Incidence and causal association of functional atrial mitral regurgitation in HFpEF.

Heart failure with preserved ejection fraction (HFpEF) is as common as heart failure with reduced ejection fraction. Atrial fibrillation (AF), as well as the presence of mitral regurgitation (MR), is highly prevalent in these patients. Atrial functional MR (AFMR) is a type of functional MR characterized by severe left atrial dilatation and remodeling with normal left ventricular (LV) dimensions and function. Dilatation of the mitral annulus is considered to be the main underlying mechanism, though the leaflets and the rest of the mitral apparatus play significant role in the development of MR, mainly in patients with long standing AF. There are several echocardiographic differences between atrial and ventricular functional MR, better identified with 3D echocardiography. Significant AFMR impairs prognosis, especially of patients with HFpEF, and this is important while they represent a group of under-diagnosed and under-treated patients. Finally, because focused medical evidence-based approach is not available yet, it seems that the prevention of left atrial dilatation and early restoration of sinus rhythm (SR) is the best therapeutic option.

Danon Cardiomyopathy: Specific Imaging Signs.

Danon disease (DD) is a rare, X-linked genetic disorder caused by LAMP2 deficiency. Clinical phenotype involves early cardiomyopathy development along with pre-excitation, skeletal myopathy, retinopathy, and cognitive impairment. We highlight how a noninvasive diagnostic approach based on clinical and imaging red flags for DD can be employed to raise high clinical suspicion for DD, which was confirmed by genetic testing results. (Level of Difficulty: Intermediate.).

Pathophysiological alterations of left ventricular myocardial systolic function during normal pregnancy assessed by speckle tracking echocardiography: a prospective cohort echocardiography study.

PURPOSE: By using conventional echocardiographic indices, cardiac pumping function remains unaltered during pregnancy. However, two-dimensional speckle tracking echocardiography (2D-STE) can detect subclinical changes of myocardial function even in patients with normal and stable left ventricular ejection fraction (LVEF).The aim of this study was to evaluate LV systolic performance during normal low risk pregnancy by using both conventional 2D and 3D echo indices and 2D-STE. METHODS: One hundred and twelve pregnant women without any history of heart disease were prospectively recruited. They underwent serial echocardiographic evaluation in each pregnancy trimester and 6 months after delivery (time indicated as 1,2,3 and 4). 2D LVEF, 3D LVEF, LV global longitudinal strain (LVGLS), LV global circumferential strain (LVGCS) and LV-twist were measured and compared to the control group (c). RESULTS: 2D-LVEF and 3D-LVEF were not significantly different among the three trimesters, postpartum and controls. LVGLS progressively decreased during pregnancy (1st :21.71 ± 2.13%, 2nd : 21.20 ± 2.30%, 3rd : 19.82 ± 2.10%, 4th : 21.81 ± 2.05%, c: 21.71 ± 2.2%, overall p < 0,001) which receded during puerperium. No significant difference was noted in LVGCS (1st : 18.08 ± 5.54%, 2nd : 18.57 ± 3.41%, 3rd :18.20 ± 3.33%, 4th : 17.95 ± 3.39%, c: 18.8 ± 2.2%, p > 0.3). LV-Twist was significantly higher in the 1st trimester compared to controls (p = 0.04) and remained constantly high during the rest of the pregnancy and puerperium (1st :13.80 ± 5.09°, 2nd :13.46 ± 5.35°, 3rd :13.58 ± 4.32°, 4th :13.37 ± 4.26°, c: 11.5 ± 4.3°). CONCLUSIONS: In low risk individuals with normal pregnancy, a redistribution of force occurs especially in the 3rd trimester. Longitudinal strain decreases, while torsional movement of the heart increases and counterbalances the temporal change of longitudinal systolic function. These changes would probably reflect the pathophysiological alterations related to pregnancy.

Segmentally impaired left ventricular longitudinal strain: a new predictive diagnostic parameter for asymptomatic patients with severe aortic stenosis and preserved ejection fraction.

INTRODUCTION: This study aims to investigate the correlation between severe aortic stenosis (sAS) and impairment of left ventricular global longitudinal strain (LVGLS) in particular segments, using two-dimensional speckle tracking echocardiography in patients with sAS and normal ejection fraction of left ventricle (LVEF). METHODS: The study included 53 consecutive patients with asymptomatic sAS and preserved LVEF. The regional longitudinal systolic LV wall strain was evaluated at the area opposite of the aorta as the median strain value of the basal, middle, and apical segments of the lateral and posterior walls and was compared to the average strain value of the interventricular septum (IVS) at the same views. RESULTS: LVGLS was decreased and was not statistically different between three- and four-chamber views (-12.5 ± 3.6 vs -11.4 ± 5.5%, p = 0.2). The average strain values of the lateral and posterior walls were statistically reduced compared to the average value of the IVS (lateral vs IVS: -7.8 ± 3.7 vs -10 ± 5.3%, p = 0.005, posterior vs IVS: -7.7 ± 4.2 vs -10.3 ± 3.8%, p < 0.0001). There was no significant difference between lateral and posterior walls (-7.8 ± 3.7 vs -7.7 ± 4.2%, p = 0.9). CONCLUSIONS: The strain of lateral and posterior walls of left ventricle, which lay just opposite to the aortic valve seem to be more reduced compared to other walls in patients with sAS and preserved LVEF possibly due to their anatomical position. This impairment seems to be the reason of the overall LVGLS reduction. Regional strain could be used as an extra tool for the estimation of the severity of AS as well as for prognostic information in asymptomatic patients.

Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: An expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology.

Stress echocardiography (SE) is a well established and valid technique, widely used for the diagnostic evaluation of patients with ischemic and nonischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of present medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training-which focus on the preparation, the protocols used, the analysis of the SE images, and updated, evidence-based knowledge about SE applications on ischemic and nonischemic heart diseases, such as in cardiomyopathies, heart failure, and valvular heart disease.

Biventricular myocardial function in Covid-19 recovered patients assessed by speckle tracking echocardiography: a prospective cohort echocardiography study.

Although severe acute respiratory syndrome coronavirus 2 causes respiratory disease, it may also lead to cardiovascular involvement with unknown long-term consequences. The aim of our study was to evaluate prospectively cardiac involvement in patients after the recovery from Covid-19, using two-dimensional speckle tracking echocardiography. 100 Covid-19 recovered patients with preserved left ventricular ejection fraction, were included, divided based upon clinical manifestation into two groups, those who were treated ambulant and those who were hospitalized. All patients underwent echocardiographic evaluation after their recovery. Although overall LV systolic function expressed by EF was normal, left ventricular global longitudinal strain (LVGLS) was significantly lower in Covid-19 recovered patients (33.28 ± 9.4 days after diagnosis) compared to controls (- 18.47 ± - 2.4 vs. - 21.07 ± - 1.76% respectively, p < 0.0001). Εspecially the lateral wall longitudinal strain (LATLS) and posterior wall longitudinal strain (POSTLS) were significantly reduced in all patients compared to controls (- 17.77 ± - 3.48 vs. - 20.97 ± - 2.86%, p < 0.0001 and - 19.52 ± - 5.3 vs. - 22.23 ± - 2.65%, p = 0.01). right ventricular global longitudinal strain (RVGLS) was significantly diminished only in the hospitalized group of Covid-19 recovered patients, compared to controls (- 18.17 ± - 3.32 vs. - 26.03 ± - 4.55% respectively, p < 0.0001). LVGLS is affected in almost all individuals after Covid-19 infection independently of the infection severity, with LATLS being the most sensitive marker of LV impairment and with POSTLS to follow. RV shows impaired GLS in severely ill patients highlighting RVGLS as a helpful tool of prognosis. Recovered patients from Covid-19 infection have to be monitored for a long time, since the term "long Covid disease" might also include the cardiac function.

Left ventricular ejection fraction and Global Longitudinal Strain variability between methodology and experience.

INTRODUCTION: Although ejection fraction (EF) is the cornerstone of the assessment of left ventricular (LV) systolic function, its measurement faces a number of challenges related to image quality, assumptions of LV geometry, and expertise. The aim of this study was to test the inter-observer variability of EF and GLS measurement in patients with a broad spectrum of LV function, between physicians and investigators (Inv) with different levels of expertise. METHODS: In 122 patients, EF and GLS were measured by 4 Inv blinded to each other with different level of experience in echocardiography; EF was measured using 3 methods: visual assessment, biplane Simpson's method, and auto-EF method. GLS was measured from the 3 apical views. A significant difference for LVEF and for LVGLS was considered to be >10 and >2 absolute values, respectively. RESULTS: Intra-observer agreement was excellent for visually assessed EF (ICC = 0.87, P < .001) and GLS (ICC = 0.82, P < .001) and good for EF measured by Simpson's method (ICC = 0.70, P < .001) and auto-EF (ICC = 0.72, P < .001). Intra-observer and inter-observer agreements were excellent for GLS with ICCs above 0.8. GLS discordance between the 4 Inv was not significant. Discordance in EF and GLS measurements among the Inv was not related to image quality or wall motion abnormalities. CONCLUSION: Although EF has proved its prognostic value in various cardiovascular entities, GLS seems to be more reliable for serial assessment of LV function, demonstrating lower intra- and inter-observer variability, even by different physicians with variant level of expertise.

Cardio-oncology: a new and developing sector of research and therapy in the field of cardiology.

Cardio-oncology is a new field of interest in cardiology that focuses on the detection, monitoring, and treatment of cardiovascular disease occurring as a side effect of chemotherapy and radiotherapy. Both cancer treatment modalities can cause cardiac dysfunction, a major cause of morbidity and mortality in the oncologic population. It is necessary to periodically monitor cancer patients under treatment, especially those receiving anthracyclines and trastuzumab (monoclonal antibody), using mainly 3D echocardiography to calculate left ventricular ejection fraction and to estimate myocardial deformation. Additionally, measuring various biomarkers, such as natriuretic peptides, could facilitate early identification and appropriate response to potential cardiotoxicity. In this regard, cardiological assessment before starting cancer treatment is essential and should be continued throughout, since cardiac dysfunction can occur at any time, even several years after therapy onset. High-risk individuals, in particular, should receive a detailed management plan designed in collaboration between an oncology and a cardiology specialist. If heart failure develops, even in the absence of overt clinical symptoms, standard heart treatment is to be followed and causal agent discontinued if possible. One important question is whether and when to stop cardiac medication in case of heart dysfunction reversal, after completion of cancer treatment. Further cardio-oncology evolution can lead to a deeper understanding of the adverse mechanisms and effects causing heart failure, as well as the development of personalized treatment regimens in order to limit cardiotoxicity.

Subclinical left ventricular dysfunction and correlation with regional strain analysis in myocarditis with normal ejection fraction. A new diagnostic criterion.

BACKGROUND: The diagnosis of myocarditis is challenging, especially in case of normal left ventricular systolic function. The aim of this study is to test the hypothesis that 2D speckle tracking echocardiography (2DSTE) can detect subclinical left ventricular (LV) dysfunction in patients with myocarditis and preserved LV function without regional wall motion abnormalities and that regional strain analysis can correlate with cardiac magnetic resonance (CMR) findings. METHODS: Study population consisted of 25 consecutive patients with myocarditis and 19 controls. All patients underwent a full echocardiographic study at the first day of their admission and in addition to conventional echocardiographic measurements, global longitudinal and circumferential strain of the left ventricle (LVGLS, LVCS accordingly), as well as regional strains of the lateral wall, were estimated. Moreover, all patients underwent a CMR scan during the first week from their admission. RESULTS: Although there was no statistical difference between the two groups of patients in systolic function, myocarditis patients demonstrated significantly impaired LVGLS (-16.5 ±â€¯2.2 vs -20.5 ±â€¯1.3%, p < 0.0001) and LVCS (-16.4 ±â€¯3.7 vs -20.9 ±â€¯2%, p = 0.002), as well as segmental longitudinal strains of the lateral wall. CMR in all myocarditis patients revealed late gadolinium enhancement in the lateral left ventricle free wall. CONCLUSIONS: In patients with acute myocarditis with preserved ejection fraction, 2DSTE evaluation appears to be a promising, useful noninvasive and inexpensive tool in addition to existing methods used for the diagnosis of acute myocarditis, since it seems to be able to identify myocardial fibrosis early in the setting of the disease.

Coronary artery disease: not always the case for ST-elevation myocardial infarction.

We report a case of an acute ST-T elevation myocardial infarction in a middle-aged female with a mechanical mitral valve prosthesis and subtherapeutic INR levels. We performed a primary coronary intervention, using a thromboaspiration catheter. After blood clot aspiration, a TIMI III flow was restored and no residual lesions remained at the site of the occlusion. A transesophageal echo revealed a movable thrombus over the mechanical mitral valve prosthesis and patient underwent subsequent mitral valve replacement. Embolic myocardial infarction remains underdiagnosed. A high level of suspicion and the quest of the source of embolus are crucial.

Ebstein's anomaly: a potential cause of misinterpretation of myocardial perfusion scintigraphy.

We present the case of a 43-year-old woman with a history of Ebstein's anomaly, who was referred for a myocardial perfusion single-photon emission computed tomography (SPECT) study due to angina-like symptoms. Dilatation of the right ventricle and right atrium, apical displacement of the septal tricuspid leaflet, small left ventricle with good left ventricular and a moderate degree of tricuspid regurgitation with mild pulmonary hypertension were found on echocardiography. Myocardial SPECT perfusion imaging with [99m Tc]tetrofosmin demonstrated a large defect in the inferior septal wall in the stress study with mild partial reversibility at rest. Coronary angiography revealed normal coronary arteries. Histological studies have shown that these patients develop increased fibrosis in the left ventricular wall and ventricular septum, especially in the basal and middle region of the septum, which adjoins with the atrialized component of the right ventricle. This is in concordance with the findings of the myocardial perfusion scan in the case described.

Discordance between echocardiographic and MRI findings in two cases of acute myocarditis mimicking myocardial infarction.

Two male adolescents were admitted due to chest pain influenced by the respiratory movements. A lobar pneumonia caused by Mycoplasma pneumoniae, was radiographically and serologically diagnosed in the first patient (a 15-year-old boy) and a febrile diarrhea of unidentified etiology, despite repetitive stool cultures and serological assessments in the second one (a 19-year-old male). Both patients combined the aforementioned infectious conditions with outstanding thoracic pain the previous hours before admission, markedly elevated cardiac enzymes and ST-segment elevation in the inferior and left precordial leads with a normal coronary angiogram, thus composing a clinical setting highly indicative of acute myocarditis. Surprisingly however, the echocardiogram performed in both patients failed to reveal any regional or global wall motion abnormalities or even diastolic dysfunction and remained absolutely normal throughout their 3-month follow-up period. Cardiac MRI within 7 days, using T2-weighted and gadolinium-enhanced T1-weighted images demonstrated extensive focal contrast enhancement, consistent with acute inflammatory myocardial involvement. It can therefore be concluded that contrast MRI is a more sensitive method than the echocardiogram for the diagnosis of acute focal myocarditis.

Clinical and prognostic value of elevated CA125 levels in patients with congestive heart failure.

BACKGROUND: Increased serum levels of carbohydrate antigen 125 (CA125), a tumor marker associated with ovarian cancer, have also been reported in other malignant and non-malignant diseases. We assessed the correlation of the CA125 serum levels with the severity of congestive heart failure (CHF) and investigated their potential prognostic value in relation to major cardiovascular events. METHODS: CA125 levels were measured in 95 male patients aged 70+/-10 years, admitted for decompensated CHF. The patients were divided into three groups, according to their New York Heart Association (NYHA) functional class. Group A contained 23 patients in NYHA IV, group B 34 patients in NYHA III, and group C 38 patients in NYHA I-II. The patients were also divided into two groups according to their CA125 value on admission. Group 1 included 45 patients with normal CA125 levels and group 2 50 patients with elevated CA125. All patients were followed for 15+/-8.5 months and the major cardiovascular events (death and re-hospitalizations due to CHF) were recorded. RESULTS: Serum levels of CA125 were higher in groups A and B than in group C (36.4 [19.8-82] U/ml and 34.6 [26-78] U/ml vs. 25.3 [9.1-29] U/ml, respectively, p<0.05). No correlation was detected between CA125 levels and left ventricular ejection fraction. However, patients with pulmonary congestion and peripheral edemas had higher levels of CA125 (p=0.002 and p<0.03, respectively). Nineteen patients died during the follow-up period, but the mortality rate was not significantly different between groups 1 and 2 (p=0.8). Nevertheless, the patients of group 1 reported fewer re-hospitalizations than patients of group 2 (p=0.003). The relative risk (RR) for re-hospitalization was calculated to be RR: 0.4, 95% CI: 0.215-0.76 (p<0.005), in patients with elevated levels of CA125. Cox regression analysis revealed that CA125 had independent prognostic value (OR: 1.007 [95% CI: 1.004-1.010], p<0.0001) for re-hospitalizations. CONCLUSION: Serum levels of CA125 are associated with the severity of CHF and are also independent predictive markers for re-hospitalizations. We therefore conclude that CA125 can be used as a prognostic marker of disease severity and increased morbidity in patients with decompensated CHF.

Mitral valve repair versus replacement for isolated non-ischemic mitral regurgitation in patients with preoperative left ventricular dysfunction. A long-term follow-up echocardiography study.

UNLABELLED: The aim of this study was to evaluate LV function, by means of echocardiography, after mitral valve repair (MVr) or mitral valve replacement (MVR) in patients (pts) with chronic degenerative mitral regurgitation (MR) and depressed LV systolic function during a 6-years follow-up (FU) period. PATIENTS AND METHODS: Forty-five pts with moderately severe or severe MR and preoperative EF

Atrioventricular conduction disturbances in a young patient with Fabry's disease without other signs of cardiac involvement.

A 30 year-old male patient with a history of Fabry's disease, was referred to hospital with symptoms of dizziness, hypotension and weakness. Fabry's disease had been diagnosed 2 years before, based on angiokeratoma and hypohidrosis on physical examination and complete lack of alpha-galactosidase A on laboratory examination. The ECG on admission demonstrated sinus bradycardia, with a poor response to atropine administration. Echocardiograms on admission and 2 years before were normal, as well as Holter ambulatory ECG recording. Subsequent electrophysiological study demonstrated mild AV conduction disturbances at a site proximal to His, and the patient was simply advised to be regularly followed up. It can therefore be concluded that even young patients with Fabry's disease and normal echocardiograms might develop cardiac symptoms due to AV conduction abnormalities.

The significance of CA125 levels in patients with chronic congestive heart failure. Correlation with clinical and echocardiographic parameters.

OBJECTIVE: To assess serum levels of carbohydrate antigen 125 (CA125) in patients with chronic congestive heart failure (CHF) and to assess any correlation with clinical symptoms and echocardiographic indices. PATIENTS AND METHODS: We enrolled 77 male patients (mean age: 73+/-10 years) admitted to the Cardiology Emergency Department (ED) with cardiac symptoms requiring hospitalization. Diagnosis of CHF was based upon medical history or initial echocardiographic evaluation on current admission. Serum CA125 was measured by an enzyme immunoradiometric assay, on admission and before discharge. RESULTS: The median overall CA125 value was 22.4 (11.5-48.9) U/ml. Serum CA125 levels were related to the severity of CHF [New York Heart Association (NYHA) class I: 19.2 (7.2-31) U/ml, NYHA class II: 17.6 (10-23) U/ml, NYHA class III: 32 (25-77) U/ml and NYHA class IV: 34.3 (18.6-77) U/ml (p<0.04)]. Patients in NYHA classes III and IV had significantly higher mean values of CA125, than patients in class II (p<0.005 and p<0.05, respectively). Moreover, patients with fluid congestion (pulmonary congestion, ankle edema) had higher levels of serum CA125 than patients without congestion (p=0.002 and p<0.03, respectively). Finally, levels of serum CA125 correlated weakly with right ventricular systolic pressure (RVSP) and renal function, while no significant correlation was found between CA125 and E wave deceleration time on Doppler echocardiography, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), liver function and the medical treatment prescribed. CONCLUSION: Serum CA125 is associated with the clinical severity of CHF and the symptoms and signs of fluid congestion and therefore may be a useful additional tool for the evaluation and clinical staging of these patients.