Pre-Operative Point-of-Care Assessment of Left Ventricular Diastolic Dysfunction, an Observational Study

Background Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e’ and E/e’ for identification and grading of diastolic dysfunction pre-operatively. Methods 96 ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e’-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC). Results Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e’ and E/e’, diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e’-velocities (mean<9 cm s−1) had an AUROC of 0.901 (95%CI 0.840-0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78. Conclusions The results of this study indicate that a simplified approach with tissue Doppler e’-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e’ ratio the severity of diastolic dysfunction may be overestimated. Trial registration: Clinicaltrials.gov, Identifier: NCT 03349593. Date of registration 2017-11-21. https://clinicaltrials.gov.

Exome Sequencing Identifies a Novel FBN1 Variant in a Pakistani Family with Marfan Syndrome That Includes Left Ventricle Diastolic Dysfunction

Introduction: Cardiomyopathies are diseases of the heart muscle and are important causes of heart failure. Dilated cardiomyopathy (DCM) is a common form of cardiomyopathy that can be acquired, syndromic or non-syndromic. The current study was conducted to explore the genetic defects in a Pakistani family with cardiac disease and features of Marfan’s syndrome (MFS). Methods: A family with left ventricle (LV) diastolic dysfunction and MFS phenotype was assessed in Pakistan. The clinical information and blood samples from the patients were collected after physical, cardiovascular, and ophthalmologic examinations. An affected individual (proband) was subjected to whole-exome sequencing (WES). The findings were further validated through Sanger sequencing in the family. Results: Through WES and sanger validation, we identified a novel variant NM_000138.4; c.1402A>G in the Fibrillin-1 (FBN1) gene that segregates with LV diastolic dysfunction and MFS. Furthermore, bioinformatic evaluation suggested that the novel variant is deleterious and disease-causing. Conclusions: This study identified for the first time a novel FBN1 variant in a family with LV diastolic dysfunction and MFS in Pakistan.

Safety, Feasibility, and Impact of Enalapril on Cardiorespiratory Physiology and Health in Preterm Infants with Systemic Hypertension and Left Ventricular Diastolic Dysfunction

Neonatal hypertension has been increasingly recognized in premature infants with bronchopulmonary dysplasia (BPD); of note, a sub-population of these infants may have impaired left ventricular (LV) diastolic function, warranting timely treatment to minimize long term repercussions. In this case series, enalapril, an angiotensin-converting enzyme (ACE) inhibitor, was started in neonates with systemic hypertension and echocardiography signs of LV diastolic dysfunction. A total of 11 patients were included with birth weight of 785 ± 239 grams and gestational age of 25.3 (24, 26.1) weeks. Blood pressure improvement was noticed within 2 weeks of treatment. Improvement in LV diastolic function indices were observed with a reduction in Isovolumic Relaxation Time (IVRT) from 63.1 ± 7.2 to 50.9 ± 7.4 msec and improvement in the left atrium size indexed to aorta (LA:Ao) from1.73 (1.43, 1.88) to 1.23 (1.07, 1.29). Neonatal systemic hypertension is often underappreciated in ex-preterm infants and may be associated with important maladaptive cardiac changes with long term implications. It is biologically plausible that identifying and treating LV diastolic dysfunction in neonates with systemic hypertension may have a positive modulator effect on cardiovascular health in childhood and beyond.

Study of Ventricular Interdependence in Hemodialysis Patients

Background and objectivesStudy of respiratory variations in mitral valve (MV) Doppler flow in hemodialysis (HD) patients has not been investigated and normal adult referenced echocardiographic value is used as an echocardiographic reference to HD patients who have unique hemodynamic. This work aimed to study the respiratory variation in MV Doppler flow in HD patients to determine if it has a unique pattern in these patients, and to study any relation between this variation and volume-related parameters.MethodsWe conducted a prospective cohort study, carried out on 118 patients who underwent regular HD. A standard echocardiography was performed on the patients before and within 6 hs after dialysis. During quiet breathing, the transmitral spectral Doppler E wave was measured during inspiratory and expiratory phases using plethysmography breath-cycle chest-adhesive electrodes. The mathematic differences and the percent changes (ventricular interdependent; VI) in E wave were calculated pre-and post-dialysis. Post dialysis difference in the percent changes (∆ E wave % changes) was calculated as follows: pre-dialysis percent changes of E wave – post dialysis percent changes of E wave/pre dialysis percent changes E wave x 100. ResultsThe means of the mathematic differences between the MV inspiratory and expiratory E pre-and post-dialysis were 0.07 ± 0.18 m/s and 0.08 ± 0.22 m/s respectively with an insignificant difference between both phases; p = 0.337. Meanwhile, the means of the percent variation in the MV inspiratory and expiratory E pre-and post-dialysis were 56 ± 7 % and 44 ± 1.1 % respectively, with a significant reduction after dialysis; P = 0.000. Spearman correlation showed a significant positive correlation between post- dialysis ∆ E wave % change and post-dialysis % change of weight (r = 0.318; P = 0.000). Moreover, post- dialysis % change of weight and post- dialysis % changes of most other volume-related variable were independent predictors of post- dialysis ∆ E wave % in HD patients. ConclusionThe pre- and post- dialysis respiratory changes in the MV E wave in HD patients were higher than the normal adult referenced values. This marked variation could be explained by the unique overloading condition and could explain the LV diastolic dysfunction and the unexplained pulmonary hypertension in HD patients.

Diagnostic efficiency of a new method for determining the left ventricular diastolic dysfunction in heart failure

A new scientifically substantiated method for determining the left ventricle (LV) diastolic dysfunction (DD) in chronic heart failure (CHF) is based on the concept of a comprehensive assessment of the leading pathofunctional and hemodynamic mechanisms of development and progression of LV DD and CHF, global heart remodeling and contains the first developed diagnostic criteria obtained on the basis of 2D Speckle Tracking echocardiography. The method has a high diagnostic efficiency: the determination accuracy of LV DD types in an independent examination sample of patients with CHF with the less than 50 % preserved ejection fraction (EF) and LV EF was 98.5 %.

Speckle-tracking echocardiography in early diagnosis of lipotoxic myocardial damage in epicardial obesity

Epicardial obesity (EO) can lead to lipotoxic myocardial damage with the development of myocardial fibrosis, which underlie the impairment of left ventricular (LV) diastolic function. The identification of markers of lipotoxic myocardial damage is important at an early preclinical stage for preventive measures. Objective. To study the relationship of plasma levels of markers of insulin resistance and lipotoxic fibrosis with the parameters of LV mechanics in patients with EO. We hypothesized that there are significant differences in plasma levels of markers of insulin resistance and myocardial fibrosis and that they are associated with the parameters of LV mechanics in EO. Design and methods. The study included 143 men. Inclusion criteria: general obesity I–III degree. Exclusion criteria: type 2 diabetes mellitus, hypertension, LV diastolic dysfunction based on echocardiography (Echo). Patients were divided into 2 groups: EO (+) with epicardial fat thickness (tEAT) ≥ 7 mm (n = 70); EO (–) with tEAT < 7 mm (n = 31). All patients were assessed for glucose, blood insulin, profibrotic factors and free fatty acids (FFA) using enzyme-linked immunosorbent assay. HOMA-IR insulin sensitivity index was calculated as (insulin × glucose)/22,5. With the help of speckle-tracking Echo, the mechanics of LV were studied (LV twisting, LV twisting ratio, time to LV twisting peak, LV untwisting ratio, time to LV untwisting peak). Results. The patients with EO (+) showed a statistically significant increase in the level of FFA up to 0,82 (0,39; 1,30) mmol/L (< 0,0001) and HOMA-IR index up to 3,89 (2,02; 5,76) (< 0,0001) in comparison with the group EO (–). There was a statistically significant effect of tEAT on the level of FFA (F = 7,90; p = 0,006) and on the development of insulin resistance (F = 14,85; p < 0,001). The correlation analysis in the EO (+) group showed the relationship between FFA and type III collagen (r = 0,29, p = 0,01) and procollagen type I carboxy-terminal propeptide (PICP) (r = 0,26, p = 0,03), as well as between HOMA-IR and MMP-3 (r = 0,30, p = 0,01). In the EO (–) group, the relationship of profibrotic factors with the level of FFA and HOMA-IR was not found. There was also a significant relationship between LV untwisting ratio and level of FFA (r = 0,24, p = 0,04) in the group EO (+). Conclusions. Thus, an increase in the level of FFA in patients with EO may be accompanied by an increase in the level of some profibrotic factors and a LV untwisting violation determined by speckle-tracking Echo. Our data supports the need for assessing the FFA level and speckle-tracking Echo for the early diagnosis of LV diastolic dysfunction in patients with EO.

One-Year Change in the H2FPEF Score After Catheter Ablation of Atrial Fibrillation in Patients With a Normal Left Ventricular Systolic Function

Background: It is unclear whether atrial fibrillation (AF) catheter ablation (AFCA) improves the left ventricular (LV) diastolic function. We evaluated the 1-year change in the H2FPEF score, which reflects the degree of LV diastolic function, after AFCA among patients with a normal LV systolic function.Methods and Results: We included 1,471 patients (30.7% female, median age 60 years, paroxysmal-type AF 68.6%) who had available H2FPEF scores at baseline and at 1-year after AFCA to evaluate the 1-year change in the H2FPEF score (ΔH2FPEF score[1−yr]) after AFCA. Baseline high H2FPEF scores (≥6) were independently associated with the female sex, left atrium (LA) diameter, LV mass index, pericardial fat volume, and a low estimated glomerular filtration rate. One year after AFCA, decreased ΔH2FPEF scores[1−yr] were associated with baseline H2FPEF scores of ≥6 [OR, 4.19 (95% CI, 2.88–6.11), p &lt; 0.001], no diabetes [OR, 0.60 (95% CI, 0.37–0.98), p = 0.04], and lower pericardial fat volume [OR, 0.99 (95% CI, 0.99–1.00), p = 0.003]. Increased ΔH2FPEF scores[1−yr] were associated with a baseline H2FPEF score of &lt;6 [OR, 3.54 (95% CI, 2.08–6.04), p &lt; 0.001] and sustained AF after a recurrence within 1 year [SustainAF[1−yr]; OR, 1.89 (95% CI, 1.01–3.54), p = 0.048]. Throughout a 56-month median follow-up, an increased ΔH2FPEF score[1−yr] resulted in a poorer rhythm outcome of AFCA (at 1 year, log-rank p = 0.003; long-term, log-rank p = 0.010).Conclusions: AFCA appears to improve LV diastolic dysfunction. However, SustainAF[1−yr] may contribute to worsening LV diastolic dysfunction, and it was shown by increased ΔH2FPEF scores[1−yr], which was independently associated with higher risk of AF recurrence rate after AFCA.Clinical Trial Registration:ClinicalTrials.gov Identifier: NCT02138695.

Cardiac Abnormalities in Children with Pre-Dialysis Chronic Kidney Disease in a Resource-Limited Setting: A Cross-Sectional Observational Study

Background Cardiovascular disease is the leading cause of morbidity and mortality in children with chronic kidney disease (CKD). We aim to estimate the prevalence of cardiac abnormalities in children up to age 16 years with CKD and their association with various risk factors. Methods This cross-sectional observational study was conducted on 107 CKD children. We assessed the systolic and diastolic function using 2D echocardiographic evaluation and M-mode measurements of the left ventricle (LV) indexed for BSA and z-scores were calculated. Results were compared with age, sex, stage of CKD, anaemia, estimated glomerular filtration rate (eGFR) and various laboratory parameters. Results LV diastolic dysfunction was seen in 88%, followed by increased LV dimensions in 33.6%, LV systolic dysfunction in 16%, right ventricle systolic dysfunction in 11.2% while increased pulmonary artery (PA) systolic pressure was seen in 9.3% of cases. LV dimensions correlated directly with parathormone levels and inversely with eGFR, serum calcium and haemoglobin levels. Left ventricular hypertrophy correlated directly with parathormone while inversely with eGFR, serum calcium and haemoglobin. Ejection fraction directly correlated to eGFR and serum calcium while inversely related to parathormone. Left PA pressure directly correlated with age and inversely with eGFR. Right ventricular systolic function assessed by tricuspid annular plane systolic excursion correlated inversely with haemoglobin. Conclusion LV diastolic dysfunction and increased LV dimensions were the most common cardiac abnormality in children with CKD. LV dimensions correlated directly with parathormone levels and inversely with eGFR, serum calcium and haemoglobin. Diastolic dysfunction positively correlated with serum creatinine and parathormone levels.

The Prognostic Value of Echocardiographic Findings in Prediction of In-Hospital Mortality of COVID-19 Patients

Introduction: The correlation between echocardiographic findings and the outcome of COVID-19 patients is still under debate. Objective: In the present study it has been endeavored to evaluate the cardiovascular condition of COVID-19 patients using echocardiography and to assess the association of these findings with in-hospital mortality. Methods: In this retrospective cohort study, hospitalized COVID-19 patients from February to July 2020 with at least one echocardiogram were included. Data were extracted from patients’ medical records and the association between echocardiographic findings and in-hospital mortality was assessed using a multivariate model. The findings were reported as relative risk (RR) and 95% confidence interval (95% CI). Results: Data from 102 COVID-19 hospitalized patients were encompassed in the present study (63.7±15.7 mean age; 60.8% male). Thirty patients (29.4%) died during hospitalization. Tricuspid regurgitation (89.2%), mitral valve regurgitation (89.2%), left ventricular (LV) diastolic dysfunction (67.6%), pulmonary valve insufficiency (PI) (45.1%) and LV systolic dysfunction (41.2%) were the most common findings on patients’ echocardiogram. The analyses of data showed that LV systolic (p=0.242) and diastolic (p=0.085) dysfunction was not associated with in-hospital mortality of COVID-19 patients, while the presence of PI (RR=1.85; 95% CI: 1.02 to 3.33; p=0.042) and patients’ age (RR=1.03; 95% CI: 1.01 to 1.08; p=0.009) were the two independent prognostic factors of in-hospital mortality. Conclusions: It seems that LV systolic and diastolic dysfunction was not associated with in-hospital mortality of COVID-19 patients. However, presence and PI and old age are possible prognostic factors of COVID-19 in-hospital mortality. Therefore, using echocardiography might be useful in management of COVID-19.

Cardiac function abnormalities in rheumatoid arthritis and its association with duration of disease: a hospital-based case control study

Background: Rheumatoid Arthritis is associated with many extra-articular manifestations including cardiac abnormalities, which increases the risk of morbidity and premature death. Sub-clinical cardiac abnormalities occur many years before their clinically overt manifestations. The objective of the present study is to compare cardiac function abnormality in rheumatoid arthritis patients and healthy controls by echocardiography and to determine its relation with duration of disease.Methods: A hospital based case control study was conducted at a tertiary care centre of northern India including 70 rheumatoid arthritis patients and 70 controls. All subjects were evaluated by Electrocardiography and Trans-thoracic Echocardiography to determine cardiac function abnormalities.Results: ECG abnormalities were detected in 30% of RA cases as compared to only 7.1% of controls. Most common ECG abnormality was LV diastolic dysfunction (p=0.001), followed by pericardial effusion. A weak positive correlation was found between duration of disease and IVRT (r=0.329, p=0.005) indicating worsening of cardiac function with increasing duration of disease.Conclusions: Echocardiographic abnormalities are fairly common among RA patients with LV diastolic dysfunction being most common. Cardiac abnormalities increase with duration and severity of disease.