Evaluation of the Left Ventricular Myocardium Using Layer-Specific Strain Analysis in Adolescent Athletes Performing High-Intensity Interval Training.

High-intensity interval training (HIIT) has been demonstrated to be an efficient way of improving physical performance in adolescent athletes compared to conventional training modalities. The objective of this study was to evaluate the impact of HIIT on the myocardial function of adolescent athletes, specifically focusing on left ventricular (LV) function, using conventional echocardiography and layer-specific strain (LSS) analysis. A total of 19 male adolescent athletes (with mean age of 16.83 ± 1.29 years) participating in various football clubs were recruited for this study. During the course of 8 weeks, these adolescent male athletes engaged in HIIT program centered around running. Upon completion of HIIT program, a treadmill exercise test was conducted. Subsequently, conventional and LSS echocardiography were conducted to acquire the evaluation of LV myocardial function. Interventricular septum thickness and ventricular mass index were significantly increased post high-intensity interval training (p < 0.005). After the HIIT, the treadmill exercise test demonstrated a significant increase in test duration and metabolic equivalent compared to the pre-training values (p < 0.005). Post high-intensity interval training, LSS analysis revealed significantly improved LV circumferential strain values in the basal and mid-segments of the left ventricle when compared to the pre-training measurements (p < 0.005). The implementation of high-intensity interval training led to an enhancement of circumferential LSS in the LV, indicating a favorable physiological adaptation and improved efficiency of the myocardium.

Evaluation of Early Repolarization Pattern in Male Teenage Competitive Athletes and Association With Left Ventricular Remodeling.

OBJECTIVE: Early repolarization pattern (ERP) on electrocardiogram is more common among young athletes than in the general population, and has been considered a benign finding. However, ERP has been associated with increased risk of sudden cardiac death. The objectives of this study were to evaluate ERP in teenage athletes; investigate associations between ERP and echocardiographic findings of the left ventricle (LV); and to describe the impact of different sports disciplines on ERP. METHODS: ERP was assessed in male teenage athletes from sports institutions for 5 different types of sport--basketball, swimming, football, wrestling, and tennis. All had been training for at least 3 hours per week for over at least 2 years. ERP was defined as J-point elevation ≥ 1 mV in 2 contiguous and/or lateral leads. A conventional echocardiography was performed in all athletes. RESULTS: ERP was evaluated in 159 athletes with a mean age of 14 (range 10-18 years). It was more common in those training with combined exercise. There was no association between ERP and echocardiographic findings of left ventricular remodeling and geometric pattern. CONCLUSION: ERP is a frequent finding among teenage athletes. However, frequency varies by sports type, being more common in those training with combined exercise. It is not associated with structural echocardiographic alterations and is primarily seen as an electrophysiological change.

Obstructive sleep apnea syndrome is associated with impaired pulmonary artery distensibility and right ventricular systolic dysfunction

Background/aim: We investigated whether obstructive sleep apnea syndrome (OSAS) has any impact on pulmonary artery distensibility (PAD) and right ventricular (RV) function. Materials and methods: Subjects were categorized according to apnea­hypopnea index (AHI) as follows: controls (n = 17 and AHI < 5), mild-to-moderate OSAS (n = 22 and AHI = 5­30), and severe OSAS (n = 29 and AHI > 30). All subjects underwent transthoracic echocardiography after polysomnography to assess PAD and RV function. PAD was recorded as M-Mode trace of the right pulmonary artery and was defined as (PAmax ­PAmin/PAmin) × 100. S' was measured by means of TDI of the lateral annulus of the RV using apical four-chamber view. Results: Patients with severe OSAS demonstrated impaired RV longitudinal systolic function (S') compared to the other groups (P < 0.05). Impaired pulmonary vasculature elastic properties as reflected by decreased PAD were more prevalent in severe OSAS (26.2 ± 5.7%) compared to the controls (29.9 ± 4.6%; P < 0.05) and mild-to-moderate OSAS (29.0 ± 4.1%; P < 0.05). An inverse relation between PAD (P < 0.05), RV myocardial performance index (MPI) (P < 0.05), and AHI was demonstrated. S' also correlated with PAD (P < 0.05). Conclusion: PAD is a significant tool to evaluate pulmonary vasculature stiffening and is well correlated with disease severity in OSAS. Further, impaired PAD may lead to RV systolic dysfunction.

Subclinical anthracycline-induced cardiotoxicity in long-term follow-up of asymptomatic childhood cancer survivors: Assessment by speckle tracking echocardiography.

OBJECTIVE: Survivors of childhood cancer treated with anthracyclines carry the risk for developing late-onset cardiotoxicity. The purpose of this study was to evaluate left ventricular (LV) function in this patient group and compare it with healthy controls by means of conventional and speckle tracking echocardiography (STE) after exposure to chemotherapy. MATERIAL AND METHODS: Conventional and STE were performed in 45 childhood cancer survivors (mean age 11 ± 4.6; 26 male) treated with anthracyclines (median cumulative dosage 240 mg/m2 ; range, 100-460) and compared with age, gender and body surface area matched healthy controls. Follow-up period after chemotherapy was 21.9 ± 17.8 months. Blood samples were taken from survivors and controls to determine brain natriuretic peptide (BNP). RESULTS: Following anthracycline exposure, pediatric cancer survivors had lower longitudinal, radial anteroseptal, and radial anterior strain values compared to controls (P < .05). The calculated global longitudinal and global radial strain values were lower compared to the control group (P < .05). Both groups had normal ejection fraction (EF) and fractional shortening (FS). Brain natriuretic peptide (BNP) levels of both groups were in the normal range. CONCLUSION: Despite normal EF and FS, children exposed to anthracycline therapy may have late-onset subtle changes of LV strain values measured by STE. Whether these changes of strain can predict future risk of developing heart failure needs to be explored in further studies.

Left atrial remodelling may predict exercise capacity in obstructive sleep apnoea patients.

BACKGROUND: Left atrial volume (LAV) and LA deformation has been proposed as a good marker of exercise performance in patients with diastolic dysfunction (DD). As DD is more prevalent in obstructive sleep apnoea (OSA) we aimed to evaluate the influence of LAV and LA deformation parameters on exercise performance in varying severity of OSA. MATERIALS AND METHODS: OSA was diagnosed after polysomnography. Fifty-five OSA patients were enrolled in the study. OSA patients were divided into two groups with apnoea-hypopna-index (AHI) > 30 and <30. LAV was calculated. LA strain and LA strain rates were assessed with speckle tracking echocardiography (STE). Exercise capacity was evaluated by treadmill exercise test. RESULTS: MET values were lower in group II compared to group I (p < .05). Echocardiographic findings: Comparison within groups: In both groups E/E', LA stain, LA strain rate S and LA strain rate E were higher after exercise than before (p < .05). In group I LA strain rate A was higher after exercise than before (p < .05). Comparison between groups: LA strain, LA strain rate S, LA strain rate E and LA strain rate A were lower and E/E' and LAVI were higher in group II compared to group I before and after exercise (p < .05). Correlation with METs: AHI, LVEDV, E/E' and LAVI were negatively and LA strain was positively correlated with METs (p < .05). CONCLUSIONS: Left ventricular diastolic dysfunction is more prevalent in severe OSA and is associated with impaired exercise performance. Additionally, LA remodelling may predict exercise capacity in this subgroup of patients.

Left ventricular torsion in patients with obstructive sleep apnoea before and after continuous positive airway pressure therapy: assessment by two-dimensional speckle tracking echocardiography.

BACKGROUND: The purpose of the present study was to evaluate how obstructive sleep apnoea (OSA) influences left ventricular (LV) torsion and whether nasal continuous positive airway pressure (CPAP) therapy has any impact on LV torsion in OSA patients with established cardiovascular risk factors. METHODS: LV torsion was assessed by two-dimensional speckle tracking echocardiography (STE) in 162 participants without overt cardiovascular disease. The participants were categorized according to the apnoea-hypopnea index (AHI) as controls and mild, moderate and severe OSA patients. Forty-three patients with AHI greater than 30 were enrolled to receive CPAP therapy for 24 weeks. Twenty-eight patients received CPAP therapy effectively (compliance: 65%). After completion of CPAP therapy, STE was repeated to evaluate LV torsion. RESULTS: LV torsion was decreased in the severe OSA group compared to mild and moderate OSA but was similar to controls as a result of predominant decrease in apical rotation. AHI had no correlation with LV torsion in moderate OSA but a significant and mild negative correlation with LV torsion in severe OSA. When adjusted for potential confounding variables such as left ventricular mass index, diastolic dysfunction and the presence of hypertension, AHI and E/E' remained significant predictors of LV torsion in OSA patients. LV apical rotation tended to increase after effective CPAP therapy. On the other hand, LV basal rotation decreased significantly. CONCLUSIONS: LV torsion was altered in OSA patients with varying degrees according to the disease severity. Furthermore, there was no significant change of torsion after 24 weeks of CPAP therapy.

Epicardial fat thickness regression with continuous positive airway pressure therapy in patients with obstructive sleep apnea: assessment by two-dimensional echocardiography.

BACKGROUND: Obstructive sleep apnea (OSA) is a common syndrome in patients with metabolic syndrome (MetS). Epicardial fat thickness (EFT), an indicator of visceral adiposity, is a novel parameter for studying patients with OSA. Our aim was to investigate the effects of continuous positive airway pressure therapy (CPAP) therapy on EFT. METHODS: A total of 162 subjects (68 women and 94 men) were included and divided into three groups: Group I: Apnea-hypopnea index (AHI) < 5 (n = 45), Group II: AHI 5-15 (n = 22), and Group III: AHI > 15 (n = 95). All participants underwent full-night polysomnography and transthoracic echocardiography. There were 28 symptomatic patients with AHI > 15 who received compliant CPAP therapy for 24 weeks. RESULTS: MetS was more frequent, and systolic blood pressure (SBP), diastolic blood pressure (DBP), blood glucose were higher in Group III compared with I (p < 0.05). High-density lipoprotein (HDL) levels were lower in Group III compared with I (p < 0.05). Triglyceride levels and waist circumference were higher in Group III compared with I and II (p < 0.05). EFT was higher in Group III compared with I and higher in Group II compared with I (p < 0.05). EFT was predicted by MetS and AHI. After CPAP therapy high-sensitive C-reactive protein (hsCRP) and EFT were reduced (p < 0.05). CONCLUSION: EFT was significantly higher in patients with AHI > 15 and predicted by MetS and AHI. CPAP therapy reduced hsCRP levels and EFT.

Loeffler endocarditis: silent right ventricular myocardium!

We present the case of a 54-year-old male patient with Loeffler endocarditis. It is a rare disorder characterized by fibrous thickening of the endocardium leading to apical obliteration and restrictive cardiomyopathy resulting in heart failure, thromboembolic events or atrial fibrillation. To the best of our knowledge, this is the first case reporting the electrical silence of the right ventricular (RV) apex caused by fibrothrombotic thickening of this area. Under these circumstances RV apical implantation of an implantable cardioverter defibrillator (ICD) or pacemaker electrode may lead to unsuccessful stimulation of these devices.

Assessment of left atrial appendage function during sinus rhythm in patients with obstructive sleep apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) is associated with thromboembolic events. Compromised left atrial appendage (LAA) function due to left ventricular (LV) performance abnormality, often present in patients with OSA, may play an important role. The purpose of this study is to evaluate LV and LAA mechanical functions during sinus rhythm (SR) in patients with OSA. METHODS: LV and LAA functions were assessed in 43 OSA patients and compared with that of 20 control patients in SR. Tissue Doppler velocities of the LAA apex and emptying velocities (EV) of LAA were obtained on parasternal short-axis view. RESULTS: The baseline clinical characteristics were similar except for AHI (apnea-hypopnea index), minimal SaO2, mean SaO2, hypertension, and body-surface area. Most of the LV echocardiographic parameters significantly deteriorated in OSA patients in comparison with those in the control group. LAA EV, LAA systolic relaxation velocity (SM), LAA early-diastolic velocity (EM), LAA contraction velocity (AM), left atrial (LA) minimum volume index, LA ejection fraction, LA conduit volume index, and LA reservoir volume index were lower in OSA patients compared with those in the control group (p<0.05). LAA AM was negatively correlated with AHI and the ratio of peak early diastolic flow velocity (E) to early-diastolic (E') and positively correlated with LA conduit volume (p<0.05). Multiple predictors for LAA AM were AHI, presence of diastolic dysfunction, and E/E' values (p<0.05). CONCLUSION: LAA mechanical function is significantly depressed in patients with OSA and SR. LAA dysfunction may predispose these patients to thromboembolic events. The evaluation of LAA mechanical function by tissue Doppler study using transthoracic echocardiography (TTE) may become an alternative for routine work-up in OSA patients.

Relation between Left Atrial Remodeling in Young Patients with Cryptogenic Stroke and Normal Inter-atrial Anatomy.

BACKGROUND AND PURPOSE: To investigate an association between left atrial (LA) structural and P wave dispersion (PWD) during sinus rhythm, and electrical remodeling in cryptogenic stroke (CS) patients. METHODS: Forty CS patients and 40 age- and sex-matched healthy controls were enrolled. P wave calculations were based on 12-lead electrocardiography (ECG) at a 50-mm/s-paper speed with an amplitude of 10 mm/mV. Difference between the maximum and minimum P wave duration was the P wave dispersion (PWD=Pmax-Pmin). LA deformation was evaluated by speckle tracking echocardiography within 3 days of the acute event. RESULTS: PWD was 30.1±7.0 ms and 27.4±3.5 ms in CS and control group (P=0.02), whereas LA maximum volume index [LAVImax] was 20.4±4.5 mL/m(2) and 19.9±2.4 mL/m(2) in CS and control group, respectively (P = 0.04). While global peak LA strain was [pLA-S] (LA reservoir function) 41.4 ± 6.3% and 44.5 ± 7.1% in CS and control group, (P = 0.04), global peak late diastolic strain rate values [pLA-SRa] (LA pump function) were 2.5 ± 0.4% and 2.9 ± 0.5% in CS and control group, respectively (P = 0.001). A mild and a strong negative correlation between global pLA-S and LAVImax (r=-0.49; P<0.01), and between PWD and global pLA-S (r = -0.52; P < 0.01), respectively, was observed in CS. CONCLUSIONS: Increased PWD is associated with impaired LA mechanical functions and enlargement, and involved in the pathophysiology of AF or an AF-like physiology in CS.

Infliximab, an anti-TNF-alpha agent, improves left atrial abnormalities in patients with rheumatoid arthritis: preliminary results.

BACKGROUND: Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality. In the current prospective study, we addressed the impact of RA on left atrial (LA) function and electrical remodelling. Further, we tried to demonstrate the effects of infliximab, an anti-TNF-alpha agent, on echocardiographical LA abnormality in RA patients with preserved left ventricular (LV) ejection fraction. METHODS: We compared 38 female RA patients without clinical evidence of heart disease and 30 female controls without RA and clinical evidence of heart disease. Further, we compared RA patients receiving infliximab and increasing doses of prednisolone over a three-month period. At baseline and post treatment, this study assessed (1) LA and LV parameters using conventional and speckle tracking echocardiography (STE), and (2) electrocardiographic P-wave changes. RESULTS: The values of C-reactive protein (CRP), isovolumic relaxation time (IVRT), A wave, and deceleration time (DT) were significantly higher in RA patients compared to the control group (p < 0.05), whereas E/E' and E/A values were found to be lower (p < 0.05) in RA patients. E/E' values were lower in prednisolone- compared to infliximab-treated patients (p < 0.05). After three months of infliximab and prednisolone treatment, CRP and disease activity score (DAS 28) values decreased in both groups (p < 0.05), and Duke activity status index (DASI) increased (p < 0.05). Maximal left atrial volume index (LAVImax), pre-contraction left atrial volume index (LAVIpreA) and maximum P wave (Pmax) of the RA patients were higher compared to the control group (p < 0.05), whereas LA global strain was found to be lower (p < 0.05). There was no difference in Pmax values between groups before and after the treatment period. E/E', LAVImax and LAVIpreA values of infliximab-treated patients decreased and LA global strain increased after three months of therapy compared to baseline (p < 0.05). At baseline in both treatment groups, E/E' and LA global late diastolic strain rate were lower in prednisolone-compared to infliximab-treated patients (p < 0.05). CONCLUSION: There was echocardiographic LA abnormality in these RA patients. In this patient group there was also a meaningful increase in maximum P wave assessed by electrocardiography. Infliximab therapy for a period of three months improved LA abnormality.

Impact of continuous positive airway pressure therapy on left atrial function in patients with obstructive sleep apnoea: assessment by conventional and two-dimensional speckle-tracking echocardiography.

OBJECTIVE: The objective of this study was to evaluate left atrial (LA) function in patients with obstructive sleep apnoea (OSA) receiving continuous positive airway pressure therapy (CPAP), incorporating two-dimensional speckle-tracking echocardiography (2D-STE). METHODS: Forty-five control and 117 OSA patients were enrolled in the study. They were categorized into mild, moderate and severe OSA groups according to the apnoea-hypopnoea index (AHI). All patients underwent conventional and 2D-STE. Forty-three patients with AHI greater than 20 were enrolled to receive CPAP therapy for 24 weeks. They underwent echocardiography examination at baseline, after 12 weeks and 24 weeks of CPAP therapy. RESULTS: Severe OSA patients have higher total emptying volume index (EVI) and lower total emptying fraction (EFr) (P < 0.05). LA contractile strain and strain rate values of severe OSA were greater than in the other groups (P < 0.05). Left ventricular filling pressure (E/E') increased with severity of OSA (P < 0.05). The AHI correlated positively with LA-maximal, -pre-contraction, -minimum volume index, contractile strain and strain rate and E/E' (P < 0.05). AHI correlated negatively with LA reservoir strain and strain rate, conduit strain and strain rate (P < 0.05). In the compliant CPAP group: (i) reduction in the E/E' ratio (P < 0.05); (ii) reduction in the LA volume indexes (P < 0.05); (iii) reduction in the LA-total EVI, -active EVI and -active EFr (P < 0.05); (iv) increase in the LA-passive emptying volume and -passive emptying fraction (P < 0.05); (v) increase in the LA reservoir strain, -conduit strain and strain rate (P < 0.05) were observed. CONCLUSION: LA volumetric and deformation abnormalities in OSA patients can be reversed as early as 12 weeks into CPAP therapy, with progressive improvement in LA anatomical remodelling over 24 weeks as assessed by conventional and 2D-STE.

Increased coronary intervention rate among diabetic patients with poor glycaemic control: a cross-sectional study.

The relationship between glycaemic control and coronary artery disease (CAD) in type 2 diabetes mellitus (T2DM) is controversial. In the current cross-sectional study, we addressed the relationship between Hemoglobin A1c (HbA1c) values and the need for revascularization among diabetic patients undergoing coronary angiography. A total of 301 consecutive patients with known T2DM (age 61.8±10.1 years, 46.2 % women) requiring coronary angiography due to CAD symptoms were included. T2DM patients were categorized into two groups based on their HbA1c values: 93 (30.9%) diabetics with good glycaemic control (HbA1c≤7 %), and 208 (69.1%) diabetics with poor glycaemic control (HbA1c>7 %). A total of 123 patients (40.9%) required revascularization. The revascularization rate was 28.0% among T2DM patients with good glycaemic control and 46.6% among T2DM patients with poor glycaemic control, respectively (p=0.002). In a logistic regression analysis, the need for revascularization was predicted by poor glycaemic control (Odds Ratio [OR] 2.26, 95% Confidence Interval [CI] 1.32-3.82; p=0.003) adjusted for age, gender, Body-Mass-Index and diabetes duration. Moreover, there was a linear relationship between HbA1c values and number of affected coronary arteries (r= 0.169; p=0.003). Our data suggest that there is a close association between poor glycaemic control and increased revascularization rate in T2DM, which should be considered in primary and secondary prevention models.