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Objectives: The prognostic value of echocardiographic atrial and ventricular strain imaging in patients with biopsy-proven cardiac amyloidosis was assessed., Background: Although left ventricular global longitudinal strain (GLS) is known to be predictive of outcome, the additive prognostic value of left (LA), right atrial (RA), and right ventricular (RV) strain is unclear., Methods: One hundred thirty-six patients with cardiac amyloidosis and available follow-up data were studied by endomyocardial biopsy, noncardiac biopsy with supportive cardiac imaging, or autopsy confirmation. One hundred nine patients (80%) had light-chain, 23 (17%) had transthyretin, and 4 (3%) had amyloid A type cardiac amyloidosis. GLS, RV free wall strain, peak longitudinal LA strain, and peak longitudinal RA strain were measured from apical views. Clinical and routine echocardiographic data were compared. All-cause mortality was followed (median 5 years)., Results: Strain data were feasible for GLS in 127 (93%), LA strain in 119 (88%), RA strain in 117 (86%), and RV strain in 102 (75%). Strain values from all 4 chambers were significantly associated with survival. Hazard ratio (HR) and 95% confidence interval (CI) for low median strain values were as follows: GLS, HR: 2.3; 95% CI: 1.3 to 3.8 (p < 0.01); LA strain, HR: 7.5; 95% CI: 3.8 to 14.7 (p < 0.001); RA strain, HR: 3.5; 95% CI: 2.0 to 6.2 (p < 0.001); and RV free wall strain, HR: 2.8; 95% CI: 1.5 to 5.1 (p < 0.001). Peak longitudinal LA strain and RV strain remained independently associated with survival in multivariable analysis. Peak LA strain had the strongest association with survival (p < 0.001), and LA strain combined with GLS and RV free wall strain had the highest prognostic value (p < 0.001)., Conclusions: Strain data from all 4 chambers had important prognostic associations with survival in patients with biopsy-confirmed cardiac amyloidosis. Peak longitudinal LA strain was particularly associated with prognosis. Atrial and ventricular strain have promise for clinical utility., Competing Interests: Funding Support and Author Disclosures Dr. Gorcsan has received research support from GE Healthcare, TomTec, Hitachi, V-wave Ltd, EBR Systems, and Canon. Dr. Lenihan is a consultant for Lilly, Roche, Pfizer, Prothena, and Acorda; and has received research support from Myocardial Solutions. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to test the hypothesis that speckle tracking strain echocardiography can quantify neurocardiac injuries in patients with aneurysmal subarachnoid hemorrhage (SAH), which is associated with worse clinical outcome., Background: SAH may be a life-threatening disease associated with variable degrees of neurocardiac injury. Strain imaging has the potential to detect subtle myocardial dysfunction which is additive to conventional measurements., Methods: A total of 255 consecutive patients were prospectively enrolled with acute SAH, who were admitted to the intensive care unit with echocardiography studies within 72 h. Left ventricular (LV) and right ventricular (RV) strains were acquired from standard apical views. Abnormal LV global longitudinal strain (GLS) and RV free-wall strain were pre-defined as <17% and <23% (absolute values), respectively., Results: Performing LV GLS was feasible in 221 patients (89%) 53 ± 10 years of age, 71% female, after excluding those with previous cardiac disease. Abnormal LV GLS findings were observed in 53 patients (24%) and were associated with worse clinical severity, including a Hunt-Hess grade >3 (34% vs. 15%; p = 0.005) and biomarker evidence of neurocardiac injury and higher troponin values (1.50 [interquartile range (IQR): 0.01 to 3.87] vs. 0.01 [IQR: 0.01 to 0.22] ng/ml; p < 0.001). A reverse Takotsubo pattern of segmental strain was observed in 49% of patients (apical sparing and reduced basal strain). Importantly, LV GLS was more strongly associated with in-hospital mortality than left ventricular ejection fraction (LVEF), even after adjusting for clinical severity (odds ratio [OR]: 3.11; 95% confidence interval [CI]: 1.12 to 8.63; p = 0.029). RV strain was measured in 159 subjects (72%); abnormal RV strain was added to LV GLS for predicting in-hospital mortality (p = 0.007)., Conclusions: Neurocardiac injury can be detected by LV GLS and RV strain in patients with acute SAH. LV GLS was significantly associated with in-hospital mortality. RV strain, when available, added prognostic value to LV GLS. Abnormal myocardial strain is a marker for increased risk of in-hospital mortality in SAH and has clinical prognostic utility., (Copyright © 2020. Published by Elsevier Inc.)

Objectives: In this study, the authors tested the hypotheses that the systolic stretch index (SSI) developed by computer modeling and applied using echocardiographic strain imaging may characterize the electromechanical substrate predictive of outcome following cardiac resynchronization therapy (CRT). They included patients with QRS width 120 to 149 ms or non-left bundle branch block (LBBB), where clinical uncertainty for CRT exists. They further tested the hypothesis that global longitudinal strain (GLS) has additional prognostic value., Background: Response to CRT is variable. Guidelines favor patient selection by electrocardiographic LBBB with QRS width ≥150 ms., Methods: The authors studied 442 patients enrolled in the Adaptive CRT 94-site randomized trial with New York Heart Association functional class III-IV heart failure, ejection fraction ≤35%, and QRS ≥120 ms. A novel computer program semiautomatically calculated the SSI from strain curves as the sum of posterolateral prestretch percent before aortic valve opening and the septal rebound stretch percent during ejection. The primary endpoint was hospitalization for heart failure (HF) or death, and the secondary endpoint was death over 2 years after CRT., Results: In all patients, high longitudinal SSI (≥ group median of 3.1%) was significantly associated with freedom from the primary endpoint of HF hospitalization or death (hazard ratio [HR] for low SSI: 2.17; 95% confidence interval [CI]: 1.45 to 3.24, p < 0.001) and secondary endpoint of death (HR for low SSI: 4.06; 95% CI: 1.95 to 8.45, p < 0.001). Among the 203 patients with QRS 120 to 149 ms or non-LBBB, those with high longitudinal SSI (≥ group median of 2.6%) had significantly fewer HF hospitalizations or deaths (HR for low SSI: 2.08; 95% CI: 1.27 to 3.41, p = 0.004) and longer survival (HR for low SSI: 5.08; 95% CI: 1.94 to 13.31, p < 0.001), similar to patients with LBBB ≥150 ms. SSI by circumferential strain had similar associations with clinical outcomes, and GLS was additive to SSI in predicting clinical events (p = 0.001)., Conclusions: Systolic stretch by strain imaging characterized the myocardial substrate associated with favorable CRT response, including in the important patient subgroup with QRS width 120 to 149 ms or non-LBBB. GLS had additive prognostic value., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to evaluate mechanical dyssynchrony in patients with acute onset cardiomyopathy with narrow QRS interval, and its association with improvements in left ventricular (LV) function., Background: LV dyssynchrony has been usually studied in patients with chronic heart failure and wide QRS in the context of cardiac resynchronization therapy., Methods: We studied 201 patients enrolled in the IMAC-2 (Inflammatory Mediators in Acute Cardiomyopathy) trial with recent onset nonischemic cardiomyopathy and ejection fraction <40%. Dyssynchrony was assessed using speckle-tracking velocity vector imaging. Diastolic function was assessed by mitral inflow E and mitral E' annular velocities (E/E'). A normal control group of 15 normal volunteers was studied for comparison., Results: Although mean QRS was narrow (98 ± 21 ms), 108 (54%) acute cardiomyopathy patients had significant LV dyssynchrony at presentation: opposing wall delay 89 ± 51 ms, versus 35 ± 11 ms in controls, and 12-site standard deviation 43 ± 23, versus 24 ± 8 ms in controls (p < 0.001). Patients with dyssynchrony had greater degrees of diastolic dysfunction: E/E' 15 ± 8 versus 12 ± 6 (p < 0.05). At 6 months, group mean ejection fraction improved from 23 ± 8% to 40 ± 12% and E/E' improved from 14 ± 7 to 9 ± 5 (both p < 0.001). Dyssynchrony improved from 89 ± 51 ms to 52 ± 35 ms in maximum opposing wall delay, and 43 ± 23 ms to 32 ± 19 ms in 12-site standard deviation, and the prevalence of dyssynchrony decreased to 12% after 6 months (p < 0.001 vs. baseline)., Conclusions: Mechanical dyssynchrony was observed in a significant number of patients with acute onset cardiomyopathy, despite having a narrow QRS interval. Resolution of dyssynchrony associated with improvements in LV function occurred in the large majority of these patients., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The goals of this study were to compare patterns of mechanical activation in patients with chronic right ventricular (RV) pacing with those with left bundle branch block (LBBB) using 2-dimensional and novel 3-dimensional speckle tracking, and to compare ejection fraction (EF) response and long-term survival after cardiac resynchronization therapy (CRT)., Background: Several randomized CRT trials have excluded patients with chronic RV pacing, and current guidelines for CRT include patients with intrinsically widened QRS, typically LBBB., Methods: We studied 308 patients who were referred for CRT: 227 had LBBB, 81 were RV paced. Dyssynchrony was assessed by tissue Doppler, routine pulsed Doppler, and 2-dimensional speckle-tracking radial strain. 3D strain was assessed using speckle tracking from a pyramidal dataset in a subset of 57 patients for mechanical activation mapping. Survival after CRT was compared with survival in a group of 46 patients with attempted, but failed, CRT., Results: Patients with chronic RV pacing and LBBB had similar intraventricular dyssynchrony, with opposing wall delays by tissue Doppler of 82 +/- 45 ms versus 87 +/- 63 ms and anteroseptum-to-posterior delays by speckle tracking of 225 +/- 142 ms, versus 211 +/- 107 ms, respectively. RV-paced patients, however, had greater interventricular dyssynchrony: 44 +/- 24 ms versus 35 +/- 21 ms (p < 0.01), which correlated with their greater QRS duration (p < 0.001). Sites of latest mechanical activation were most often posterior or lateral in both groups, but RV-paced patients had sites of earliest activation more often from the inferior-septum and apex (p < 0.05). EF response was similar in RV-paced and LBBB groups, and survival free from transplantation or mechanical support after CRT was similarly favorable as compared with failed CRT patients over 5 years (p < 0.01)., Conclusions: RV-paced patients, when compared with LBBB patients, had similar dyssynchronous patterns of mechanical activation and greater interventricular dyssynchrony. Importantly, RV-paced patients had similar EF response and long-term outcome as those with LBBB, which supports their candidacy for CRT., (Copyright 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To test the hypothesis that echocardiographic dyssynchrony may assist in the selection of patients with borderline QRS duration for cardiac resynchronization therapy (CRT)., Background: Although echocardiographic dyssynchrony is currently not recommended to select patients with QRS duration widening for CRT, its utility in patients with borderline QRS widening is unclear., Methods: Of 221 consecutive heart failure patients with an ejection fraction (EF) < or =35% referred for CRT, 86 had a borderline QRS duration of 100 to 130 ms (115 +/- 8 ms) and 135 patients had wide QRS >130 ms (168 +/- 26 ms). Dyssynchrony was assessed using interventricular mechanical delay, tissue Doppler imaging longitudinal velocity opposing wall delay, and speckle tracking radial strain for septal to posterior wall delay. Response to CRT was defined as > or =15% increase in EF, and reverse remodeling as > or =10% decrease in end-systolic volume., Results: There were 201 patients with baseline quantitative echocardiographic data available, and 187 with follow-up data available 8 +/- 5 months after CRT. A smaller proportion of borderline QRS duration patients (53%) were EF responders compared with 75% with widened QRS (p < 0.05). Interventricular mechanical delay > or =40 ms and opposing wall delay > or =65 ms were predictive of EF response in the wide QRS duration group, but not the borderline QRS duration group. Speckle tracking radial dyssynchrony > or =130 ms, however, was predictive of EF response in both wide QRS interval patients (88% sensitivity, 74% specificity) and borderline QRS interval patients (79% sensitivity, 82% specificity) and associated reverse remodeling with reduction in end-systolic volume (p < 0.0005)., Conclusions: Radial dyssynchrony by speckle tracking strain was associated with EF and reverse remodeling response to CRT in patients with borderline QRS duration and has the potential to assist with patient selection., (2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: We hypothesize that left ventricular (LV) segmental dyssynchrony, quantified by paradoxical systolic wall thinning, determines changes in global LV performance in a model of canine right ventricular (RV) pacing-induced dyssynchrony and the response to cardiac resynchronization therapy (CRT)., Background: Quantification of LV dyssynchrony is important to assess the impact of CRT., Methods: Seven pentobarbital-anesthetized open-chest dogs had LV pressure-volume relations and mid-LV short-axis echocardiographic speckle tracking radial strain imaging during right atrial (RA) pacing, RV pacing to simulate left bundle branch block, and CRT using RV pacing plus either LV free-wall (CRTfw) and apical (CRTa) pacing. The area under the segmental LV time-radial strain positive and negative curves defined global thickening and thinning, respectively. Dyssynchrony was defined as the maximum time difference between earliest and latest peak segmental positive strain among 6 radial sites., Results: RA pacing had minimal dyssynchrony (58 + or - 40 ms). RV pacing induced both dyssynchrony (213 + or - 67 ms, p < 0.05) and reduced LV stroke work (SW) (67 + or - 51 mJ, p < 0.05). CRTfw and CRTa decreased dyssynchrony (116 + or - 47 ms and 50 + or - 34 ms, respectively, p < 0.05 vs. RV pacing), but only CRTa restored LV SW to RA pacing levels. RV pacing decreased global thickening (129 + or - 87%.ms) compared with RA pacing (258 + or - 133%.ms, p < 0.05), whereas CRTfw and CRTa restored regional thickening to RA pacing levels (194 + or - 83%.ms and 230 + or - 76%.ms, respectively). The sum of thickening and thinning during RV (230 + or - 88%.ms vs. 258 + or - 133%.ms, p < 0.05) correlated (r = 0.98) with RA thickening, suggesting that all the loss of LV function was due to thinning., Conclusions: Dyssynchrony causes proportional changes in regional LV wall thinning and global LV SW that were reversed by CRT, suggesting that dyssynchrony impairs LV systolic function by causing paradoxical regional wall thinning and that CRT effectiveness can be monitored by its reversal. Thus, monitoring paradoxical regional thinning reversal may be used to define CRT effectiveness.