated by both conventional echocardiography and velocity vector maging (VVI) based strain imaging at baseline and 24 months follow-up. To evaluate LV longitudinal systolic function, segmental peak systolic strain and strain rate (SRs) data were acquired from apical four-chamber, two-chamber and long-axis views. Longitudinal peak systolic strain and SRs of the LV were decreased in patients with severe AR compared to controls at baseline (P = 0.0001). The impairment was more significant in 24 months follow-up (P = 0.0001 for strain, P = 0.01 for SRs). Longitudinal peak systolic strain was significantly correlated with left ventricular end-diastolic (LVEDD; r =-0.42, P = 0.0001) and left ventricular end-systolic diameter (LVESD) (r =-0.41, P = 0.0001) There was also a strong negative correlation between LV SRs and LVEDD (r =-0.50, P = 0.0001), and LVESD (r =-0.39, P = 0.0001). CONCLUSIONS: VVI-derived strain and SRs may be used as adjunctive, noninvasive parameters in the assessment of subclinical LV dysfunction and its progress during clinical follow-up, in patients with severe AR.

The impact of body mass index on right ventricular systolic functions in normal and mildly obese healthy patients: a velocity vector imaging study.

BACKGROUND: Increasing prevalence of obesity is a significant problem in Western countries. Obesity has many effects on cardiovascular structure, function, and hemodynamics. Our aim was to compare the impact of body mass index (BMI) on right ventricular (RV) functions among healthy subjects with conventional echocardiography, tissue Doppler imaging (TDI), and velocity vector imaging (VVI). METHODS: Eighty-one healthy subjects divided into three group according to their BMI. All subjects were evaluated by conventional echocardiography, TDI, and VVI. A full polysomnogram were performed in subjects with BMI ≥ 30 km/m(2). RESULTS: RV end-diastolic and end-systolic diameters of patients in these three groups were similar (P > 0.05). There were no differences between each group in RV outflow tract fractional shortening (P = 0.52) and tricuspid annular plane systolic excursion (P = 0.94). No correlation observed between BMI and RV systolic parameters obtained with TDI. Longitudinal peak systolic strain and SRs were similar in all groups through each segment (P > 0.05). CONCLUSION: The results of our study show no changes in the RV functions in obese and overweight who were otherwise healthy subjects. We also revealed a significant correlation between BMI and left ventricular diameters and wall thickness but no relation with RV diameters or functions.

Assessment of right atrial pressure using echocardiography and correlation with catheterization.

PURPOSE: Right ventricular systolic pressure is crucial for both treatment and prognosis of cardiovascular and pulmonary diseases. The proper measurement of right ventricular systolic pressure depends on an accurate estimation of right atrial pressure (RAP). There is no standard method for estimating RAP noninvasively. The purpose of this study was to compare different noninvasive methods, namely, inferior vena cava (IVC) size and inspiratory collapse, tissue Doppler derived E/E' (TV E/E') for estimating RAP, and their correlation with catheter-based measurements in patients with mitral valve stenosis with atrial fibrillation (AF) or normal sinus rhythm (NSR). METHODS: The study group consisted of 39 patients (13 men, mean age 58.9 ± 11.8 years) with rheumatic mitral valve stenosis. We performed cardiac catheterization and transthoracic echocardiography on all patients. RESULTS: Mean RAP measured by catheterization was 9.7 ± 3.8 mmHg. No correlation was found between RAP and TV E/E' ratio, but there was a significant correlation between RAP and IVC diameter (r = 0.51, p < 0.05). Seventeen patients (43.6%) were in AF and 22 patients (56.4%) were in NSR. There was no correlation between TV E/E' ratio and RAP in patients with AF and in patients with NSR. RAP was correlated with collapsibility index in patients with AF (r = 0.56, p < 0.05). RAP was significantly correlated with IVC diameter (r = 0.62, p < 0.005) and collapsibility index (r = 0.49, p < 0.05) in patients with NSR. CONCLUSIONS: The combination of IVC diameter and collapsibility index is a simple a semiquantitative approach that might provide a better estimation of RAP.

[Evaluation of left ventricular regional systolic functions in patients with coronary artery disease by two-dimensional strain imaging: a velocity vector imaging study]. / Koroner arter hastalarinda sol ventrikül bölgesel sistolik fonksiyonlarinin ikiboyutlu gerilim (strain) görüntüleme ile degerlendirilmesi: Hiz vektör görüntüleme çalismasi

OBJECTIVES: The aim of the study was to assess left ventricular (LV) regional systolic functions in coronary artery disease (CAD) using a novel strain imaging method, namely, velocity vector imaging (VVI). STUDY DESIGN: The study included 69 patients (51 men, 18 women; mean age 52.9±10.3 years) with CAD and 30 healthy volunteers (22 men, 8 women; mean age 58.1±13.8 years). Thirty-three patients had previous myocardial infarction (MI). In all the patients, LV wall motions were analyzed as akinetic, hypokinetic, or normokinetic using the 16-segment model of the American Heart Association. In addition, LV peak systolic strain, strain rate (SRs), and segmental ejection fraction (SEF) of all the segments were calculated by using VVI. RESULTS: Patients with MI had significantly lower mean peak systolic strain, SRs, and SEF compared to patients without MI and controls (p=0.0001). The presence of multivessel disease was accompanied by significantly decreased peak systolic strain (p=0.04), SRs (p=0.02), and SEF (p=0.0001). Myocardial segments affected by subtotal/total occlusion (≥99%) had lower peak systolic strain (p=0.02), SRs (p=0.001), and SEF (p=0.0001) values compared to segments with less severe occlusion. In segmental analysis, longitudinal deformation was most significant in akinetic segments (p=0.0001), but hypokinetic and normokinetic segments also differed significantly with respect to deformation (for strain, p=0.01; for SRs and SEF, p=0.0001). Moreover, deformation in the normokinetic segments was more significant than normal segments of the controls (for strain, p=0.02; for SRs and SEF, p=0.0001). CONCLUSION: Velocity vector imaging allows regional deformation analysis for quantitative assessment of regional LV systolic functions; this technique may be more reliable than conventional echocardiography in determining wall motion abnormalities.

Preoperative left atrial mechanical dysfunction predicts postoperative atrial fibrillation after coronary artery bypass graft operation ­ a velocity vector imaging-based study ­.

BACKGROUND: The aim of the present study was to evaluate pre-existent subclinical mechanical atrial dysfunction in patients with postoperative atrial fibrillation (POAF) by using novel echocardiographic techniques. METHODS AND RESULTS: Ninety-six patients with sinus rhythm, undergoing coronary artery bypass graft (CABG) operation were prospectively enrolled. Preoperative left atrial (LA) reservoir, conduit and booster functions were evaluated by 3 different methods: conventional echocardiography, tissue Doppler imaging (TDI), and 2-dimensional strain imaging based-velocity vector imaging (VVI). POAF occurred in 25 out of 96 patients (26%). LA volume index (LAVI) was the only conventional parameter associated with POAF. TDI-derived LA velocities were similar in study groups. In VVI analysis, LA systolic strain, strain rate (SRs) and early diastolic strain rate (ESRd) were impaired in patients who developed POAF after CABG (P=0.0001). Age, LAVI, LA peak systolic strain, SRs and ESRd were found to be the independent predictors of POAF. The optimal cut-off point of 44.0% (88.7% sensitivity, 96% specificity) for LA strain, 1.7 s(-1) (88% sensitivity, 86.2% specificity) for SRs and 1.95 s(-1) (sensitivity 72%, 70.4% specificity) for ESRd predicted POAF in this study. CONCLUSIONS: VVI-derived strain imaging could be used as an adjunctive non-invasive method for evaluating subclinical atrial mechanical dysfunction in patients undergoing CABG. This might help us to identify patients with high risk of POAF in clinical practice.

Impact of myocardial acceleration during isovolumic contraction in evaluating subclinical right ventricular systolic dysfunction in type 2 diabetes mellitus patients.

AIM: In diabetes mellitus (DM) patients, left ventricular dysfunction is widely evaluated and established by conventional diagnostic methods, whereas right ventricular (RV) function is not as sufficiently evaluated. The aim of this study is to assess the preclinical effects of DM on RV function by using novel Tissue Doppler Imaging (TDI)-derived indices. METHODS: The study included 96 patients with type II DM [60 with DM only and 36 patients with coexisting DM and hypertension (DMHT)] and 40 healthy controls. Conventional parameters and TDI-derived systolic velocities of tricuspid annulus [isovolumic myocardial acceleration (IVA), peak myocardial velocity during isovolumic contraction (IVV), peak systolic velocity during ejection period (Sa), RV Tei index] were measured. RESULTS: TDI-derived RV IVA was significantly lower in both DM and DMHT patients compared to controls indicating subclinical impairment in RV systolic function in the study patients (P = 0,0001). However RV IVA was similar in DM and DMHT subgroup supporting RV systolic impairment in DM was independent from HT. In correlation analysis, RV IVA was significantly correlated with the existence of diabetic nephropathy (r =-0,38; P = 0,003), retinopathy (r =-0,35; P = 0,006), insulin resistance (r =-0,52; P = 0,0001). CONCLUSIONS: Diabetes is associated with subclinical RV systolic dysfunction, regardless of coexisting hypertension. Tissue Doppler-derived IVA; is a novel, non-invasive parameter which may be used in early detection of RV systolic dysfunction in patients with DM.

Subclinical left ventricular dysfunction in asymptomatic severe aortic regurgitation patients with normal ejection fraction: a combined tissue Doppler and velocity vector imaging study.

OBJECTIVES: Our aim was to evaluate subclinical left ventricular (LV) dysfunction, by two novel echocardiographic techniques, velocity vector imaging (VVI)-derived strain imaging and tissue Doppler imaging (TDI), in patients with asymptomatic, severe aortic regurgitation (AR). METHODS: Forty patients with severe AR with normal ejection fraction and 30 controls were included to the study. All patients underwent a standard echocardiography extended with TDI and VVI analyses. To evaluate the LV longitudinal and circumferential deformation, segmental systolic peak strain and strain rate (SRs) data were acquired from parasternal short axis, apical four-chamber, two-chamber, and long axis views, and additionally LV myocardial velocities, isovolumic myocardial acceleration (IVA), peak systolic velocity (Sa) and peak myocardial velocity during isovolumic contraction (IVV) assessed by TDI. RESULTS: IVA was the only TDI-derived parameter which was significantly impaired in AR patients (P = 0.0001). Both longitudinal and circumferential strain and SRs of the LV were significantly decreased in patients with severe AR (P = 0.0001). Longitudinal and circumferential strain/SRs and TDI-derived LV IVA were inversely correlated with LV end-diastolic diameter (P = 0.0001) and end-systolic diameter (P = 0.0001). TDI-derived IVA was also very well correlated with longitudinal deformation parameters (P = 0.0001). CONCLUSIONS: VVI- derived strain imaging and TDI-derived IVA may be used as adjunctive, reliable, noninvasive parameters for evaluating subclinical ventricular dysfunction in patients with chronic, severe AR. This may help to identify patients for closer follow-up and to determine the need for surgery before developing irreversible, severe heart failure.