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HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the incremental prognostic value of CPET for the HFA-PEFF score among patients with unexplained dyspnea with preserved ejection fraction (EF). Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography in the left ventricle, left atrium and right ventricle. The primary outcome was defined as a composite cardiovascular event including cardiovascular-related mortality, acute recurrent heart failure hospitalization, urgent repeat revascularization/myocardial infarction or any hospitalization due to cardiovascular events. The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2–4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO 2 slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure were independently associated with composite cardiovascular events. Furthermore, the addition of VE/VCO 2 and HFA-PEFF to the base model showed incremental prognostic value for predicting composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement 0.129, p = 0.032; net reclassification improvement 1.043, p ≤ 0.001). CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic value and diagnosis among patients with unexplained dyspnea with preserved EF. • This study showed the incremental prognostic value of CPET for HFA-PEFF in patients with unexplained dyspnea with preserved EF. • Even the HFA-PEFF ≥5 group, which should be diagnosed as HFpEF, had considerable proportions of normal and indeterminate diastolic function in this study. • Moreover, CPET parameters, such as peak VO 2 and VE/CO 2 , were significantly different between groups. Patients with unexplained dyspnea should be approached with a comprehensive diagnostic evaluation including HFA-PEFF score and CPET as well as diastolic function grading. [ABSTRACT FROM AUTHOR]

A subset of patients with atrial fibrillation (AF) presents without established AF risk factors and normal left ventricular (LV) systolic function, called idiopathic AF (IAF). Traditionally, echocardiography derived LV dimensions and ejection fraction (EF) are used to exclude LV dysfunction in IAF, but their sensitivity is limited. Our objective is to evaluate the presence of subtle alterations in LV function despite normal LVEF in patients with IAF compared to healthy controls, using speckle-tracking echocardiography (STE) based global longitudinal strain (GLS). Standard transthoracic echocardiography was performed in 80 patients with IAF and 129 healthy controls. Patients with overt cardiac disease as well as known established AF risk factors were excluded. STE analysis was performed to assess GLS of the LV, and left atrial strain (LAS). LVEF was normal and comparable between patients with IAF and healthy controls (63 ± 4% for both groups; p = 0.801). Mean GLS was within normal limits for both groups but statistically significantly more negative in patients with IAF (−20.6 ± 2.5% vs. -19.7 ± 2.5%; p = 0.016), however not when indexed for ventricular cycle length (p = 0.784). No differences in LA volume or non-indexed LAS were seen in patients with IAF compared to healthy controls. In this selected group of IAF patients, STE did not detect any overt LV or LA dysfunction compared to healthy controls. Thus, IAF occurred in these patients not only in the absence of established AF risk factors but also without evidence of ventricular or atrial dysfunction. • Idiopathic atrial fibrillation occurred in the absence of established AF risk factors. • Global longitudinal strain was normal in patients with idiopathic atrial fibrillation. • Speckle-tracking imaging did not detect any overt LV dysfunction compared to healthy controls. [ABSTRACT FROM AUTHOR]

Echocardiographic assessment of adolescent athletes for arrhythmogenic cardiomyopathy (ACM) can be challenging owing to right ventricular (RV) exercise-related remodelling, particularly RV outflow tract (RVOT) dilation. The aim of this study is to evaluate the role of RV 2-D speckle tracking echocardiography (STE) in comparing healthy adolescent athletes with and without RVOT dilation to patients with ACM. A total of 391 adolescent athletes, mean age 14.5 ± 1.7 years, evaluated at three sports academies between 2014 and 2019 were included, and compared to previously reported ACM patients (n = 38 definite and n = 39 borderline). Peak systolic RV free wall (RVFW-S l), global and segmental strain (S l), and corresponding strain rates (SR l) were calculated. The participants meeting the major modified Task Force Criteria (mTFC) for RVOT dilation were defined as mTFC+ (n = 58, 14.8%), and the rest as mTFC- (n = 333, 85.2%). Mean RVFW-S l was −27.6 ± 3.4% overall, −28.2 ± 4.1% in the mTFC+ group and − 27.5 ± 3.3% in the mTFC- group. mTFC+ athletes had normal RV-FW-S l when compared to definite (−29% vs −19%, p < 0.001) and borderline ACM (−29% vs −21%, p < 0.001) cohorts. In addition, all mean global and regional S l and SR l values were no worse in the mTFC+ group compared to the mTFC- (p values range < 0.0001 to 0.1, inferiority margin of 2% and 0.1 s−1 respectively). In athletes with RVOT dilation meeting the major mTFC, STE evaluation of the RV can demostrate normal function and differentiate physiological remodelling from pathological changes found in ACM, improving screening in grey-area cases. The use of 2D speckle tracking echocardiography in the assessment of the athlete RV. [Display omitted] • Training induced right ventricular outflow dilation is frequent in athletes and can raise suspicion of cardiomyopathy • These athletes have normal right ventricular myocardial mechanics, in contrast with confirmed and borderline non-athlete cases. • Speckle tracking echocardiography can improve current screening criteria in athletes with right ventricular outflow dilation [ABSTRACT FROM AUTHOR]

A number of anterior chest wall deformities, most notably pectus excavatum (PE), may have a detrimental effect on cardiac motion and function. Interpretation of transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) results may be hampered by the possible influence of PE on cardiac kinetics. A comprehensive search of all articles assessing cardiac function in PE individuals was carried out. Inclusion criteria were: 1) individuals aged >10 years; 2) studies providing objective assessment of chest deformity (Haller index). Studies that measured myocardial strain parameters in PE patients were also included. The search (EMBASE and Medline) yielded a total of 392 studies, 36 (9.2%) of which removed as duplicates; a further 339 did not meet inclusion criteria. The full-texts of 17 studies were then analyzed. All studies concordantly reported impaired right ventricular volumes and function. With respect to left ventricle (LV), TTE studies uniformly demonstrated a significant impairment in conventional echoDoppler indices in PE individuals, whereas STE studies provided conflicting results. Importantly, LV functional alterations promptly reverted upon surgical correction of chest defect. In subjects with PE of mild-to-moderate severity, we observed that degree of anterior chest wall deformity, as noninvasively assessed by modified Haller index (MHI), was strongly associated with myocardial strain magnitude, in heterogenous cohorts of otherwise healthy PE individuals. Clinicians should be aware that in PE individuals, TTE and STE results may not always be indicative of intrinsic myocardial dysfunction, but may be, at least in part, influenced by artifactual and/or external chest shape determinants. Multimodality imaging assessment of chest wall conformation. Panel A: Conventional radiological Haller index assessment by CT scan. The Haller index is measured as the ratio of the maximum internal transverse diameter of the chest divided by the minimum antero-posterior diameter, at the deepest point of the deformity, at end inspiration. CT, computed tomography. Panels B1 and B2: Conventional radiological Haller index assessment by CXR. Panel B1: The internal L-L major thoracic diameter is measured, on a P-A view, at the level of the distal third of the sternum and/or of the eighth thoracic vertebra, without including the soft tissues (red line). Panel B2: The internal A-P minor thoracic diameter measured, on a L-L view, at the level of the maximum sternal depression, from the internal anterior chest wall to the anterior surface of the eighth thoracic vertebral (red line). CXR, chest X-ray; A-P, antero-posterior; L-L, latero-lateral; P-A, postero-anterior. Panels C1 and C2: MHI assessment. Panel C1: The L-L thoracic diameter is measured with the subject in the standing position and with open arms, by using a rigid ruler in centimeters coupled to a level (the measuring device), placed at the distal third of the sternum, at level of the point of maximum depression of the sternum. Panel C2: The A-P thoracic diameter is obtained during conventional transthoracic echocardiography, from the parasternal long-axis view, by measuring the distance between the true apex of the sector and the posterior wall of the descending thoracic aorta, visualized behind the left atrium. A-P, antero-posterior; Asc ao, ascending aorta; Desc ao, descending aorta; LA, left atrium; L-L, latero-lateral; LV, left ventricle; MHI, modified Haller index; RV, right ventricle. [Display omitted] • Chest wall abnormalities may impair cardiac motion and function. • Modified Haller index (MHI) is a radiation-free technique for assessing chest shape. • The MHI method may identify subjects with concave-shaped chest wall (MHI >2.5). • Subjects with MHI >2.5 have small cardiac chambers and impaired strain indices. • Impairment in myocardial deformation indices is strongly correlated with MHI. [ABSTRACT FROM AUTHOR]

Supra-physiologic doses of anabolic androgenic steroids (AAS) lead to multiple cardiovascular complications. The long-term clinical effect of AAS overuse on cardiac structure and function, which persists during off-cycle periods, remains unclear. A total of 15 sedentary subjects and 79 bodybuilders (26 AAS non-users and 53 AAS-users), matched for age and male gender, were assessed in a cross-sectional design for echocardiography measures. AAS-users were included during an off-cycle phase, abstained from AAS for at least 1 month. 2D standard M-mode and speckle tracking echocardiography were used to measure cardiac dimensions and functions. Inter-ventricular septum and posterior wall thickness were significantly higher among chronic off-cycle AAS-users compared to AAS non-users and sedentary group. Off-cycle AAS-users showed lower E/A ratio of the diastolic function. Left ventricular systolic function was not affected in terms of ejection fraction, but significant subclinical systolic dysfunction, assessed by GLS, was observed for chronic off-cycle AAS-users compared to AAS non-users (GLS = -16.8% vs. - 18.5 %, respectively; p = 0.001). Diameter of left atrium and right ventricle were significantly enlarged among off-cycle AAS-user bodybuilders (p = 0.002 and 0.040). TAPSE and RV S′, and cardiac vasculature of aorta were comparable in all groups. This study demonstrates that during off-cycle phase, AAS-users show long-term impaired GLS, even after considerable AAS abstain, despite normal LVEF. It highlights the importance of following GLS to predict hypertrophy and heart failure events, and not relying on LVEF alone. In addition, the hypertrophic effect of chronic AAS consumption is transitional during AAS washout periods. • Bodybuilders misusing anabolic androgenic steroids (AAS) present long-term subclinical systolic dysfunction. • Off-cycleAAS-user bodybuilders show impaired global longitudinal strain despite normal left ventricular ejection fraction. • AAS-induced hypertrophy is transient during off-cycle phase. [ABSTRACT FROM AUTHOR]

Provocative maneuvers have the potential to overcome the low sensitivity of resting echocardiography and biomarkers in the detection of heart failure with preserved ejection fraction (HFpEF). We investigate the mechanical response of the left ventricle to an afterload challenge in patients with preclinical and early-stage HFpEF (es-HFpEF). Three groups of patients (non-HFpEF - n = 42, pre-HFpEF - n = 43, and es-HFpEF - n = 39) underwent echocardiography at rest and during an afterload challenge induced by handgrip maneuver combined with pneumatic constriction of limbs. Patients in the non-HF group displayed a median ΔLPSS = −4% (IQR: −10%, +2%), LPSS rest<16% in 3/42(7%) and LPSS stress<16% in 6/43(14%). Subjects in the pre-HFpEF group displayed median ΔLPSS = -3% (IQR: −10%, +5%) LPSS rest<16% in 13/43(30%) and LPSS stress<16% in 19/43 (44%). 11/43 (25%) subjects in this group increased at least one absolute point in LPSS during stress. Patients in es-HFpEF group displayed a median ΔLPSS = −10% (IQR: −18%, −1%), LPSS rest<16% in 15/39(38%) and LPSS stress<16% in 25/39(64%). Changes in LPSS (ΔLPSS) were significantly greater in es-HFpEF than pre-HFpEF (p = 0.022). In multivariate analysis, this group effect was maintained after adjustment of the LPSS for systolic blood pressure, use of β-blockers, LV mass, RWT, age, and sex. Our data suggest that patients with HFpEF have a marked decrease in peak strain during acute pressure overload. Longitudinal studies are needed to test and compare the clinical impact of each pattern in early and long-term follow-ups. • Afterload increase challenge is a provocative maneuver that potentially overcomes the low sensitivity of resting echocardiography and biomarkers in the detection heart failure with preserved ejection fraction (HFpEF) • We studied the mechanical response of the left ventricle to afterload challenge in a population of 124 subjects with different stages of HFpEF • Subjects with early-stage HFpEF display a marked decrease in peak strain during increased afterload [ABSTRACT FROM AUTHOR]

Presence of left ventricular diastolic dysfunction (DD) is key in the pathogenesis of heart failure with preserved ejection fraction (HFpEF). However, non-invasive assessment of diastolic function is complex, cumbersome, and largely based on consensus recommendations. Novel imaging techniques may help detecting DD. Therefore, we compared left ventricular strain-volume loop (SVL) characteristics and diastolic (dys-)function in suspected HFpEF patients. 257 suspected HFpEF patients with sinus rhythm during echocardiography were prospectively included. 211 patients with quality-controlled images and strain and volume analysis were classified according to the 2016 ASE/EACVI recommendations. Patients with indeterminate diastolic function were excluded, resulting in two groups: normal diastolic function (control; n = 65) and DD (n = 91). Patients with DD were older (74.8 ± 6.9 vs. 68.5 ± 9.4 years, p < 0.001), more often female (88% vs 72%, p = 0.021), and more often had a history of atrial fibrillation (42% vs. 23%, p = 0.024) and hypertension (91% vs. 71%, p = 0.001) compared to normal diastolic function. SVL analysis showed a larger uncoupling i.e., a different longitudinal strain contribution to volume change, in DD compared to controls (0.556 ± 1.10% vs. -0.051 ± 1.14%, respectively, P < 0.001). This observation suggests different deformational properties during the cardiac cycle. After adjustment for age, sex, history of atrial fibrillation and hypertension, we found an adjusted odds ratio of 1.68 (95% confidence interval 1.19–2.47) for DD per unit increase in uncoupling (range: −2.95–3.20). Uncoupling of the SVL is independently associated with DD. This might provide novel insights in cardiac mechanics and new opportunities to assess diastolic function non-invasively. • Uncoupling of the Strain - Volume Loop is associated with diastolic (dys)function in suspected HFpEF. • Novel imaging methods to assess cardiac function over a complete cardiac cycle. • Combining speckle tracking echocardiography and LV volume to assess cardiac function. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) hypertrophy is the main feature of cardiac involvement in Anderson-Fabry disease (FD), but the right ventricle (RV) is also frequently affected. Previous studies failed to demonstrate an independent association between conventional parameters of RV performance and outcomes in FD. Nevertheless, if RV free wall strain (RV-FWS), assessed by 2D speckle tracking analysis, may provide a better prognostication is currently unknown. We retrospectively evaluated the association between RV-FWS and the occurrence of cardiovascular events in a cohort of 56 patients with FD. The study endpoint comprises cardiovascular mortality, severe heart failure symptoms, new-onset atrial fibrillation and major arrhythmias requiring device implantation. Reduced RV-FWS, defined by values lower than 23%, was found in 25 (45%) patients. During a median follow-up of 47 months, 16 (29%) patients met the study endpoint. A ROC-curve analysis confirmed the threshold of reduced RV-FWS (<23%) as the best cut-off for predicting cardiovascular events, but with a lower power compared to left-sided parameters. On univariable Cox regression analysis, RV-FWS, expressed as continuous variable, was significantly associated with the study endpoint (HR: 0.795, 95% CI: 0.710–0.889, p < 0.001). However, RV-FWS did not retain a significant association with outcomes, after adjustment for LV global longitudinal strain or indexed left atrial volume (p = 0.340 and p = 0.289 respectively). RV-FWS was not independently associated with the occurrence of cardiovascular events in FD, confirming previous observations that prognosis is mainly driven by the severity of LV cardiomyopathy. • Impaired RV-FWS is associated with a higher risk of cardiac events in Fabry disease. • However this association was not significant after adjustment for left-sided parameters. • The severity of LV cardiomyopathy is the main prognostic determinant in Fabry disease. [ABSTRACT FROM AUTHOR]

Moderate aortic stenosis (AS) often coexists with left ventricular (LV) systolic dysfunction and may affect survival through afterload mismatch. Because outcomes are ultimately driven by the condition of the LV, accurate assessment of LV performance is crucial to improve risk stratification. This study investigated the prognostic value of LV global longitudinal strain (GLS) in patients with moderate AS and reduced LV systolic dysfunction. Patients with moderate AS (aortic valve area 1.0–1.5 cm2) and reduced LV ejection fraction (EF) (<50%) were identified. LVGLS was evaluated with speckle-tracking echocardiography. Patients were divided into 2 groups according to an LVGLS value of 11%, based on spline curve analysis. The primary endpoint was all-cause mortality. A total of 166 patients (mean age 73 ± 11 years, 71% male) were included. The cumulative 1- and 5-year mortality rates were higher in patients with LVGLS <11% (25% and 60%) versus LVGLS ≥11% (10% and 27%) (p < 0.001). On multivariable analysis, LVGLS as a continuous variable (HR 0.753; 95% CI 0.673–0.843; p < 0.001) and as a categorical variable (<11%) (HR 3.028; 95% CI 1.623–5.648; p < 0.001) were independently associated with outcomes, whereas LVEF was not. LVGLS provided additional prognostic information in patients with/without coronary artery disease and with mildly versus severely reduced LVEF. In addition, LVGLS had incremental prognostic value over established risk factors, including LVEF. The combination of moderate AS and reduced LV systolic dysfunction is associated with a high mortality risk. LVGLS, but not LVEF, is independently associated with mortality and provides incremental prognostic value over established risk factors in patients with moderate AS and reduced LVEF. [Display omitted] • The combination of moderate AS and LV systolic dysfunction is associated with very high mortality rates. • LV GLS, but not LVEF, is independently associated with outcomes in patients with moderate AS and LV dysfunction. • An LV GLS value of 11% discriminates well between high-risk and low-risk patients. • LV GLS provides incremental prognostic value over established risk factors in patients with moderate AS. [ABSTRACT FROM AUTHOR]

Response to cardiac resynchronization therapy (CRT) is reduced in patients with high left ventricular (LV) scar burden, in particular when scar is located in the LV lateral wall or septum. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can identity scar, but is not feasible in all patients. This study investigates if myocardial metabolism by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and contractile function by echocardiographic strain are alternatives to LGE-CMR. In a prospective multicenter study, 132 CRT candidates (91% with left bundle branch block) were studied by speckle tracking strain echocardiography, and 53 of these by FDG-PET. Regional myocardial FDG metabolism and peak systolic strain were compared to LGE-CMR as reference method. Reduced FDG metabolism (<70% relative) precisely identified transmural scars (≥50% of myocardial volume) in the LV lateral wall, with area under the curve (AUC) 0.96 (95% confidence interval (CI) 0.90–1.00). Reduced contractile function by strain identified transmural scars in the LV lateral wall with only moderate accuracy (AUC = 0.77, CI 0.71–0.84). However, absolute peak systolic strain >10% could rule out transmural scar with high sensitivity (80%) and high negative predictive value (96%). Neither FDG-PET nor strain identified septal scars (for both, AUC < 0.80). In CRT candidates, FDG-PET is an excellent alternative to LGE-CMR to identify scar in the LV lateral wall. Furthermore, preserved strain in the LV lateral wall has good accuracy to rule out transmural scar. None of the modalities can identify septal scar. The present study is part of the clinical study "Contractile Reserve in Dyssynchrony: A Novel Principle to Identify Candidates for Cardiac Resynchronization Therapy (CRID–CRT)", which was registered at clinicaltrials.gov (identifier NCT02525185). The ability of peak systolic strain by echocardiography and glucose metabolism by FDG-PET to identify transmural LV lateral and septal scar in CRT candidates compared to LGE-CMR, illustrated in three representative patients. LGE-CMR (left images) allows for direct scar identification independent of wall motion, and was used as reference standard for scar. Peak systolic strain by echocardiography (middle images) was generally inconclusive of scar, but absolute strain >10% in the LV lateral wall implies that transmural scar in this region is unlikely. Glucose metabolism by FDG-PET (right images) accurately identified transmural LV lateral wall scar, but was unable to distinguish transmural septal scar from septal hypo-metabolism due to left bundle branch block in itself. FDG-PET = 18F-fluorodeoxyglucose Positron Emission Tomography; LV = left ventricular; CRT = cardiac resynchronization therapy; LGE = late gadolinium enhancement; CMR = cardiac magnetic resonance. [Display omitted] • FDG-PET is a good alternative to CMR to identify transmural left ventricular lateral wall scars in patients referred for CRT. • Strain by echocardiography is only moderately accurate, but relatively preserved strain (>10%) in the lateral wall strain means that transmural scar in this region is unlikely. • Contrary to preserved strain, reduced strain in the lateral wall is inconclusive with regard to scar. • Neither FDG-PET nor echocardiographic strain identifies septal scar. [ABSTRACT FROM AUTHOR]

We aimed to assess if right ventricular (RV) 4-chamber longitudinal strain (RV4CLS), RV free wall longitudinal strain (RVFWLS) and RV mechanical dispersion index (RVMDI) have prognostic independent value in patients with preserved ejection fraction (pEF), without clearly elevated LV filling pressure. Retrospective analysis of Peak RV4CLS, RVFWLS, RVMDI and comprehensive echocardiographic assessment including left ventricle (LV), atrium (LA) strain and RV parameters in patients with pEF (EF ≥ 50%; E/e' < 14). Multivariate Cox regression hazards model were used to determine the independent association between RV strain parameters to all-cause mortality and cardiovascular events. We analyzed 224 consecutive patients with pEF (age 65.2 ± 19.8, 44% female, Charlson Comorbidity Index median = 3.8), with all-cause mortality of 64 patients and 28 cardiovascular events, during a median follow-up of 8.2 years (interquartile range: 6.8 to 8.4 years). The best strain univariate predictors of mortality were RV4CSL [1.16 (1.07–1.26); p = 0.0001] and RVMDI [1.01 (1.001–1.02); p = 0.02] being superior to LV and LA strain, or other RV functional indices. Moreover, after adjustment for clinical (age, gender, Charlson Comorbidity Index), conventional echocardiographic parameters (LA volume, E/e' average, LVEDD, routine RV functional indices), LV and LA STE, RV4CLS and RVFWLS remained statistically significant associates of all-cause mortality and cardiac events. RV4CLS, or RVFWLS remained statistically significant associated for all-cause mortality, after additional adjustment for RVFAC and RVMDI. RV4CSL and RVMDI provide significant prognostic additive value in patients with preserved ejection fraction with excellent reproducibility, incremental to routine clinical, hemodynamic and LV and LA STE parameters. • RV4CLS, RVFWLS and RVMDI provide significant association with mortality in patients with normal LVEF and filling pressure. • These indices have excellent reproducibility, incremental to clinical, hemodynamic and echocardiographic parameters in patients with normal left function. • RV4CLS, or RVFWLS remained significantly associated even when adjusted additionally for conventional RV echo parameters and for RVMD [ABSTRACT FROM AUTHOR]

Current echocardiographic criteria cannot accurately differentiate exercise induced left ventricular (LV) hypertrabeculation in athletes from LV non-compaction cardiomyopathy (LVNC). This study aims to evaluate the role of speckle tracking echocardiography (STE) in characterising LV myocardial mechanics in healthy adolescent athletes with and without LVNC echocardiographic criteria. Adolescent athletes evaluated at three sports academies between 2014 and 2019 were considered for this observational study. Those meeting the Jenni criteria for LVNC (end-systolic non-compacted/compacted myocardium ratio > 2 in any short axis segment) were considered LVNC+ and the rest LVNC-. Peak systolic LV longitudinal strain (S l), circumferential strain (S c), rotation (Rot), corresponding strain rates (SR l/c) and segmental values were calculated and compared using a non-inferiority approach. A total of 417 participants were included, mean age 14.5 ± 1.7 years, of which 6.5% were LVNC+ (n = 27). None of the athletes showed any additional LVNC clinical criteria. All average S l , SR l S c , SR c and Rot values were no worse in the LVNC+ group compared to LVNC- (p values range 0.0003–0.06), apart from apical SR c (p = 0.2). All 54 segmental measurements (S l /S c SR l /SR c and Rot) had numerically comparable means in both LVNC+ and LVNC-, of which 69% were also statistically non-inferior. Among healthy adolescent athletes, 6.5% met the echocardiographic criteria for LVNC, but showed normal LV STE parameters, in contrast to available data on paediatric LVNC describing abnormal myocardial function. STE could better characterise the myocardial mechanics of athletes with LV hypertrabeculation, thus allowing the transition from structural to functional LVNC diagnosis, especially in suspected physiological remodelling. The use of 2D speckle tracking echocardiography in athlete assessment. [Display omitted] • Even among healthy adolescent athletes, 6.5% meet echocardiographic criteria for left ventricular non-compaction. • These athletes have normal global and segmental myocardial mechanics despite apparent significantly remodelled LV. • Adding speckle tracking echocardiography to current criteria could improve screening in athletes with LV hypertrabeculation. [ABSTRACT FROM AUTHOR]

The relief of congestion is crucial to improve heart failure (HF) patient's quality of life and prognosis. N-terminal-pro-brain natriuretic peptide (NT-proBNP) is a well-known marker of congestion, although with limited specificity. Peak atrial longitudinal strain (PALS) by speckle tracking echocardiography (STE) is an index of intracardiac pressure and HF prognosis. We aimed to determine the association between NT-proBNP and PALS and its prognostic implications in patients with HF. Patients hospitalized for de-novo or recurrent HF and outpatients with chronic HF were included in this retrospective study. Patients with missing data, previous cardiac surgery, non-feasible STE were excluded. Clinical, laboratory and echocardiographic data were collected. STE was performed on echocardiographic records. Primary endpoint was a combination of all-cause death and HF hospitalization. Overall, 388 patients were included (172 acute HF, 216 chronic HF, mean age = 65 ± 12 years, 37% female). Mean LV ejection fraction = 31 ± 9%. Global PALS showed a significant inverse correlation with NT-proBNP in acute and chronic HF (all p < 0.001). During a median follow-up of 4 years, 180 patients reached the combined endpoint. NT-proBNP (AUC = 0.87) and global PALS (AUC = 0.82) were good predictors of the combined endpoint. Global PALS was the only independent predictor of the combined endpoint. Optimal risk stratification for the composite endpoint was provided combining PALS ≤15% and NTproBNP ≥874.5 ng/l. Global PALS is associated with NT-proBNP in acute and chronic HF and may be used as additional index of congestion to optimize therapeutic management. The combination of global PALS and NT-proBNP could enhance the prognostic stratification of HF. [Display omitted] • The relief of congestion is one of the main therapeutic targets in heart failure (HF). • Left atrial (LA) strain is correlated with NT-proBNP in acute and chronic HF. • Speckle tracking echocardiography adds prognostic information to NT-proBNP in HF. • The combination of LA strain and NT-proBNP provides optimal risk stratification in HF. [ABSTRACT FROM AUTHOR]

This study aimed at investigating whether tissue Doppler imaging (TDI) is associated with adverse events in arrhythmogenic right ventricular cardiomyopathy (ARVC). Transthoracic echocardiography was performed in 72 patients with definite (n = 63) or borderline (n = 9) ARVC diagnosed according to the 2010 Task Force Criteria and included in the prospective Zurich ARVC registry. Myocardial peak systolic tissue velocity (S′) was measured by TDI at lateral tricuspid (tricuspid S′), medial mitral (septal S′), and lateral mitral annulus (lateral S′). Association of echocardiographic parameters with outcome was assessed by univariable Cox regression. During a median follow-up of 4.9 ± 2.6 years, 6 (8.3%) patients died of cardiovascular cause or received heart transplantation and 21 (29.2%) patients developed sustained ventricular arrhythmia. Tricuspid, septal, and lateral S′ were lower in patients who died (p = 0.001; p < 0.001; p = 0.008; respectively), while tricuspid and septal S′ were lower in those with ventricular arrhythmia (p = 0.001; p = 0.008; respectively). There was a significant association of tricuspid, septal, and lateral S′ with mortality (HR = 1.61, p = 0.011; HR = 2.15, p = 0.007; HR = 1.67, p = 0.017; respectively), while tricuspid and septal S′ were associated with ventricular arrhythmia (HR = 1.20, p = 0.022; HR = 1.37, p = 0.004; respectively). Kaplan-Meier analyses demonstrated a higher freedom from mortality with tricuspid S′ >8 cm/s (p = 0.001) and from ventricular arrhythmia with S′ >10.5 cm/s (p = 0.021). This study demonstrates that TDI provides information on the ARVC phenotype, is associated with adverse events in ARVC patients, and differentiates between patients with and without adverse events. [Display omitted] • Tissue Doppler tricuspid and mitral annulus velocity useful for assessing ARVC phenotype. • Tissue Doppler tricuspid and mitral annulus velocity associated with adverse events in ARVC. • Tissue Doppler annulus velocity differentiates patients with and without adverse events in ARVC. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common arrythmia following ST-segment elevation myocardial infarction (STEMI) and can lead to stroke and other heart-related diseases. This study aimed to determine the prognostic value of left atrial (LA) strain, obtained by speckle tracking echocardiography (STE), in predicting incident AF outcomes following STEMI treated with primary percutaneous coronary intervention (pPCI). This prospective study comprised of 392 STEMI patients treated with pPCI. The patients had an echocardiography performed at a median of two days after their STEMI. Along with conventional measures, LA strain was obtained by speckle tracking from two apical projections. The outcome was new-onset atrial fibrillation. LA reservoir, contractile and conduit strain were measurable from echocardiograms of 303 included patients. At a median follow-up time of 5.6 years (IQR: 5.0–6.1 years), 18 patients (6,3%) developed incident AF. Mean age was 62.0 years ±11.5 and follow-up was 100%. Significantly lower LA strain values were observed in patients who experienced AF during follow-up as compared to patients who didn't. Both reservoir, contractile and conduit strain were significant univariable predictors. In the multivariable model, only LA reservoir strain remained a significant independent predictor of AF. Left atrial reservoir strain obtained by two-dimensional speckle tracking echocardiography is an independent predictor of incident AF following STEMI. • Prognostic value of left atrial strain obtained by speckle tracking echocardiography. • Prognostic value of strain on atrial fibrillation following myocardial infarction. • Significantly lower left atrial strain in patient with atrial fibrillation. • Left atrial reservoir strain is a significant predictor of atrial fibrillation. [ABSTRACT FROM AUTHOR]

Despite improvement in treatment strategies of atrial fibrillation (AF), a considerable number of patients still experience recurrence of atrial tachyarrhythmia (ATA) following catheter ablation (CA). This study aimed to investigate the prognostic value of left atrial (LA) deformation analysis in a large group of patients undergoing CA for AF. This study included 678 patients with AF. Echocardiography including two-dimensional speckle tracking echocardiography (2DSTE) was performed in all patients prior to CA. Logistic regression analysis was used to assess the association between ATA recurrence and LA strain during reservoir phase (LASr), LA strain during contraction phase (LASct), and LA strain during conduit phase (LAScd). During one-year follow-up, 274 (40%) experienced ATA recurrence. Median age of the included study population was 63.2 years (IQR: 55.5, 69.5) and 485 (72%) were male. Patients with recurrence had lower LASr (22.6% vs. 25.1%, p = 0.001) and LASct (10.7% vs. 12.4%, p < 0.001). No difference in LAScd was observed. After adjusting for potential clinical and echocardiographic confounders LASr (OR = 1.04, CI95% [1.01; 1.07], p = 0.015, per 1% decrease) and LASct (OR = 1.06, CI95% [1.02; 1.11], p = 0.007, per 1% decrease) remained independent predictors of recurrence. However, in patients with a normal-sized LA (LA volume index<34 mL/m2), only LASct remained an independent predictor of recurrence (OR = 1.07, CI95% [1.01; 1.12], p = 0.012, per 1% decrease). In patients undergoing CA for AF, LA deformation analysis by 2DSTE could be of use in risk stratification in clinical practice regarding ATA recurrence, even in patients with a normal-sized LA. • LA strain by 2DSTE may predict recurrence of atrial tachyarrhythmia after catheter ablation for AF. • LA contractile strain may predict recurrence even in patients with normal-sized LA. • LA strain could be useful in clinical practice to help identify high-risk patients and make a personalised treatment plan. • The present findings promote the current understanding of the pathophysiology of the LA in patients with AF. [ABSTRACT FROM AUTHOR]

This study aimed to detect late sub-clinical patterns of cardiac dysfunction using speckle tracking echocardiography (STE) in children with cancer remission more than 12 months after the end of anthracycline treatment. This prospective controlled study enrolled 196 children, 98 of which had been treated with anthracyclines (mean age 10.8 ± 3.6 years; 51% female) and 98 were age- and gender-matched healthy subjects in a 1:1 case-control design. Conventional echocardiographic variables were collected for left ventricle (LV) and right ventricle (RV). STE analyses were performed in the LV longitudinal, radial, and circumferential displacements and in the RV free wall longitudinal displacement. The association between LV global longitudinal strain (GLS) and the main clinical and biological parameters was evaluated. After a mean time interval of 5.1 ± 3.2 years since the end of chemotherapy (mean cumulative anthracycline dose of 192 ± 96 mg/m2), conventional echocardiographic measures were normal. GLS was significantly decreased in the anthracycline group (−19.1% vs. −21.5%, P < 0.0001), with a higher proportion of children with abnormal values (Z -score < −2 in 18.6% vs. 1.0%, P < 0.0001). No association was found between GLS and clinical or biological parameters. Circumferential strain was significantly worse in the anthracycline group (−16.8% vs. −19.4%, P < 0.0001), and radial strain significantly better (+51.4% vs. +35.9%, P < 0.0001). RV conventional echocardiography and STE parameters were normal and not different between anthracycline and control groups. The existence of a modified LV strain despite normal LV function in children treated with anthracyclines represents an important perspective for cardiomyopathy surveillance in childhood cancer survivors. Clinical Trial Registration - ClinicalTrials.gov Identifier: NCT02893787. • Children have normal conventional echocardiograms 5-years after chemotherapy. • Global longitudinal strain and circumferential strain are lower in this population. • Radial strain is significantly higher. [ABSTRACT FROM AUTHOR]

Myocardial work (MW) estimation by pressure-strain loops using speckle tracking echocardiography (STE) has shown to evaluate left ventricular (LV) contraction overcoming the load-dependency limit of LV global longitudinal strain (GLS). This has proved useful in hemodynamic variation settings e.g. heart failure and valvular heart disease. However, the variation of MW and strain parameters across different stages of primary mitral regurgitation (MR) and its impact on symptoms, which was the aim of our study, has never been investigated. Consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery. Clinical evaluation, blood sample tests, ECG and echocardiography with STE and MW measurement were performed. Patients were then divided into groups according to MR severity. Differences among the groups and predictors of symptoms (as NYHA class≥2) were explored as study endpoints. Overall, 180 patients were enrolled (60 mild,60 moderate,60 severe MR). LV GLS and global peak atrial longitudinal strain (PALS) reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved, while global work efficiency (GWE) reduced, in patients with moderate and severe MR. Among echocardiographic parameters, global PALS emerged as the best predictor of NYHA class (p < 0.001;area under curve,AUC = 0.7). MW parameters accurately describe the pathophysiology of MR, with initial attempt of LV increased contractility to compensate volume overload parallel to the disease progress, although with low efficacy, while global PALS is the most associated with the burden of MR symptoms. [Display omitted] • Myocardial work (MW) provides non-load dependent analysis of myocardial function. • MW may add information on intrinsic cardiac damage in primary mitral regurgitation. • Left atrial strain is the most associated with symptoms in mitral regurgitation. [ABSTRACT FROM AUTHOR]

This study aims at investigating left atrial (LA) deformation by left atrial reservoir (LARS) and pump strain (LAPS) and its implications for long-term survival in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). Speckle tracking echocardiography was performed in 198 patients with severe AS undergoing TAVI. Association of strain parameters with cardiovascular mortality was determined. Over a follow-up time of 5 years, 49 patients (24.7%) died. LAPS was more impaired in non-survivors than survivors (P = 0.010), whereas no difference was found for LARS (P = 0.114), LA ejection fraction (P = 0.241), and LA volume index (P = 0.292). Kaplan-Meier analyses yielded a reduced survival probability according to the optimal threshold for LAPS (P = 0.002). A more impaired LAPS was associated with increased mortality risk (HR 1.12 [95% CI 1.02–1.22]; P = 0.014) independent of LVEF, LAVI, age, and sex. Addition of LAPS improved multivariable echocardiographic (LVEF, LAVI) and clinical (age, sex) models with potential incremental value for mortality prediction (P = 0.013 and P = 0.031, respectively). In contrast, LARS and LAVI were not associated with mortality. In patients undergoing aortic valve replacement for severe AS, LAPS was impaired in patients dying during long-term follow-up after TAVI, differentiated survivors from non-survivors, was independently associated with long-term mortality, and yielded potential incremental value for survival prediction after TAVI. LAPS seems useful for risk stratification in severe AS and timely valve replacement. [Display omitted] • Cardiac remodelling involves the left atrium in patients with severe aortic stenosis undergoing TAVI. • Left atrial pump strain, but not reservoir strain, is an independent predictor of long-term survival in these patients. • Left atrial dysfunction as reflected by pump strain may be a preferred parameter for long-term risk assessment after TAVI. [ABSTRACT FROM AUTHOR]

Current evidence suggests that Brugada syndrome (BrS), far from being a purely electrical condition, is associated with subtle mechanical abnormalities primarily affecting the right ventricle (RV). We aimed to characterize RV function in BrS and investigate the echocardiographic profile of patients with arrhythmic events, with a special focus on parameters of RV dyssynchrony using speckle-tracking echocardiography (STE). An echocardiogram was performed in 71 BrS patients and 25 healthy controls. STE was performed to assess regional and global RV mechanics, including RV outflow tract shortening (RVOTS). RVOT contraction time was considered to calculate the modified RV mechanical dispersion (RVMD m). Arrhythmic events were prospectively evaluated in the BrS cohort. Compared to controls, BrS patients showed subtle contractile abnormalities, including impaired RV longitudinal strain, higher RV index of myocardial performance (RIMP) and lower RVOTS. BrS patients also exhibited a greater contraction delay between the lateral and the septal aspect of the RV. After a median follow-up of 7.3 year (IQR 5.2–10.8), 6 patients presented malignant arrhythmic events. RIMP >0.50, RVOTS <16.2% and RVMD m > 42 ms showed high sensitivity for the identification of BrS patients with arrhythmic events during follow-up. Subtle RV mechanical abnormalities were present in BrS patients. RIMP and RVOTS, a novel STE-derived parameter, were found to be sensitive markers of arrhythmic events. Adding the RVOT contraction time to the analysis of RVMD may help identify patients at higher risk, reflecting the importance of the RVOT mechanical substrate in the assessment of the arrhythmic risk in BrS. • A subtle impairment in RV function is present in patients with Brugada syndrome (BrS). • RVOT shortening (RVOTS) measured by STE is feasible and reproducible. • Patients with arrhythmic events show reduced RVOTS and higher RIMP. • Adding the RVOT contraction time to the calculation of RV mechanical dispersion may help the identification of patients at high risk for arrhythmic events during follow-up. [ABSTRACT FROM AUTHOR]

Accurate non-invasive estimation of right atrial pressure (RAP) is essential to assess volume status and optimize therapy in heart failure (HF). This study aimed to evaluate the utility of right atrial reservoir strain (RASr) assessed by speckle-tracking echocardiography to identify elevated RAP in HF and compare diagnostic performance with estimated RAP employing inferior vena cava size and collapsibility (RAP IVC), in addition to RA area. Association between RASr and invasive RAP (RAP Invasive) was examined in 103 HF subjects that underwent standard echocardiography with speckle-tracking strain analysis directly followed by right heart catheterization. The discriminatory ability of RASr to identify RAP Invasive > 7 mmHg was evaluated and compared with RAP IVC and RA area. RASr demonstrated association with RAP Invasive (β = −0.41, p < 0.001) and was an independent predictor when adjusted for potential confounders (β = −0.25, p < 0.001). Further, RASr showcased strong discriminatory ability to identify subjects with RAP Invasive > 7 mmHg (AUC = 0.78; 95% CI 0.68–0.87; p < 0.001). At a cut-off value of −15%, RASr displayed 78% sensitivity and 72% specificity to identify elevated RAP Invasive. In comparison, RAP IVC (AUC = 0.71; 95% CI 0.61–0.81; p < 0.001) demonstrated 89% sensitivity and 32% specificity with high false positive rate. RA area (AUC = 0.66; 95% CI 0.55–0.76, p = 0.005) displayed 64% sensitivity and 53% specificity. RASr demonstrates good ability to identify elevated RAP and relatively stronger diagnostic performance when compared with conventional non-invasive measures. RASr may be useful as a novel noninvasive estimate of RAP in HF management. • We explored the utility of right atrial strain (RASr) to identify elevated right atrial pressure (RAP) in heart failure. • RASr demonstrated good feasibility and strong diagnostic performance as compared with conventional echo measures. • RASr is a novel, non-invasive identifier of elevated RAP with potential applications in heart failure management. [ABSTRACT FROM AUTHOR]

Diagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with dyspnea and paroxysmal atrial fibrillation (AF) is challenging. Speckle tracking-derived left atrial strain (LAS) provides an accurate estimate of left ventricular (LV) filling pressures and left atrial (LA) phasic function. However, data on clinical utility of LAS in patients with dyspnea and AF are scarce. To assess relationship between the LAS and the probability of HFpEF in patients with dyspnea and paroxysmal AF. The study included 205 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%), who underwent speckle tracking echocardiography during sinus rhythm. Probability of HFpEF was estimated using H 2 FPEF and HFA-PEFF scores, which combine clinical characteristics, echocardiographic parameters and natriuretic peptides. Patients with high probability of HFpEF were significantly older, had higher body mass index, NT-proBNP, E/e', pulmonary artery pressure and larger LA volume index than patients in low-to-intermediate probability groups (all p < 0.05). All components of LAS and LA strain rate showed proportional impairment with increasing probability of HFpEF (all p < 0.05). Out of the speckle tracking-derived parameters, reservoir LAS showed the largest area under the curve (AUC = 0.78, p < 0.001) and the strongest independent predictive value (OR: 1.22, 95% CI 1.08–1.38) to identify patients with high probability of HFpEF. Reservoir LAS shows a high diagnostic performance to distinguish HFpEF from non-cardiac causes of dyspnea in symptomatic patients with paroxysmal AF. • LA strain showed to be a useful index to diagnose HFpEF in patients with history of AF. • LA strain might provide additional clue for diagnosing HFpEF in patients with intermediate probability of HFpEF. • Monitoring atrial function in this clinical setting might provide useful prognostic information. [ABSTRACT FROM AUTHOR]

Hypoplastic Left Heart Syndrome (HLHS) has high mortality and morbidity and systemic right ventricle (RV) dysfunction may play a key-role. Study aim is to evaluate the accuracy of speckle-tracking echocardiographic (STE) assessment of RV deformation and 2D standard echo parameters in predicting outcome in HLHS patients. We studied 27 HLHS patients (17 male) who successfully completed Norwood palliation. All the patients underwent in-hospital interstage stay. Serial echocardiographic assessment was performed: baseline, one-month after Norwood, three-months after Norwood, one-week before bidirectional cavopulmonary anastomosis (BCPA) and two-months after BCPA. From the apical view we measured: tricuspid annulus peak systolic excursion (TAPSE), fractional area change (FAC), longitudinal strain (LS) and strain rate (LSR). After a mean follow-up of 1.18 (± 1.16) years, 8 out of 27 of the included patients met the composite endpoint of death/heart transplant (HT). At pre-Norwood assessment, there was no difference in echo measurements between survivors and patients with events. In death/HT group TAPSE and LS declined already one-month after Norwood procedure: TAPSE ≤5 mm had good sensitivity (85.71%) and moderate specificity (63.16%) for death/HT (AUC = 0.767); a decrease of LS > 8.7% vs baseline showed 100% sensitivity and 84.21% specificity for death/HT (AUC = 0.910). At multivariate analysis, one-month-after-Norwood LS drop >8.7% was the best predictor of outcome (P = 0.01). RV dysfunction in HLHS carries prognostic value. Our findings encourage serial measurements of RV function to identify the subgroup of HLHS patients at higher risk. In our experience, ∆ LS showed the best predictive value. • Hypoplastic left heart syndrome still carries high mortality and morbidity. • Systemic right ventricle dysfunction is one of the major causes of the poor outcome. • Speckle tracking echocardiography is accurate in right ventricular function assessment. • Serial evaluations may precociously identify patients with poor prognosis. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) global longitudinal strain (GLS) can detect an early dysfunction in arterial hypertension. We investigated regional LV patterns of longitudinal strain (LS) and base-to-apex behaviour in newly diagnosed, never-treated hypertensive patients (HTN) without LV hypertrophy. 180 HTN and 115 healthy controls underwent standard echocardiography, including regional LS and GLS assessment (in absolute values). The average LS of six basal (BLS), six middle (MLS), and six apical (ALS) segments and relative regional strain ratio = [ALS/(BLS + MLS)] were also computed. The two groups were comparable for sex, age and heart rate. Body mass index (BMI), systolic, diastolic and mean blood pressure (BP) (all p < 0.0001) were higher in HTN. Despite LV ejection fraction (EF) was comparable, GLS, BLS and MLS resulted lower in HTN (all p < 0.0001), without difference in ALS. Relative regional strain ratio resulted higher in HTN (p < 0.001). Dividing HTN group according to lower normal values derived from the controls, BLS was able to identify a higher rate of LV dysfunction than GLS. By a multiple linear regression analysis performed in the pooled population after adjusting for age, sex, BMI, end-systolic stress, relative wall thickness and LV mass index, the association between BLS and mean BP remained significant (β coefficient = −0.42, p < 0.0001), despite the significant impact of male sex. In a similar model, MLS and mean BP resulted also independently associated (β = −0.21, p < 0.002). Despite normal LV EF, LS dysfunction is detectable in HTN, mainly involving basal and middle segments, resulting in higher relative regional strain ratio. • In native hypertensive patients a longitudinal dysfunction is detectable. • Longitudinal impairment mainly involves basal and middle segments. • More prominent base-to-apex gradient results in high relative regional strain ratio. • Basal and middle strains resulted negatively associated with mean blood pressure. [ABSTRACT FROM AUTHOR]

Brugada syndrome (BrS) is characterized by a high risk of sudden cardiac death. The clinical value of deformation imaging in patients with BrS is unknown. We aimed to assess whether echocardiographic speckle tracking parameters differ between: 1) BrS patients and healthy controls, 2) BrS patients with and without life-threatening ventricular arrhythmias. Left ventricle (LV) and right ventricle (RV) longitudinal strain and mechanical dispersion (MD) were derived from echocardiography at inclusion. Clinical and ECG data were retrospectively assessed. A life-threatening ventricular arrhythmia was defined as an aborted cardiac arrest or sustained ventricular tachyarrhythmia. We included 175 BrS patients and 82 controls. LV and RV longitudinal strain were lower (−18.1 ± 2.6% vs. −18.8 ± 2.0%, p = 0.01 and − 24.4 ± 5.4% vs. 25.6 ± 3.7%, p = 0.04), while MD was higher [38 ± 11 ms vs. 33 ± 8 ms, p = 0.001 and 15 (8–25) ms vs. 11 (6–19) ms, p = 0.03] in BrS patients compared to controls. BrS patients who experienced a life-threatening ventricular arrhythmia (n = 19) had higher LV MD compared to those without events (43 ± 11 ms vs. 37 ± 11 ms, p = 0.02). An LV MD ≥40 ms was optimally associated with life-threatening ventricular arrhythmias [odds ratio 4.62 (95%CI 1.58–13.50), p = 0.005]. BrS patients had lower longitudinal strain and more heterogeneous contractions than healthy controls. Furthermore, BrS patients with a history of life-threatening ventricular arrhythmia had more heterogeneous LV contractions than those without. Therefore, LV MD may be a risk marker in BrS and its evaluation in prospective studies is needed. Unlabelled Image • Brugada syndrome patients have an increased risk for sudden cardiac death • Selection of candidates for defibrillator implantation is challenging • Speckle tracking echocardiography shows contraction alterations in Brugada syndrome • Left ventricle mechanical dispersion is higher in arrhythmic Brugada patients • Cardiac imaging might improve risk stratification in Brugada syndrome patients [ABSTRACT FROM AUTHOR]

Heart failure (HF) patients present with a variety of symptoms at different stages of the disease, but the underlying pathophysiology still is unclear. Left atrial (LA) function might be tightly related to changes in patients' symptoms, more than morphological and anatomic heart features, measurable by ultrasound imaging technique. This study sought to investigate the correlation between LA function, assessed by Speckle Tracking Echocardiography (STE) and Quality of Life (QoL), assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), in patients with chronic HF. Clinically stable HF outpatients (n = 369) were enrolled from 7 different international centres and underwent echocardiographic studies. Patients >75 years old and with atrial fibrillation were excluded. LA strain during reservoir phase (LASr) by STE was measured in all subjects by averaging the 6 atrial segments. LA size was assessed using biplane volume and 4-chamber area acquisition. LASr strongly correlated with both MLHFQ total score (r = −0.87; p < 0.0001). Less significant correlations between MLHFQ and either LA volume or left ventricular global longitudinal strain (LV-GLS) were found (r = 0.28; p = 0.05 and r = 0.30; p = 0.01, respectively). No significant correlation was found between MLHFQ score, LVEF (r = −0.15; p = ns), E/E' ratio (r = 0.19; p = ns), and E/A ratio (r = 0.20; p = ns). Among all echocardiographic parameters analyzed, LASr presented the highest diagnostic accuracy (AUC = 0.74) in predicting a poor QoL (>45), when compared with LV-GLS (AUC = 0.61), LA volume (AUC = 0.54) and E/e' ratio (AUC = 0.51). In patients with HF, irrespective of etiology, LA function strongly correlates with patients' QoL. • In heart failure, left atrial reservoir strain inversely correlated with MLHFQ • There was a weak correlation between left atrial volume and MLHFQ • There was no relationship between MLHFQ and LVEF and E/E' ratio • STE is a useful tool to evaluate atrial dysfunction with a clinical impact [ABSTRACT FROM AUTHOR]

Abstract Background Accurate risk stratification of patients with Ebstein's anomaly (EA) is crucial. Aim of the study was to assess the prognostic value of echocardiography, including 2D speckle tracking (STE) derived myocardial deformation indices, for predicting outcome in pediatric and young adult unrepaired EA patients. Methods Fifty consecutive EA patients (1 day–18 years, 52% males) underwent echocardiography and were followed for a mean follow-up of 60 ± 41 months for clinical outcome (ventricular tachyarrhythmia, heart failure, need for surgery and/or death). Clinical and instrumental features of EA patients with stable disease were compared with those of EA patients with progressive disease. Results Twenty-four (48%) EA patients had progressive disease. A more severe grade of tricuspid valve (TV) displacement [59.7 mm/m2 (IQR 27.5–83) vs 28.4 mm/m2 (IQR 17.5–47); p = 0.002], a lower functional right ventricle (RV) fractional area change (FAC) (29.2 ± 7.7% vs 36.7 ± 9.6%; p = 0.004), a higher Celermajer index [0.8 (IQR 0.7–0.98) vs 0.55 (IQR 0.4–0.7); p = 0.000], a lower functional RV-longitudinal strain (−10.2 ± 6.2% vs −16.2 ± 7.3%; p = 0.003) and a lower right atrium peak systolic strain (RA-PALS) (25.2 ± 13.5% vs 36.3 ± 12.5%; p = 0.004) were detected in progressive disease group compared to stable one, respectively. Functional RV-FAC and RA-PALS were independent predictors of progressive disease at multivariate analysis. Conclusion Our study demonstrated for the first time the prognostic role of RV-FAC and RA-PALS in a long-term follow-up of EA young patients. A complete echocardiographic evaluation should be regular part in the evaluation and risk-stratification of EA children. Highlights • Accurate risk stratification of Ebstein's anomaly (EA) patients is crucial. • Echocardiographic parameters may help in predicting outcome in EA patients, • Speckle tracking echo should be a regular part in the evaluation of EA children, [ABSTRACT FROM AUTHOR]

Abstract Background Given that in patients with cardiac amyloidosis (CA), deposition of amyloid protein is not restricted to the left ventricular (LV) myocardium, it can be hypothesized that the diagnostic value of deformation mechanics would be enhanced by considering right ventricular (RV) strain measures. The aim of the present study was to examine the potential utility of left ventricular (LV) and right ventricular (RV) deformation and rotational parameters derived from three-dimensional speckle-tracking echocardiograph (3DSTE) to diagnose cardiac amyloidosis and differentiate this disease from other forms of myocardial hypertrophy. Methods Twenty-three patients with biopsy-proven light-chain (AL) amyloidosis, 23 patients with systemic arterial hypertension (HTN), 23 patients with hypertrophic cardiomyopathy (HCM), 23 athletes and 23 normal controls were prospectively studied by conventional echocardiography and 3DSTE. LV longitudinal strain (LV LS), LV circumferential strain (LV CS), RV global longitudinal strain and RV free-wall longitudinal strain (RV FW LS) were obtained by 3DSTE, as well as LV rotation and rotational velocities. Results LV and RV longitudinal strains were reduced in cardiac amyloidosis (CA) patients compared to controls. By multivariate analysis, LV basal LS (p = 0.002), LV peak basal rotation (p = 0.003), and RV basal FW LS (p = 0.014) were independently associated with CA in the overall population. A significant improvement in global χ2 value was noted with RV 3D-strain parameters over only LV-3DSTE + conventional indices for detection of CA (p < 0.001). Comparison of ROC curves showed that the AUC using combined LV basal LS, LV basal rotation and RV basal FW LS had a higher discriminative value than the other echocardiographic parameters used for detecting CA (AUC 0.93, 95%CI 0.81–0.97). Conclusions Three-dimensional speckle tracking echocardiography reveals regional and global biventricular dysfunction in CA. Assessment of RV ventricular dysfunction has an additive value in differentiating CA from other causes of myocardial wall thickening. Highlights • We examined the potential utility of three-dimensional speckle-tracking echocardiography in cardiac amyloidosis (CA). • Three-dimensional speckle tracking echocardiography revealed regional and global biventricular dysfunction in CA. • Right ventricular dysfunction assessment had an additive value in differentiating CA from other myocardial hypertrophies. [ABSTRACT FROM AUTHOR]

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 ± 2.2 vs −20.5 ± 1.3%, p < 0.0001) and LVCS (−16.4 ± 3.7 vs −20.9 ± 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. [ABSTRACT FROM AUTHOR]

Background We hypothesized that right atrial (RA) performance is abnormal in repaired tetralogy of Fallot (TOF). Methods TOF patients were prospectively enrolled for cardiovascular magnetic resonance (CMR), echocardiography and exercise stress following a standardized 14-center protocol. Peak RA longitudinal strain (RALS) and right ventricular longitudinal strain (RVLS) were measured using CMR feature tracking (FT) and correlated to RA and RV end diastolic volumes (EDVi) and ejection fraction (EF). Results The cohort had 311 subjects: 171 TOF (94 male, age 18.2 ± 8 years) and 140 healthy controls (69 male, 16.4 ± 11 years). RAEDVi, RALS, RVEDVi, RVLS, RAEF, and RVEF in TOF were 60.8 ± 17.1 ml/m 2 , 13.6 ± 5.7%, 120.3 ± 30.3 ml/m 2 , 12.3 ± 4.2%, 32.5 ± 9.9% and 51.2 ± 8.4% and differed from respective indices in controls: 51.7 ± 15.7 ml/m 2 , 27 ± 10.1%, 74 ± 19.0 ml/m 2 , 18.5 ± 5.3%, 54 ± 8% and 62.5 ± 5.5% (p < 0.001). RAEDVi and RALS correlated with RVLS (p = 0.004, < 0.001, r = 0.2,0.3). RAEDVi was higher in older TOF, while RALS did not increase with age. RAEDVi but not RALS correlated with RV systolic pressure(r = 0.2, 0). Neither RAEDVi nor RALS was associated with tricuspid regurgitation grade or peak oxygen uptake (r = 0.1, 0). Positive correlation was observed for RVEDVi with RAEDVi (p = 0.035, r = 0.2) and a trend toward negative correlation with RALS (p = 0.09, r = 0.1). Conclusion RALS, RAEDVi and RAEF are abnormal in TOF. Reduced RALS indicates decreased RA reservoir function. Because they correlate with other functional RV indices, these abnormalities may represent RA diastolic burden from chronic RV dysfunction in TOF. The young cohort age might explain the absence of RALS correlation to tricuspid regurgitation and peak oxygen uptake. [ABSTRACT FROM AUTHOR]

Background Up to one third of patients with chronic myocarditis (MC) have preserved left ventricular (LV) ejection fraction (MCpEF). The purpose of this study was to evaluate the role of adding 2D speckle-tracking echocardiography (STE) to cardiac magnetic resonance imaging (cMRI) in the diagnosis of patients with MCpEF. Methods and results We analyzed 67 patients with suspected MCpEF who underwent endomyocardial biopsy (EMB). Thirty-two patients with confirmed chronic myocardial inflammation by EMB served as study group (MCpEF) and the remaining patients ( n = 35) served as control group. In all patients, 2D STE and cMRI were performed within 48 h before EMB. Patients with MCpEF had significantly lower LV global longitudinal systolic strain (GLS) than controls (GLS: − 17.01 ± 2.42% vs. − 19.39 ± 3.81%, p < 0.001; respectively). In line, an abnormal GLS had adequate diagnostic performance to detect MCpEF (sensitivity, specificity, and accuracy of 82%, 70%, and 76%, respectively), which was superior to cMRI based on the Lake-Louise criteria (sensitivity, specificity, and accuracy 54%, 71%, and 67%, respectively). In addition, adding GLS to the Lake-Louise criteria improved significantly the diagnostic performance of cMRI to detect MCpEF (sensitivity, specificity, and accuracy 96%, 55%, and 75%, respectively). Conclusion The findings of this study suggest that GLS using 2D STE could play an important role in the diagnostic evaluation of patients with suspected chronic myocarditis with preserved LV ejection fraction (MCpEF). [ABSTRACT FROM AUTHOR]

Background In patients who have undergone arterial switch operation (ASO) for d-transposition of the great arteries a gothic aortic arch (GA) morphology has been found and it has been associated with abnormal aortic bio-elastic properties. Hypothesis GA is frequent in ASO patients and may have an impact on cardiac mechanics. Our study aims were to assess 1- the occurrence of GA in a large sample of patients after ASO; 2- the association between GA and aortic bio-elastic properties; and 3- the impact of GA on left ventricular (LV) function using speckle tracking echocardiography (STE). Methods We studied one hundred and five asymptomatic patients, who have undergone first stage ASO for d-TGA, with normal left ventricular ejection fraction (LVEF ≥ 53%). Results Forty-six (44%) patients showed a GA (mean age 11.5 ± 7.2 years, 26 males) while fifty-nine (56%) patients (mean age 9.6 ± 6.7 years, 37 males) did not present GA. The two groups were comparable for age, sex, BSA, and office blood pressure values. In group GA aortic root was significantly dilated (27.4 ± 7.5 mm vs. 21.2 ± 6.9 mm, p < 0.0001), aortic stiffness index (Group GA = 1.8 ± 1.2 vs. 1.4 ± 0.7, p = 0.025) was significantly increased, left atrial volume was larger ( p = 0.0145), global longitudinal strain (Group GA = − 18.4 ± 2.5% vs. − 20.1 ± 3.3%, p = 0.012) and basal LV longitudinal strains (Group GA = − 16.9 ± 4.8% vs. − 20.4 ± 7.0%, p = 0.013) were significantly reduced. Conclusions After ASO the presence of a GA is associated with a significantly dilated aortic root, stiffer aortic wall, larger left atrial volume, and worse LV longitudinal systolic deformations, well known predictors of cardiovascular morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background Published correlations between histological abnormalities and right ventricular (RV) function, as evaluated by speckle tracking echocardiography (STE), are scarce in patients with tetralogy of Fallot (TOF). The purpose of the study is to assess age-associated differences in the effect of RV myocardial remodeling on ventricular function in patients with TOF. Methods Operatively resected crista supraventricularis muscle from 30 patients (median age 12 months) undergoing intracardiac repair of TOF were studied by light microscopy. The patients were divided into younger (age at surgery ≤ 12 months) and older (age at surgery > 12 months) subgroups. The RV global longitudinal peak systolic strain (GLS), strain rate (GLSRs) and early diastolic strain rate (GLSRe) were measured by two-dimensional STE before and 6 months after repair. Results The histopathological data revealed hypertrophy of the cardiomyocytes, a thickened endocardium, and increased interstitial and perivascular collagen in RV, which were associated with older age at the time of repair. The RV global systolic and diastolic functions in patients with repaired TOF were increased compared with the preoperative values. The RV cardiomyocyte diameter and collagen volume fraction (CVF) correlated with the preoperative GLS, GLSRs and GLSRe, respectively, in the younger patients (r1 = - 0.566, P1 = 0.018; r2 = - 0.493, P2 = 0.004; r3 = - 0.504, P3 = 0.039). The RV cardiomyocyte diameter and CVF correlated with preoperative GLS, GLSRs and GLSRe, respectively, in the older patients (r1 = - 737, P1 = 0.004; r2 = - 0.588, P2 = 0.035; r3 = - 0.812, P3 = 0.001). The correlation of the RV cardiomyocyte diameter with the postoperative GLS and GLSRe (r1 = - 665, P1 = 0.036; r2 = - 0.787, P2 = 0.007) and the CVF with the postoperative GLSRs and GLSRe (r1 = - 762, P1 = 0.002; r2 = - 0.713, P2 = 0.004) were identified only in the older patients. Multivariate analysis indicated that the age at repair was an independent predictor of postoperative GLSRs and GLSRe in all of the patients (β = - 0.449, P = 0.041; β = - 0.607, P = 0.004). Conclusions The effect of RV myocardial remodeling on preoperative RV function was more pronounced in the older patients with TOF than in the younger ones. Preoperative myocardial remodeling affected the postoperative RV function in the older but not in the younger patients. The age at the time of surgical repair was the independent determinant of the postoperative RV myocardial function. [ABSTRACT FROM AUTHOR]

Abstract: Background: Amino-terminal B-type natriuretic peptide (NT-proBNP) may detect early cardiac dysfunction in adults with tetralogy of Fallot (ToF) late after corrective surgery. We aimed to determine the value of NT-proBNP in adults with ToF and establish its relationship with echocardiography and exercise capacity. Methods and results: NT-proBNP measurement, electrocardiography and detailed 2D-echocardiography were performed on the same day in 177 consecutive adults with ToF (mean age 34.6±11.8years, 58% male, 89% NYHA I, 29.3±8.5years after surgical correction). Thirty-eight percent of the patients also underwent a cardiopulmonary-exercise test. Median NT-proBNP was 16 [IQR 6.7–33.6] pmol/L, and was elevated in 55%. NT-proBNP correlated with right ventricular (RV) dilatation (r =0.271, p <0.001) and RV systolic dysfunction (r =−0.195, p =0.022), but more strongly with LV systolic dysfunction (r =−0.367, p <0.001), which was present in 69 patients (39%). Moderate or severe pulmonary regurgitation was not associated with higher NT-proBNP. Tricuspid and pulmonary regurgitation peak velocities correlated with NT-proBNP (r =0.305, p <0.001 and r =0.186, p =0.045, respectively). LV twist was measured with speckle-tracking echocardiography in 71 patients. An abnormal LV twist (20 patients, 28%) was associated with elevated NT-proBNP (p =0.030). No relationship between NT-proBNP and exercise capacity was found. Conclusions: NT-proBNP levels are elevated in more than 50% of adults with corrected ToF, while they are in stable clinical condition. Higher NT-proBNP is most strongly associated with elevated pulmonary pressures, and with LV dysfunction rather than RV dysfunction. NT-proBNP has the potential to become routine examination in patients with ToF to monitor ventricular function and may be used for timely detection of clinical deterioration. [Copyright &y& Elsevier]

Abstract: Background: The arterial switch operation (ASO) is currently the treatment of choice for infants with transposition of the great arteries (TGA). Little is known, however, about the alteration of anatomic left ventricular (LV) torsional mechanics after the operation. This study sought to evaluate LV torsion in patients of transposition of the great arteries with intact ventricular septum (TGA/IVS) using speckle tracking echocardiography. Methods: Echocardiographic images were prospectively acquired in 32 infants (age range, 0.5–60months) who successfully underwent ASO repair at about 1month of age and in 48 normal controls. They were divided into early and late categories according to the age at the time of the study. The LV peak systolic torsion and systolic twisting and diastolic untwisting velocities were determined by speckle tracking. Mitral inflow velocity obtained by Pulsed-wave Doppler and mitral annular velocities drawn by septal tissue Doppler were also analyzed. Results: Compared with controls, the early postoperative group (TGA1) had significantly higher septal E/e′ (P=0.000). In contrast, septal e′ velocity (P=0.000), LV peak apical rotation (P=0.01), twist (P=0.02) and peak untwisting velocity (PUV) (P=0.001) were lower in patients than in controls. For the normal younger group (Control1), PUV correlated positively with e′ (r=0.68, P<0.001). No significant difference in LV twisting and untwisting was noted between the TGA2 and Control2. Conclusions: Two dimensional speckle tracking echocardiography may sensitively detect impaired LV torsional mechanics in patients with TGA/IVS early after ASO, and the impairment of LV relaxation leads to increased LV filling pressure which is consistent with higher E/e′. However, all patients recovered well thereafter and the overall midterm outcome of ASO is satisfactory. [Copyright &y& Elsevier]

Abstract: Objectives: Heart failure (HF) patients with preserved left ventricular (LV) ejection fraction (EF) (HFpEF) due to systemic hypertension (SHT) are known to have limited exercise tolerance. Despite having normal EF at rest, we hypothesize that these patients have abnormal systolic function reserve limiting their exercise capacity. Methods: Seventeen patients with SHT (mean age 68±9years) but no valve disease and 14 healthy individuals (mean age of 65±10years) underwent resting and peak exercise echocardiography using conventional, tissue Doppler and speckle tracking techniques. The differences between resting and peak exercise values were also analyzed (Δ). Exercise capacity was determined as the workload divided by body surface area. Results: Resting values for left atrial (LA) volume/BSA (r=−0.66, p<0.001) and global longitudinal strain rate (GLSR) in early (e) and late (a) diastole (r=0.47 and 0.46, p<0.05 for both) correlated with exercise capacity. LVEF increased during exercise in normals (mean Δ EF=10±8%) but failed to do so in patients (mean Δ EF=0.6±9%, p<0.001 between groups). LV GLSR during systole (s) also failed to increase with exercise in patients, to the same extent as it did in normals (0.2±0.2 vs. 0.6±0.3 1/s, p<0.001). The difference between rest and exercise (Δ) in LV lateral wall systolic velocity from tissue Doppler (s′) (0.71, p<0.001), Δ in cardiac output (r=0.60, p<0.001) and Δ GLSRs (r=0.48, p<0.05) all correlated with exercise capacity independent of changes in heart rate. Conclusion: HFpEF patients with hypertensive LV disease have significantly limited exercise capacity which is related to left atrial enlargement as well as compromised LV systolic function at the time of the symptoms. The limited myocardial systolic function reserve seems to be underlying important explanation for their limited exercise capacity. [Copyright &y& Elsevier]

Background: Predicting improvement of myocardial function after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) remains a challenge. As ejection fraction (EF) may be of limited value in detecting early myocardial dysfunction and predicting outcome, we assessed the potential of echocardiographic longitudinal function in this setting. Materials and methods: Left ventricular (LV) function was assessed using EF, mitral annular plane systolic excursion (MAPSE), peak longitudinal 2D strain (LS) and strain rate (SR) in101consecutive patients with severe symptomatic AS (age 81±11years) undergoing TAVI. Echocardiography and assessment of clinical status including NYHA functional class were performed prior and after intervention (median 70days). Results: Pre-interventional EF was 57±17% and 32 patients (32%) had an EF<50% while 58 patients (57%) were found to have an impaired LS. After TAVI there was no significant change in EF. In contrast, LS, SR and MAPSE improved significantly (−14.0±4.4 vs. −15.5±4.0%; p=0.007, 0.68±0.24 vs. 0.78±0.23/s, p=0.002; and 9.1±3.2 vs. 10.2±3.3mm, p=0.006, respectively). Receiver Operating Curve characteristic analysis identified a pre-TAVI LS>−13.3% as the optimal cut-off value for predicting lack of LS recovery post TAVI. There was a marked improvement in NYHA FC after intervention (p=0.0002). Among the studied echocardiographic parameters LS change correlated closest with NYHA class improvement (r=0.42, p=0.0008). Conclusion: Overall, LS appears to be more sensitive for detecting early myocardial damage in patients with AS compared to conventional echocardiographic parameters. More importantly, pre-interventional LS may identify irreversible myocardial dysfunction and LS improvement correlates with symptomatic improvement after intervention. [ABSTRACT FROM AUTHOR]

Abstract: Background: Aortic stenosis (AS) causes significant disturbances in left ventricular (LV) and left atrial (LA) function irrespective of the extent of myocardial hypertrophy which associates the increased afterload. We hypothesize that aortic valve replacement (AVR) and removal of LV outflow tract obstruction should result in LA size and function recovery, even partial, and were set to study this in a group of patients with AVR for AS. Methods: Peak atrial longitudinal strain (PALS) was evaluated in 43 patients with severe isolated AS and normal EF (56.6±3.8%) and no obstructive coronary artery disease candidates for AVR, pre-operatively and then 40days and 3months after surgery. Results were compared with those from 34 age- and gender-matched healthy controls. Results: LVEF remained unchanged and LV mass regressed after AVR. Global PALS was reduced pre-operatively and increased 40days after surgery (p=0.002) and showed only a slight further increase at 3months follow-up (p<0.0001). Indexed LA volume was increased before surgery, but significantly fell 40days after surgery (p<0.0001) and showed only a slight further reduction after 3months (p<0.0001). Trans-aortic mean gradient change after surgery was the only independent predictor of the recovery of LA size and function. Conclusions: AVR reverses LA abnormalities and regains normal atrial function, a behavior which is directly related to the severity of pre-operative LV outflow tract obstruction. Early identification of LA size enlargement and functional disturbances might contribute to better patient's recruitment for AVR. [Copyright &y& Elsevier]

Abstract: Background: Subclinical cardiac involvement diagnosis is important for long term management of rheumatoid arthritis (RA) patients. Recently, 2D speckle tracking echocardiography (STE) allows non invasive and angle-independent measurement of left ventricular (LV) dimensions and regional myocardial strain (ε). The aim of this study was to assess whether STE can be useful to detect subclinical cardiac involvement in RA patients. Methods: We studied 22 RA patients (10M, 12F, aged 46±12years) without clinical evidence of coronary artery disease (CAD) and 20 healthy controls matched for age and sex by STE. LV end-systolic longitudinal and radial ε from apical 4-chamber view were analyzed using available software (QLAB 6.0). Results: Standard echo and Doppler parameters did not differ between the 2 groups. Tissue Doppler Imaging (TDI) showed a significant reduction of S′, E′ and E′/A′ ratio from the basal septum and lateral mitral annulus in RA patients. LV end-systolic radial and longitudinal ε of basal-lateral, basal- and mid-septal, mid-lateral and apical segments were significantly reduced compared to controls. Conclusions: Our data indicate that LV end-systolic radial and longitudinal ε are reduced in RA patients without CAD despite normal standard echo. Non invasive evaluation of LV function by STE appears to be useful to detect subclinical cardiac involvement in comparison to conventional 2D echoDoppler, representing a promising new modality to follow-up RA patients for cardiac involvement. [Copyright &y& Elsevier]

Abstract: Purpose: To distinguish focal fibrotic and non-fibrotic lesions in left-ventricular myocardium (LVM) in hypertrophic-cardiomyopathy (HCM)-subjects, we compared myocardial regional peak-strain values using two-dimensional speckle-tracking transthoracic-echocardiography (TTE) in multislice computed-tomography (CT)-detected fibrotic, non-fibrotic and normal control lesions. Methods: Twenty subjects (10 consecutive HCM-subjects (8-males, mean 63.4-years), 10 healthy controls (5-males, mean 51.5-years)) underwent speckle-tracking TTE (iE-33), and analysis of regional peak-longitudinal (LS) and radial-strain (RS), and corresponding strain rates in each of 17 LVM segments (American-Heart-Association classification). In HCM-subjects, fibrotic lesions were identified by early-phase defective enhancement and late-phase abnormal enhancement by CT (Light-Speed-Ultra-16). Regional peak LS and RS at basal, mid and apical levels were measured in MSCT-detected fibrotic and non-fibrotic LVM lesions. Results: In 10 HCM subjects, 143 lesions (84.1%) yielded good tracking on TTE. Twenty lesions showed fibrotic changes in 5 subjects by CT. Regional peak-LS and RS absolute values were significantly lower in both fibrotic and non-fibrotic lesions in HCM subjects than in controls at basal, mid, apical levels (all P<0.05). While peak-LS (%) absolute values were significantly lower in fibrotic than non-fibrotic lesions at basal, mid and apical levels (all P<0.05), regional peak-RS absolute values were significantly lower only at mid levels. LS was a more sensitive indicator than the corresponding rate, with better reproducibility. Conclusions: In HCM, regional peak-LS was significantly lower in fibrotic than non-fibrotic lesions in LVM by CT. Regional peak-LS by speckle-tracking provides useful information noninvasively to distinguish fibrotic from non-fibrotic lesions in LVM in HCM and normal LVM in healthy controls. [Copyright &y& Elsevier]

Abstract: Objective: We aimed to assess left atrial (LA) intrinsic myocardial function and its relationship to left ventricular (LV) filling pattern in a group of paroxysmal atrial fibrillation (PAF) patients. Methods: Twenty-three PAF patients (age 68±7year, 10 males) were studied using speckle tracking echocardiography and compared with 18 age and sex matched controls. LA segmental longitudinal strain (S), strain rate (SR) and myocardial velocities during atrial systole were measured as were LA diameters. E/A and E/Em were also measured. Results: LA longitudinal diameter was larger in patients (5.5±0.6 vs. 4.8±0.6cm, p<0.01) and global LA S (−9.2±4.3 vs. −12.9±4.6%, p=0.01) and SR (−1.1±0.5 vs. −1.6±0.7 1/s, p<0.01) were reduced and correlated with E/A (r=0.52, p=0.01 and r=0.43, p<0.05, respectively). LA lateral S and SR were uniformly reduced compared with controls (p<0.05 for all). Both septal and lateral wall SR correlated with E/A (p<0.05 for all), only septal S correlated with E/A (p<0.05). LA myocardial velocities were highest at the annular level and lowest at the rear in both patients and controls (p<0.01 for all). Conclusion: In PAF patients, LA systolic function is suppressed and is directly related to the pattern of LV filling which itself may suggest raised pressures. While intrinsic global and segmental function can reproducibly be studied by S and SR, myocardial velocities reflect only regional motion, thus less sensitive in demonstrating localize dysfunction. [Copyright &y& Elsevier]