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Aims To determine whether fully automated artificial intelligence-based global circumferential strain (GCS) assessed during vasodilator stress cardiovascular (CV) magnetic resonance (CMR) can provide incremental prognostic value. Methods and results Between 2016 and 2018, a longitudinal study included all consecutive patients with abnormal stress CMR defined by the presence of inducible ischaemia and/or late gadolinium enhancement. Control subjects with normal stress CMR were selected using a propensity score-matching. Stress-GCS was assessed using a fully automatic machine-learning algorithm based on featured-tracking imaging from short-axis cine images. The primary outcome was the occurrence of major adverse clinical events (MACE) defined as CV mortality or nonfatal myocardial infarction. Cox regressions evaluated the association between stress-GCS and the primary outcome after adjustment for traditional prognosticators. In 2152 patients [66 ± 12 years, 77% men, 1:1 matched patients (1076 with normal and 1076 with abnormal CMR)], stress-GCS was associated with MACE [median follow-up 5.2 (4.8–5.5) years] after adjustment for risk factors in the propensity-matched population [adjusted hazard ratio (HR), 1.12 (95% CI, 1.06–1.18)], and patients with normal CMR [adjusted HR, 1.35 (95% CI, 1.19–1.53), both P < 0.001], but not in patients with abnormal CMR (P = 0.058). In patients with normal CMR, an increased stress-GCS showed the best improvement in model discrimination and reclassification above traditional and stress CMR findings (C-statistic improvement: 0.14; NRI = 0.430; IDI = 0.089, all P < 0.001; LR-test P < 0.001). Conclusion Stress-GCS is not a predictor of MACE in patients with ischaemia, but has an incremental prognostic value in those with a normal CMR although the absolute event rate remains low. [ABSTRACT FROM AUTHOR]

Aims We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients. Methods and results Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6–15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86–1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4–63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03). Conclusion Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes. [ABSTRACT FROM AUTHOR]

Aims Positron emission tomography (PET) myocardial perfusion imaging (MPI) is often combined with coronary artery calcium (CAC) scanning, allowing for a combined anatomic and functional assessment. We evaluated the independent prognostic value of quantitative assessment of myocardial perfusion and CAC scores in patients undergoing PET. Methods and results Consecutive patients who underwent Rb-82 PET with CAC scoring between 2010 and 2018, with follow-up for major adverse cardiovascular events (MACE), were identified. Perfusion was quantified automatically with total perfusion deficit (TPD). Our primary outcome was MACE including all-cause mortality, myocardial infarction (MI), admission for unstable angina, and late revascularization. Associations with MACE were assessed using multivariable Cox models adjusted for age, sex, medical history, and MPI findings including myocardial flow reserve. In total, 2507 patients were included with median age 70. During median follow-up of 3.9 years (interquartile range 2.1–6.1), 594 patients experienced at least one MACE. Increasing CAC and ischaemic TPD were associated with increased MACE, with the highest risk associated with CAC > 1000 [adjusted hazard ratio (HR) 1.67, 95% CI 1.24–2.26] and ischaemic TPD > 10% (adjusted HR 1.80, 95% CI 1.40–2.32). Ischaemic TPD and CAC improved overall patient classification, but ischaemic TPD improved classification of patients who experienced MACE while CAC mostly improved classification of low-risk patients. Conclusions Ischaemic TPD and CAC were independently associated with MACE. Combining extent of atherosclerosis and functional measures improves the prediction of MACE risk, with CAC 0 identifying low-risk patients and regional ischaemia identifying high-risk patients in those with CAC > 0. [ABSTRACT FROM AUTHOR]

Aims Left atrial (LA) function is a marker of prognosis in patients with heart failure. The prognostic implications of an improvement in LA function in addition to an improvement in left ventricular (LV) function after cardiac resynchronization therapy (CRT) implantation are unknown. This study aimed to evaluate the prognostic value of a significant change in LA reservoir strain (RS) and/or LV global longitudinal strain (GLS) after initiation of CRT. Methods and results LARS and LVGLS were measured with speckle-tracking echocardiography. Significant improvement in LARS and LVGLS was defined as a percentage change of +5% and +20% at 6 months after CRT implantation, respectively. Patients were divided into three groups: no significant reverse remodelling (no improvement in LARS and LVGLS), incomplete reverse remodelling (improvement in LARS or LVGLS), and complete reverse remodelling (improvement in LARS and LVGLS). The primary endpoint was all-cause mortality. A total of 923 patients (mean age 65 ± 10 years, 77% male) were included, of which 221 (24%) had complete reverse remodelling, 414 (45%) incomplete reverse remodelling, and 288 (31%) no significant reverse remodelling. Five-years' mortality was 24%, 29%, and 36% for patients with complete, incomplete, and no significant reverse remodelling, respectively (P < 0.001). On multivariable analysis, complete reverse remodelling (hazard ratio 0.477; 95% confidence interval: 0.362–0.628; P < 0.001) was associated with the lowest risk of mortality. Conclusions Patients with complete reverse remodelling have a lower mortality risk than those showing incomplete or no significant reverse remodelling. The use of integrated LA and LV deformation imaging may improve risk-stratification of CRT recipients. [ABSTRACT FROM AUTHOR]

Aims Elevated left ventricular filling pressure (LVFP) is a powerful indicator of worsening clinical outcomes in heart failure with preserved ejection fraction (HFpEF); however, detection of elevated LVFP is often challenging. This study aimed to determine the association between the newly proposed echocardiographic LVFP parameter, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, and clinical outcomes of HFpEF. Methods and results We retrospectively investigated 310 well-differentiated HFpEF patients in stable conditions. VMT was scored from 0 to 3 using two-dimensional echocardiographic images, and VMT ≥2 was regarded as a sign of elevated LVFP. The primary endpoint was a composite of cardiac death or heart failure hospitalization during the 2 years after the echocardiographic examination. In all patients, Kaplan–Meier curves showed that VMT ≥2 (n  = 54) was associated with worse outcomes than the VMT ≤1 group (n  = 256) (P  < 0.001). Furthermore, VMT ≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (AF) (P  = 0.026). In the adjusted model, VMT ≥2 was independently associated with the primary outcome (hazard ratio 2.60, 95% confidence interval 1.46–4.61; P  = 0.001). Additionally, VMT scoring provided an incremental prognostic value over clinically relevant variables and diastolic function grading (χ 2 10.8–16.3, P  = 0.035). Conclusions In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it could also predict clinical outcomes in HFpEF patients with AF. [ABSTRACT FROM AUTHOR]

Aims Left ventricular (LV) mechanical dispersion (MD) may result from heterogeneous electrical conduction and is associated with adverse events. The present study investigated (i) the association between LV MD and the extent of LV scar as assessed with contrast-enhanced cardiac magnetic resonance (CMR) and (ii) the prognostic implications of LV MD in patients after ST-segment elevation myocardial infarction. Methods and results LV MD was calculated by echocardiography and myocardial scar was analysed on CMR data retrospectively. Infarct core and border zone were defined as ≥50% and 35–50% of maximal signal intensity, respectively. Patients were followed for the occurrence of the combined endpoint (all-cause mortality and appropriate implantable cardioverter-defibrillator therapy). In total, 96 patients (87% male, 57 ± 10 years) were included. Median LV MD was 53.5 ms [interquartile range (IQR) 43.4–62.8]. On CMR, total scar burden was 11.4% (IQR 3.8–17.1%), infarct core tissue 6.2% (IQR 2.0–12.7%), and border zone was 3.5% (IQR 1.5–5.7%). Correlations were observed between LV MD and infarct core (r  = 0.517, P  < 0.001), total scar burden (r  = 0.497, P  < 0.001), and border zone (r  = 0.298, P  = 0.003). In total, 14 patients (15%) reached the combined endpoint. Patients with LV MD >53.5 ms showed higher event rates as compared to their counterparts. Finally, LV MD showed the highest area under the curve for the prediction of the combined endpoint. Conclusion LV MD is correlated with LV scar burden. In addition, patients with prolonged LV MD showed higher event rates. Finally, LV MD provided the highest predictive value for the combined endpoint when compared with other parameters. [ABSTRACT FROM AUTHOR]

Aims Cardiac resynchronization therapy (CRT) can reduce left ventricular end-systolic volume (LVESV), and a decrease of ≥15% is defined as a response. CRT can also improve LV global longitudinal strain (GLS). Changes in LVESV and LV GLS are individually associated with outcome post-CRT. We investigated LVESV and LV GLS changes and prognostic implications of improvement in LVESV and/or LV GLS, compared with no improvement in either parameter. Methods and results Baseline and 6-month echocardiograms were analysed from CRT recipients with heart failure. LV reverse remodelling was defined as a ≥15% reduction in LVESV at 6 months post-CRT. A ≥5% absolute improvement in LV GLS was defined as a change in LV GLS. A total of 1185 patients were included (mean age 65 ± 10 years, 73% male), and those with an improvement in LVESV and LV GLS (n  = 131, 11.1%) had significantly lower mortality compared with other groups. On multivariable analysis, an improvement in both LVESV and LV GLS [hazard ratio (HR): 0.47; 95% confidence interval (CI): 0.31–0.71; P  < 0.001] or an improvement in either LVESV or LV GLS (HR: 0.57; 95% CI: 0.47–0.71; P  < 0.001) were independently associated with better prognosis, compared with no improvement in either parameter. Conclusion Either a reduction in LVESV and/or an improvement in LV GLS at 6 months post-CRT are independently associated with improved long-term prognosis, compared with no change in both LVESV and LV GLS. This supports the use of LV GLS as a meaningful parameter in defining CRT response. [ABSTRACT FROM AUTHOR]

Aims Functional mitral regurgitation (FMR) is a well-known pathophysiological factor in heart failure (HF) patients, and left atrial function (LAF) is a novel determinant of clinical status and outcome in this setting. However, little is known about the pathophysiological role of FMR on LAF in HFrEF patients. Aim of this study is to explore the possible interplay between the severity of FMR and LAF in heart failure with reduce ejection fraction (HFrEF) patients and their possible consequences. Methods and results We studied 97 consecutive patients with FMR classified in two groups: mild-to-moderate MR ore less (FMR group, n = 38) and moderate-to-severe or more (SFMR group, n = 59). Using the phasic method, left atrial contractile, conduit, reservoir, and total emptying function (TLAEF) were calculated to assess LAF. SFMR group showed significantly lower values of LAF compared to FMR group. LA dysfunction (LA-dys) was defined for TLAEF values below the median and groups divided in four subgroups based on its presence. Patient with LA-Dys in SFMR group showed a worse clinical status, higher incidence of right ventricular dysfunction (RV-Dys), and pulmonary hypertension (PH), and a significant worse clinical survival compared to all other groups. Conclusion In our study, the survival was significantly lower in SFMR/LA-Dys+ group. Furthermore, LA-Dys was strongly related with worse clinical status and higher incidence of PH and RV-Dys. These results suggest that in patients with SFMR and HFrEF, LA-Dys may represent both a marker of more advanced disease and a novel prognostic factor. [ABSTRACT FROM AUTHOR]

Aims: Diabetes mellitus (DM) is associated with the development of cardiovascular disease (CVD). Morphological changes in the left atrium (LA) may appear before symptoms. We aimed to investigate the association between cardiac magnetic resonance imaging (CMR) measured LA structure and function and incident CVD in asymptomatic individuals with DM. Methods and results: Tissue tracking CMR was used to measure LA size and phasic function (emptying fractions and strain) on all 536 Multi-Ethnic Study of Atherosclerosis (MESA) participants with DM and available CMR at baseline in 2000-2002. At the time of enrolment, all participants were free of clinically recognized CVD, which was defined as MI, resuscitated cardiac arrest, angina, stroke, heart failure, and atrial fibrillation. Cox regression was used to assess the association of LA parameters with incident CVD adjusted for traditional cardiovascular risk factors, LV mass, NT Pro-BNP and maximum LA volume. Kaplan-Meier curves, adjusted for traditional risk factors, were generated for each LA measurement for the 25% of participants with the most abnormal values versus the remaining 75%. After a mean follow up of 11.4 ± 3.4 years, 141 individuals developed CVD. Individuals with incident CVD (mean age 66 years, 66% male vs. mean age 64 years, 50% male) had larger maximum and minimum LA volume index (LAVI) (32.1 vs. 26.8 mm³/m² 19.4 vs. 14.2 mm³/m² respectively, P < 0.001 for both), and lower total, passive, and active EF than those without CVD (P < 0.01 for all). In the fully adjusted model, there was a significant association of minimum LAVI, LA total EF, LA passive EF and LA active EF with incident CVD (HR 1.12 per mm³/m², P < 0.001; HR 0.95 per %, P < 0.001; HR 0.97 per %, P = 0.021; HR 0.98 per %, P < 0.027, respectively). Conclusions: CMR measured LA minimum volume and LA function as measured by emptying fraction are predictive of CVD in a diabetic multi-ethnic population free of any clinically recognized CVD at baseline. [ABSTRACT FROM AUTHOR]

Aims Since natriuretic peptide and troponin are associated with renal prognosis and left atrial (LA) parameters are indicators of subclinical cardiovascular abnormalities, this study investigated whether LA expansion index can predict renal decline. Methods and results This study analysed 733 (69% male) non-diabetic patients with sinus rhythm, preserved systolic function, and estimated glomerular filtration rate (eGFR) higher than 60mL/min/1.73 m². In all patients, echocardiograms were performed and LA expansion index was calculated. Renal function was evaluated annually. The endpoint was a downhill trend in renal function with a final eGFR of <60 mL/min/1.73 m². Rapid renal decline was defined as an annual decline in eGFR>3 mL/min/1.73 m². The median follow-up time was 5.2 years, and 57 patients (7.8%) had renal function declines (19 had rapid renal declines, and 38 had incidental renal dysfunction). Events were associated with left ventricular mass index, LA expansion index, and heart failure during the follow-up period. The hazard ratio was 1.426 (95% confidence interval, 1.276-1.671; P < 0.0001) per 10% decrease in LA expansion index and was independently associated with an increased event rate. Compared with the highest quartile for the LA expansion index, the lowest quartile had a 9.7-fold risk of renal function decline in the unadjusted model and a 6.9-fold risk after adjusting for left ventricular mass index and heart failure during the follow-up period. Conclusions Left atrial expansion index is a useful early indicator of renal function decline and may enable the possibility of early intervention to prevent renal function from worsening. ClinicalTrials.gov number NCT01171040. [ABSTRACT FROM AUTHOR]

The article presents an update on recommendations for left ventricular (LV) diastolic function by echocardiography from the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI). Topics discussed include general principles for echocardiographic LV diastolic function assessment, diastolic dysfunction diagnosis in presence of normal LV ejection fraction (LVEF), and echocardiographic LV filling pressures and diastolic dysfunction grade assessment.

AIMS: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in heart failure. However, prediction of the outcome remains difficult. We aimed to investigate for echocardiographic predictors of ventricular arrhythmias and fatal outcome and to explore how myocardial function is changed by biventricular pacing in heart failure. METHODS AND RESULTS: We prospectively included 170 heart failure patients (66 ± 10 years, New York Heart Association class 2.8 ± 0.5, 48% ischaemic cardiomyopathy) and recorded ventricular arrhythmias and fatal end point defined as death, heart transplantation, or left ventricular assist device implantation during 2 years. Two-dimensional echocardiography was performed before and 6 months after CRT implantation. CRT response was defined as ≥15% reduction in end-systolic volume at 6 months. Speckle-tracking technique was performed to assess longitudinal and circumferential left ventricular function, defined as global longitudinal (GLS) and circumferential strain (GCS), and to assess mechanical dyssynchrony, defined as mechanical dispersion. GLS before CRT was a predictor of fatal end point independently of CRT response [hazard ratio, HR 1.14 (1.02-1.27), P = 0.02]. Patients with GLS better than -8.3% showed event-free survival benefit (log rank, P < 0.001). Mechanical dispersion at 6 months was an independent predictor of ventricular arrhythmias [HR 1.20 (1.06-1.35), P = 0.005]. CRT responders (59%) had improvement of both GLS and GCS. CONCLUSION: In heart failure patients with CRT, worse longitudinal function before CRT was an important predictor of fatal outcome during 2 years, independently of CRT response. Mechanical dispersion at 6 months was a strong predictor of ventricular arrhythmias. CRT response by reverse remodelling was dependent on improvement of both longitudinal and circumferential function. [ABSTRACT FROM AUTHOR]

Aims We investigated whether the addition of left atrial (LA) size determined by echocardiography improves cardiovascular risk prediction in young adults over and above the clinically established Framingham 10-year global CV risk score (FRS). Methods and results We included white and black CARDIA participants who had echocardiograms in Year-5 examination (1990–91). The combined endpoint after 20 years was incident fatal or non-fatal cardiovascular disease: myocardial infarction, heart failure, cerebrovascular disease, peripheral artery disease, and atrial fibrillation/flutter. Echocardiography-derived M-mode LA diameter (LAD; n = 4082; 149 events) and 2D four-chamber LA area (LAA; n = 2412; 77 events) were then indexed by height or body surface area (BSA). We used Cox regression, areas under the receiver operating characteristic curves (AUC), and net reclassification improvement (NRI) to assess the prediction power of LA size when added to calculated FRS or FRS covariates. The LAD and LAA cohorts had similar characteristics; mean LAD/height was 2.1 ± 0.3 mm/m and LAA/height 9.3 ± 2.0 mm2/m. After indexing by height and adjusting for FRS covariates, hazard ratios were 1.31 (95% CI 1.12, 1.60) and 1.43 (95% CI 1.13, 1.80) for LAD and LAA, respectively; AUC was 0.77 for LAD and 0.78 for LAA. When LAD and LAA were indexed to BSA, the results were similar but slightly inferior. Both LAD and LAA showed modest reclassification ability, with non-significant NRIs. Conclusion LA size measurements independently predict clinical outcomes. However, it only improves discrimination over clinical parameters modestly without altering risk classification. Indexing LA size by height is at least as robust as by BSA. Further research is needed to assess subgroups of young adults who may benefit from LA size information in risk stratification. [ABSTRACT FROM PUBLISHER]

Aims The left atrium (LA) transfers blood to the left ventricle in a complex manner. LA function is characterized by passive emptying (LA passive fraction), active emptying (LA ejection fraction), and total emptying (LA fractional change). Despite this complexity, the clinical relevance of the LA is based almost exclusively on LA maximal volume (LAmax), which may not glean the full prognostic potential. Cardiovascular magnetic resonance (CMR) is considered the most accurate method for studying LA function and size. The aim of the present study was to evaluate the prognostic importance of LA function in patients following ST elevation myocardial infarction (STEMI). Methods and results In 199 patients, a CMR scan was performed within 1–3 days after STEMI to measure LAmax and minimal volume (LAmin) and LA function. The incidence of death, re-infarction, stroke, and admission for heart failure [major adverse cardiac event (MACE)] were registered during the follow-up period [2.3 years (inter-quartile range: 2.0–2.5)]. A total of 40 patients (20%) met the clinical endpoint of MACE during follow-up. In a Cox regression analysis adjusting for known risk factors, LA fractional change remained independently associated with MACE [adjusted hazard ratio: 0.66 (95% confidence interval: 0.46–0.95)]. LAmax, LAmin, or LA passive fraction was not independently associated with MACE. Furthermore, LA fractional change provided incremental prognostic value to LAmax and other known predictors (Wald χ2 31.0 vs. 39.9, P= 0.016). Conclusion In STEMI patients, impaired LA fractional change is independently associated with outcome and provide incremental prognostic information to established predictors including LAmax. [ABSTRACT FROM PUBLISHER]

Aims The relationship between temporal changes in left ventricular (LV) dyssynchrony and LV functional recovery after acute myocardial infarction (MI) remains unclear. Accordingly, the aim of the present study was to evaluate the temporal evolution of LV synchronicity after acute MI, and to explore the relationship between changes in LV systolic function and LV synchronicity. Methods and results In 193 patients with a first acute MI, LV dyssynchrony (SDI) and global systolic function were evaluated with real-time three-dimensional echocardiography 48 h after percutaneous coronary intervention and at 6 months follow-up. Changes in LV systolic function and synchronicity were evaluated at the follow-up and the relationship between these changes was explored. A total of 59 (40%) patients had an anterior acute MI. Median peak value of troponin T was 2.97 µg/L (1.41–6.06 µg/L). Mean LVEF was 47 ± 8% and mean SDI was 5.01 ± 2.10%, respectively. At 6 months follow-up, a significant improvement in LVEF (50 ± 9 vs. 47 ± 8%; P < 0.001) and SDI (4.52 ± 1.97 vs. 5.01 ± 2.10%; P = 0.003) was noted. A strong correlation was found between LVEF change and SDI change (β = −0.63; P < 0.001). At multivariate analysis, SDI change was an independent factor associated with changes in LVEF. Importantly, an addition of SDI change to the multivariate model significantly increased the R2 from 0.41 to 0.57 (F change 49.0, P < 0.001). Conclusion A temporal evolution of LV synchronicity was observed after a first, mechanically reperfused, acute MI. The reduction in LV dyssynchrony independently influenced LV functional recovery in these patients. [ABSTRACT FROM PUBLISHER]

Aims To investigate the influence of left ventricular (LV) lead position on LV dyssynchrony in cardiac resynchronization therapy (CRT). Methods and results The LV lead was prospectively targeted to the latest activated LV segment (concordant) evaluated by two-dimensional speckle tracking radial strain (ST-RS) echocardiography in 103 CRT recipients (67 ± 12 years). Mechanical dyssynchrony was assessed by anteroseptal-to-posterior (AS-P) delay and interventricular mechanical delay (IVMD). Concordant LV leads were obtained in 72 (70%) patients. Superior LV reverse remodelling (LV-RR; ≥15% LV end-systolic volume reduction at 6-month follow-up) was observed in the concordant LV leads compared with the discordant LV leads [51 (76%) vs. 13 (45%); P = 0.003]. Mechanical resynchronization responders (≥50% AS-P delay reduction at 6-month follow-up) obtained in the concordant LV leads [44 (66%)] was greater than in the discordant LV leads [10 (34%); P = 0.005]. The discordant LV leads located adjacent to the concordant LV leads (+1 segment; n = 22) and 2 segments apart (+2 segments; n = 9) were evaluated in a subgroup analysis. Mechanical resynchronization responders 6 months after CRT were as follows: in +1 segment [n = 10 (48%)] and in +2 segments (n = 0; P = 0.001). The concordant LV lead was the only independent predictor of LV-RR at 6-month follow-up (odds ratio, 4.177; P = 0.004). Independent predictors of mechanical resynchronization responders were AS-P delay (odds ratio, 1.007; P = 0.032), IVMD (odds ratio, 1.024; P = 0.038), and concordant LV lead (odds ratio, 4.691; P = 0.004). Conclusion Concordant LV leads in CRT provided more responders according to both LV reverse remodelling and mechanical resynchronization. [ABSTRACT FROM AUTHOR]

Aims To investigate the relative importance of individual tissue Doppler imaging variables to predict adverse events in a high-risk population with diabetes, ischaemic heart disease, and/or systolic dysfunction. Methods and results Transthoracic echocardiograms were analysed in 388 diabetic patients without significant valve disease, bundle branch block, and atrial fibrillation who underwent coronary angiography. Multivariable Cox's regression analyses were used to establish the association between peak systolic (s′), early diastolic (e′), and late diastolic (a′) tissue velocities and outcomes (hospitalization for heart failure or death). The mean age and left ventricular ejection fraction (LVEF) was 66 ± 10 years and 45 ± 12%, respectively. During 2.3 (±1.0) years of follow-up, 91 patients (24%) met the combined endpoint. After adjustment for LVEF, coronary artery pathology, heart failure at baseline, age, and gender, each 1 cm/s decrease in s′, e′, and a′ was associated with a hazard ratio (HR) of 1.18 (0.89–1.57), 1.03 (0.86–1.22), and 1.20 (1.05–1.37), respectively. A significant interaction was found between s′ and a′, P < 0.01. In patients with lower than mean s′, 1 cm/s decrease in a′ was associated with HR 1.31 (1.10–1.55, P < 0.01), whereas a′ was without prognostic importance in patients with higher than mean s′ [HR 0.99 (0.78–1.25, P = 0.6)]. Patients having lower than mean values of both s′ and a′ had a poorer prognosis than patients having at least one of s′ and a′ high. Conclusion Peak systolic and late diastolic tissue velocities add prognostic information beyond LVEF in high-risk patients. Variables should be considered together as they interact on prognosis. [ABSTRACT FROM PUBLISHER]

Aims The purpose of this study was to test the hypothesis that left ventricular (LV) mechanical dyssynchrony deteriorates the longitudinal systolic and diastolic function of the left ventricle (LV) in patients with heart failure with a normal LV ejection fraction (HFNEF). Methods and results In patients with HFNEF and in a control group consisting of asymptomatic patients with LV diastolic dysfunction [LVDD], matched by age, gender, and LV ejection fraction, we assessed the global longitudinal systolic (global strain), diastolic [global early-diastolic strain rate (SRe)], and synchronous (standard deviation of time-to-peak systolic strain) function of the LV by two-dimensional speckle-tracking echocardiography using a 18-segment LV model. A total of 325 patients were included (85 with HFNEF and 240 with asymptomatic LVDD). Patients with HFNEF had a significant impairment of the longitudinal systolic and diastolic function of the LV as compared with the control group. Concerning the pathophysiological mechanisms linked to these findings, we found that HFNEF patients with asynchronous LV contractions had significantly more impaired longitudinal systolic and diastolic LV function (global strain −14.76 ± 3.44%, global SRe 0.79 ± 0.24 s−1) than patients without asynchronous LV contractions (global strain −18.57 ± 3.10%, global SRe 1.06 ± 0.32 s−1; all P < 0.0001). Accordingly, in HFNEF patients with LV mechanical dyssynchrony the rates of LV longitudinal systolic and diastolic dysfunction were 64 and 70%, respectively, whereas these rates were significantly lower (19.5 and 41.3%), respectively, in patients without asynchronous LV contractions. In addition, HFNEF patients with LV mechanical dyssynchrony presented higher LV filling pressures and worse NYHA functional class than those with normal LV contractions. Conclusion In patients with HFNEF, LV mechanical dyssynchrony is associated with an important impairment of the longitudinal systolic and diastolic function of the LV. Therefore, the restoration of asynchronous LV contractions could help to improve and/or correct both the systolic and the diastolic longitudinal dysfunction of the LV in HFNEF and thereby improve the symptomatology of these patients. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue on topics including correction of left ventricular (LV) dyssynchrony in heart failure, cardiac resynchronization therapy (CRT), and LV apical rocking.

The author reflects on mechanical dyssynchrony and its role in cardiac resynchronization therapy (CRT) wherein D’Andrea et al. assessed mechanical dyssynchrony based on one technique and one echo-system, which revealed intraventricular dyssynchrony was independently correlated with clinical outcomes and opined that a progress will be made in the assessment of dyssynchrony by increasing its feasibility and robustness.