Association of Cardiovascular Health with Epicardial Adipose Tissue and Intima Media Thickness: The Kardiovize Study.

Background: Intima-media thickness (IMT) has been proposed as a measurement of subclinical atherosclerosis and has been associated with cardiovascular disease (CVD). Epicardial adipose tissue (EAT) is a fat depot between the pericardium and myocardium and has been associated with coronary atherosclerosis. The relationship between IMT and EAT thickness has not been reported before. We investigated the relationship between EAT thickness, IMT, CVD risk factors, and ideal cardiovascular health (CVH) metrics using subjects from the Kardiovize Brno 2030 cohort study, a random urban sample population in Central Europe. Methods: We studied 102 individuals (65 males) aged 25⁻64 years (median = 37 years) with no current or past CVD history. We measured IMT using a vascular ultrasound and EAT thickness using transthoracic echocardiography, and collected data on anthropometric factors, CVD risk factors, and CVH score. Correlation tests and multiple linear regression models were applied. Results: In the age- and gender-adjusted model, we demonstrated that, among CVD risk factors, only BMI was significantly and positively associated with EAT thickness (β = 0.182, SE = 0.082, p = 0.030), while no significant associations with IMT were evident. Although both EAT thickness and IMT were negatively correlated with CVH score (r = −0.45, p < 0.001, and r = −0.38, p < 0.001, respectively), we demonstrated that overall CVH score (β = −0.262; SE = 0.077; p = 0.001), as well as BMI (β = −1.305; SE = 0.194; p < 0.001) and blood pressure CVH metrics (β = −0.607; SE = 0.206; p = 0.004) were significantly associated with EAT thickness but not with IMT. Conclusions: Our study is important as it demonstrated for the first time that CVH is associated with EAT thickness. Interestingly, this relationship seems to be dependent on BMI and blood pressure rather than on the other CVH metrics. However, outcome-driven studies are required to confirm these findings.

New echocardiographic parameters in the diagnosis of heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is a serious clinical disease. The pathophysiology of HFpEF is complex, and specific diagnostic criteria have evolved over time. Limited data are available on the quantification of diastolic function using two-dimensional real-time echocardiography, and a simple parameter has not yet been established. The aim of this work is to evaluate new echocardiographic parameters-the diastolic wall strain of the posterior wall (DWS PW) and the vortex formation time (VFT). Echocardiographic data from 111 subjects with exertional dyspnea and normal left ejection fraction (Group A) and 20 healthy volunteers (Group B) were retrospectively evaluated. In addition to the standard parameters used in the diagnosis of HFpEF, DWS PW and VFT were assessed in all patients. HFpEF was diagnosed in 38 patients with dyspnea (Group A1). The remaining 73 patients did not meet the established criteria for a positive diagnosis of HFpEF (Group A2). We discovered that both observed parameters were significantly lower in patients with HFpEF than in other groups. Multivariate analysis revealed that both DWS PW and VFT independently predicted the presence of HFpEF. DWS PW and VFT are simple parameters in the evaluation of diastolic function and may play a potential role as a part of an integrated approach to the assessment of HFpEF.

Longitudinal, circumferential and radial systolic left ventricular function in patients with heart failure and preserved ejection fraction.

INTRODUCTION: Heart failure with preserved left ventricular ejection fraction (HFPEF) is an epidemiologically serious disease. Noninvasive diagnosis of HFPEF remains challenging. The current diagnosis is based on evidence of diastolic dysfunction, albeit systolic dysfunction is also present but not included in the diagnostic algorithm. The aim of this study was to analyze the longitudinal (long), circumferential (circ) and radial (rad) component of systolic left ventricular (LV) function in patients with exertional dyspnea of unexplained etiology and normal left ventricular ejection fraction (LVEF). METHODS: One hundred and twenty-two patients with exertional dyspnea of unexplained etiology and normal LVEF and 21 healthy controls, underwent echocardiography examination at rest and at the end of symptom-limited exercise. We analysed the longitudinal, circumferential and radial deformation of myocardium using two dimensional speckle tracking echocardiography in all subjects. RESULTS: Patients with exertional dyspnea and preserved LVEF were divided into group A1 (46 patients meeting the criteria for the diagnosis HFPEF) and group A2 (76 patients without HFPEF). Group A1 had significantly worse longitudinal and circumferential systolic LV function than group A2. Subjects in group A1 compared to group A2 showed significantly different strain rates during atrial contraction (SR A), circ and ratio of peak early trans-mitral flow velocity (E) and strain rate E wave (E / SR E) circ. Multivariate logistic regression analysis showed that the SR parameter A circ is an independent predictor of HFPEF (odds ratio 0.550, 95% confidence interval: 0.370 - 0.817, P value 0.003). CONCLUSION: Longitudinal and circumferential LV deformation was significantly more impaired in patients with HFPEF than in patients with exertional dyspnea without HFPEF. In patients with exertional dyspnea and normal LVEF, the value of SRA circ appears to be a significant and independent predictor of HFPEF. This parameter may, in the future complement the diagnostic algorithm for HFPEF.

Decrease in longitudinal strain in heart transplant recipients is associated with rejection.

BACKGROUND: Around 20-40% of heart transplant patients experience moderate to severe rejection within the first year after heart transplantation. Endomyocardial biopsy (EMB) is a gold standard for diagnosing heart transplant rejection. There is a need for non-invasive alternatives that allow for early, safe and reliable diagnosis of acute graft rejection prior to the onset of clinical symptoms. AIMS: Our aim was to investigate the potential of speckle tracking derived strain analysis in the diagnosis of acute graft rejection. METHODS: Patients indicated for EMB consented to a trans-thoracic echocardiography examination (TTE) within 2 hours of the EMB. Of this cohort, those with at least 2 EMBs separated ≥ 1 week, and whose TTE could be analyzed for strain, were included. The relationship between strain and EMB results was evaluated. RESULTS: Of the 43 patients included (mean age 51.33±1.79, 67% male), 23 had findings of rejection identified on at least one EMB and at least one EMB without rejection for comparison. A significant deterioration in the longitudinal strain during rejection compared to non-rejection was found on apical 4-chamber views (-11.51±0.91 vs -13.48±0.96, P=0.025) and apical 2-chamber views (-11.84±0.78 vs -14.43±0.83, P=0.002). In the patients in whom no rejection was identified on either EBM, there was no significant change in longitudinal strain values at two different time points. CONCLUSION: Worsening of longitudinal strain was associated with acute cellular rejection. Routine TTE-based strain analysis could help in early detection of cardiac rejection and timing of EMB.

Superparamagnetic iron oxide-enhanced magnetic resonance for imaging cardiac inflammation. A minireview.

BACKGROUND: Advances in nanotechnology have lead to the development of a novel contrast media for Magnetic Resonance Imaging (MRI) - the superparamagnetic iron oxide nanoparticle (SPIO). SPIO nanoparticles are used to image inflammation on the cellular level in various settings. This review covers the physicochemical characteristics of SPIO particles as well as relevant animal and clinical studies and discusses the potential of SPIO particles to image cardiac inflammation including cardiac graft rejection. METHODS: We searched the scientific biomedical databases Medline/PubMed, BioMedCentral, Google Scholar, Ovid and, ProQuest from to 2000 to 2013 for publications relevant to the topic. CONCLUSIONS: SPIO nanoparticles due to their unique properties could become a useful tool in imaging cardiac inflammation. However, the task is to find a suitable particle size and coating with corresponding pharmacokinetics, establish the right dose and MRI scan timing for individual applications.

Embolus entrapped in patent foramen ovale: impending paradoxical embolism.

An impending paradoxical embolism is a rare finding, with fewer than 200 cases being documented so far. A 68-year-old woman, who presented with 3 weeks of increasing exertional dyspnea and exercise intolerance, underwent transesophageal echocardiography with a finding of an embolus in both right and left atria. At an emergent cardiac surgery, a worm-shaped, 5-cm-long thrombus was found in the right atrium, it was protruding to left atrium through the foramen ovale. The thrombus was removed intact, and the foramen ovale was closed. By our experience, an emergent cardiac surgery should always be considered as a treatment option for impending paradoxical embolism.

High prevalence of exercise-induced heart failure with normal ejection fraction in post-heart transplant patients.

AIM: Post-heart transplant patients are at increased risk of diastolic dysfunction. The aim of this study was to assess the prevalence of isolated only exercise-induced heart failure with normal ejection fraction (HFNEF) in heart transplant recipients. METHODS AND RESULTS: To determine pulmonary capillary wedge pressure (PCWP) at rest and during exercise, 81 patients after orthotopic heart transplantation with normal left ventricular ejection fraction (LVEF) underwent exercise right heart catheterization with simultaneous exercise echocardiography. Based on PCWP values, the patients were divided into three groups. Twenty-one patients had no evidence of HFNEF (PCWP at rest < 15 mmHg, maximal PCWP during exercise < 25 mmHg, prevalence 26%). Forty-seven subjects were found to have only exercise-induced HFNEF (PCWP at rest < 15 mmHg, maximal PCWP during exercise ≥ 25 mmHg, prevalence 58%). Thirteen patients had HFNEF already at rest (PCWP ≥ 15 mmHg at rest, prevalence 16%). Of the noninvasive parameters obtained at rest, multivariate regression analysis identified LV mass index adjusted for allograft age to be an independent predictor of exercise-induced HFNEF. CONCLUSIONS: In heart transplant recipients with normal LVEF, there is a high prevalence of exercise-induced HFNEF. LV mass index adjusted for allograft age is predictive of exercise-induced HFNEF.

Do we always consistently define the clinically important echocardiographic parameters?

AIMS: The aim of this short communication is to highlight some inconsistencies in defining two clinically important echocardiographic parameters with possible impact on clinical practice. METHODS AND RESULTS: A surview of publications in reputable cardiological journals revealed inconsistencies posing questions on the validity of the published data and on the scrupulousness of the reviewing process. We demonstrate examples of inconsistencies in the calculation of left ventricular mass using Devereux's formula and in the definition of relative wall thickness, two echocardiographic parameters commonly utilized in a clinical practice. CONCLUSION: It is desirable to follow exactly the definitions of more complex parameters and to unify ways of presenting those with several definitions.

Noninvasive prediction of the exercise-induced elevation in left ventricular filling pressure in post-heart transplant patients with normal left ventricular ejection fraction.

OBJECTIVES: At present, there are conflicting data on the ability of echocardiographic parameters to predict the exercise-induced elevation of left ventricular (LV) filling pressure. The purpose of the present study was to validate the ratio of early diastolic transmitral (E) to mitral annular velocity (e') obtained at peak exercise in its capacity to determine the exercise-induced elevation of pulmonary capillary wedge pressure (PCWP) and to reveal new noninvasive parameters with such capacity. METHODS: Sixty-one patients who had undergone heart transplantation with normal LV ejection fraction underwent simultaneous exercise echocardiography and right heart catheterization. RESULTS: In 50 patients with a normal PCWP at rest, exercise E/e' ≥8.5 predicted exercise PCWP ≥25 mmHg with a sensitivity of 64.3% and a specificity of 84.2% (area under the curve [AUC]=0.74). A comparable or slightly better prediction was achieved by exercise E/peak systolic mitral annular velocity (s') ≥11.0 (sensitivity 79.3%; specificity 57.9%; AUC=0.75) and exercise E/LV systolic longitudinal strain rate ≤-105 cm (sensitivity 78.9%; specificity 78.6%; AUC=0.87). Combined, exercise E/s' and exercise E/e' resulted in a trend toward a slightly more precise prediction (sensitivity 53.6%; specificity 89.5%; AUC=0.78) than did either variable alone. CONCLUSIONS: Exercise E/e', used as a sole parameter, is not sufficiently precise to predict the exercise-induced elevation of PCWP. Exercise E/s', E/LV systolic longitudinal strain rate or combinations of these parameters may represent further promising possibilities for predicting exercise PCWP elevation.

Can markers of collagen turnover or other biomarkers contribute to the diagnostics of heart failure with normal left ventricular ejection fraction?

AIMS: Plasma levels of some biomarkers and markers of collagen turnover may reflect myocardial structural abnormalities associated with diastolic dysfunction. The aim of this study was to determine whether these markers could contribute to the diagnostics of heart failure with normal ejection fraction (HFNEF). METHODS AND RESULTS: 91 patients with exertional dyspnea and normal left ventricular ejection fraction and 20 healthy controls underwent plasma analysis of markers of collagen turnover and other biomarkers, spirometry, and resting and exercise echocardiography. 38 patients with dyspnea had evidence of HFNEF, diagnosed at the early stage. Compared to the remaining patients, those with HFNEF had a significantly higher plasma levels of carboxy-terminal telopeptide of collagen type I (median 4.5 µg/L vs. 3.5 µg/L, P<0.05) and big endothelin (median 1.1 pmol/L vs 0.9 pmol/L, P<0.05). Univariate logistic regression analysis revealed a significant association between HFNEF and the following biomarkers: big endothelin, amino-terminal propeptide of type III procollagen (PIIINP), and matrix metalloproteinase-2 (MMP-2). However, none of these biomarkers independently contributed to the HFNEF diagnostics in a multivariate logistic regression analysis. CONCLUSION: Plasma levels of big endothelin, PIIINP, and MMP-2 were found to be associated with the presence of early diagnosed HFNEF. However, none of these biomarkers contributed independently to current noninvasive HFNEF diagnostics recommended by the European Society of Cardiology guidelines.

The role of exercise echocardiography in the diagnostics of heart failure with normal left ventricular ejection fraction.

AIMS: Few data are available on the exercise-induced abnormalities of myocardial function in patients with exertional dyspnoea and normal left ventricular ejection fraction (LV EF). The main aims of this study were to determine the prevalence of isolated exercise-induced heart failure with normal ejection fraction (HFNEF) and to assess whether disturbances in LV or right ventricular longitudinal systolic function are associated with the diagnosis of HFNEF. METHODS AND RESULTS: Eighty-four patients with exertional dyspnoea and normal LV EF and 14 healthy controls underwent spirometry, NT-proBNP plasma analysis, and exercise echocardiography. Doppler LV inflow and tissue mitral and tricuspid annular velocities were analysed at rest and immediately after the termination of exercise. Of the 30 patients with the evidence of HFNEF, 6 (20%) patients had only isolated exercise-induced HFNEF. When compared with the remaining patients, those with HFNEF had a significantly lower resting and exercise peak mitral annular systolic velocity (Sa) and the mitral annular velocity during atrial contraction, lower exercise peak mitral annular velocity at early diastole, and lower exercise peak systolic velocity of tricuspid annular motion. The multivariate logistic regression analysis including both parameters standardly defining HFNEF and the new Doppler variables potentially associated with the diagnosis of HFNEF revealed that NT-proBNP, LV mass index, left atrial volume index, and Sa significantly and independently predict the diagnosis of HFNEF. CONCLUSION: A significant proportion of patients require exercise to diagnose HFNEF. Sa appears to be a significant independent predictor of HFNEF, which may increase the diagnostic value of models utilizing the variables recommended by the European Society of Cardiology guidelines.

Estimation of left ventricular filling pressures by speckle tracking echocardiography in patients with idiopathic dilated cardiomyopathy.

AIMS: the ratio of early diastolic transmitral flow velocity (E) to early diastolic mitral annular velocity (E(a)) is frequently used to predict an increase in left ventricular filling pressure (LVFP). However, this approach has several limitations. The aim of this study was to test whether additional information is gained by new echocardiographic indexes utilizing strain and strain rate (SR) derived from 2-dimensional speckle tracking echocardiography (2D-STE) for the estimation of LVFP. METHODS AND RESULTS: fifty-one patients with idiopathic dilated cardiomyopathy (IDC) underwent pulsed-wave tissue Doppler echocardiography and 2D-STE performed simultaneously with right heart catheterization. Receiver operating characteristic analysis showed that circumferential strain and the SR during late diastolic LV filling (0.956 and 0.951, both P = 0.001), E/circumferential SR at early diastolic LV filling (0.949, P = 0.001), and E/circumferential strain at the time of peak E-wave (0.948, P = 0.001) had greater area under the curve than the E/E(a) ratio (0.911, P = 0.001) for the prediction of pulmonary capillary wedge pressure > 12 mmHg. CONCLUSION: when compared with the E/E(a) ratio, several 2D-STE-derived parameters better estimated the increase in LVFP in patients with IDC.

Left ventricular mechanics in idiopathic dilated cardiomyopathy: systolic-diastolic coupling and torsion.

BACKGROUND: In idiopathic dilated cardiomyopathy (IDC), myocardial deformational parameters and their mutual relationships remain incompletely characterized. METHODS: Thirty-seven patients with IDC underwent two-dimensional speckle-tracking echocardiography (2D-STE) to assess left ventricular rotation, torsion, and longitudinal, circumferential, and radial systolic and diastolic strains and strain rates. Additionally, 2D-STE was performed in 14 controls. RESULTS: All deformational parameters on 2D-STE were significantly lower in patients with IDC compared with controls. Seven patients exhibited opposite basal (positive, counterclockwise) and 11 patients exhibited opposite apical (negative, clockwise) rotation at end-systole. Circumferential, radial, and longitudinal early diastolic strain rates were correlated most strongly with the corresponding spatial components of systolic deformation. CONCLUSION: In patients IDC, all torsional, systolic, and diastolic deformational parameters were decreased. Corresponding three-dimensional components of systolic and diastolic deformations were closely coupled. Considerable variation in the direction of basal and apical rotation exists in a subset of patients with IDC.