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Transcatheter aortic valve implantation (TAVI) is able to determine a significant improvement of left ventricular ejection fraction (LVEF). The variations of LV global longitudinal strain (GLS) have not been yet investigated in TAVI patients with reduced LVEF. The aim of this study was to determine the effects of TAVI on LV function by 2D speckle-tracking echocardiography (STE) in patients with reduced LVEF. Eighteen consecutive patients undergoing TAVI in our centre were prospectively enrolled. Echocardiography was performed pre-procedurally the day of TAVI and at 40-day and 3-month follow-up (FU). The mean age of TAVI patients was 79.75 ± 7.68 years. The mean EuroSCORE was 26.59 ± 14.62%. A significant decrease of mean trans-aortic gradient was observed 40 days after TAVI (51.69 ± 18.82 vs. 9.62 ± 3.28 mmHg, p < 0.0001). LV mass index significantly decreased at 40-day FU (165.72 ± 37.75 vs. 145.52 ± 31.32 g/m(2), p < 0.001) with a further reduction at 3-month FU (136.91 ± 26.91 g/m(2), p < 0.05 in comparison with 40-day FU). The mean pre-procedural LVEF was 45.87 ± 7.95%. LVEF significantly increased at 40-day FU (55.20 ± 5.91%, p < 0.05) and remained stable at 3-month FU (55.58 ± 6.14%). Interestingly, an early improvement of LV GLS was observed at 40-day FU (-11.09 ± 3.40 vs. -14.40 ± 3.68%, p < 0.001) with a slight further increase at 3-month FU (-14.71 ± 3.56%). Our results indicate that significant improvements of LVEF and LV GLS can be observed in patients undergoing TAVI with impaired LVEF. Two-dimensional STE was able to detect the reverse remodeling of LV function, adding further insights into the assessment of LV mid-term recovery after TAVI.

Aims Little is known about the adaptation of the right ventricle (RV) to endurance exercise in children. The aim of this study was to assess the effects of 5months of intensive training on RV morphology and function in preadolescent endurance athletes. Methods Ninety-four children were evaluated in this study. Fifty-seven male competitive swimmers (aged 10.8±0.2years) were evaluated before (baseline) and after 5months of the training (peak-training), and compared to 37 age- and sex-matched non-athlete children evaluated at baseline and after 5months of natural growth. All subjects were asymptomatic, with negative family history for cardiomyopathies. Results At baseline no differences were found between athletes and controls for indexed RV outflow tract (RVOT) (18.5±2.7 vs. 16.8±5.0mm/m 2 , p =0.18) and RV basal end-diastolic diameter (EDD) (24.9±4.1 vs. 23.6±3.0mm/m 2 , p =0.15). After 5months, indexed RVOT and RV basal EDD significantly increased in athletes (20.2±2.9mm/m 2 and 25.4±3.3mm/m 2 , p p =0.84 and p =0.25). Despite the increase in RV size, RV function remained normal in athletes, with no changes in RV fractional area change ( p =0.97), s′ value ( p =0.22), and RV longitudinal strain ( p =0.28). Conclusions Endurance training influences the growing heart of male preadolescent athletes with an addictive increase in RV dimensions, with a preserved RV function. Therefore, in children engaged in endurance sports the increase in RV size associated with normal RV function represents a physiological expression of the athlete's heart and should not be misinterpreted as an expression of incipient RV cardiomyopathy.

Training-induced electrocardiographic changes are common in adult athletes. However, a few data are available on electrocardiogram (ECG) in preadolescent athletes and little is known about the potential changes induced by training on 12-lead electrocardiogram (ECG) at rest. Twelve-lead ECGs at rest and complete echocardiographic examinations were performed in 94 children (57 endurance athletes, 37 sedentary controls; mean age 10.8 ± 0.2 and 10.2 ± 0.2 years, respectively) at baseline and after 5 months of growth and training in athletes and of natural growth in controls. At baseline, athletes had lower heart rate at rest compared with controls (p = 0.046) and a further decrease was observed after training (p0.0001). An incomplete right bundle branch block was found in 19% of athletes and 15% of controls (p = 0.69) with no changes after training. Although none of the athletes showed negative T waves from V1 to V3, 6% of controls at baseline had T-wave inversion V1 to V3 with a decrease to 3% after 5 months (p = 0.16). The early repolarization pattern did not differ between athletes and controls and was correlated with Tanner's scale score in the overall population both at first and second evaluation (R = 0.30, R = 0.27, p = 0.005, p = 0.012, respectively). No correlations were found between ECG and echocardiographic data. In conclusion, 12-lead ECG at rest is not substantially affected by training in children, despite a physiological increase in cavity size. Thus, in preadolescent athletes, 12-lead ECG at rest does not reflect exercise-induced morphologic remodeling and seems to be influenced more by sexual maturation than by training.

RV function is an important component of overall heart function with prognostic value in predicting symptomatic limitation and outcome in different cardiovascular pathologies. RV longitudinal contraction accounts for the majority of total RV function, up to 80%, as compared to transverse shortening. Calculation of RV volume and RV ejection fraction (RVEF) remains hampered by the complex RV geometry and we lack a good geometric model allowing the calculation of right ventricular ejection fraction; secondly, the large apical trabeculations of the right ventricle make the endocardial delineation more difficult to obtain than for the left ventricle. To notice, the gold standard method for the assessment of the chamber (MRI) is resource intensive and cannot be employed in many settings. Considering these problems, multiple parameters have been developed for the evaluation of RV systolic function: tricuspid annular plane systolic excursion (TAPSE), systolic excursion velocity (S'), and longitudinal strain by speckle tracking.

We describe the case of a patient with a mitral bioprosthetic valve undergoing percutaneous closure with fluoroscopy and echocardiographic guidance of a rare left sinus of Valsalva‒left atrial fistula. The original aspect of this case is that the fistula was located at the level of the left sinus of Valsalva next to the mitral valve bioprosthesis with subsequent risk of prosthesis damage and/or occlusion of the left coronary artery at its origin during the procedure.

Previous studies investigated the exercise-induced adaptation of left (LA) and right atrium (RA) in adults, but little is known about respective changes in the growing heart of children. We aimed to longitudinally investigate the effects of endurance training on biatrial remodelling in preadolescent athletes.Ninety-four children (57 endurance athletes, 37 sedentary controls; mean age 10.8±0.2 and 10.2±0.2years, respectively) were evaluated at baseline and after 5months by ECG and by two-dimensional, three-dimensional (3D) and speckle-tracking echocardiography. Athletes were trained at least 10h/week. The resting heart rate was lower in athletes (p=0.046) and decreased further after training (p0.0001). Neither athletes nor controls had ECG evidence for LA or RA enlargement. At baseline, indexed LA volumes did not differ between groups (p=0.14) but indexed RA dimensions were larger in athletes (p=0.007). After 5months, indexed LA volumes increased in athletes but not in controls (p0.0001, p=0.29; respectively) while indexed RA volumes increased in both groups (p0.0001, p=0.018; respectively). At the same time, slight differences in biatrial reservoir and contractile function were found either in athletes, as demonstrated by speckle-tracking echocardiography, but 3D-derived LA and RA ejection fraction remained stable in both groups.Endurance training influences the growing heart of preadolescent athletes with an additive increase in biatrial size, suggesting that morphological adaptations can occur also in the early phases of the sports career. Training-induced remodelling was associated with a preserved biatrial function, supporting the hypothesis of a physiological remodelling.

Biatrial enlargement is common in athletes with a further increase occurring after training. P-wave morphology seems to be unaffected by atrial size, however longitudinal data are not available. This study aimed to prospectively investigate whether exercise-induced increase in biatrial size corresponds to electrical changes on 12-lead ECG. Thirty-five athletes were evaluated at the beginning of the training and after 6 months by ECG and standard and speckle-tracking echocardiography. Twenty-three sedentary subjects served as controls. Athletes had greater left atrial (LA) and right atrial (RA) size compared with controls (20.7 ± 4.7 vs. 27.1 ± 6.6 and 17.3 ± 3.8 vs. 23.4 ± 6.3 mL/m2, respectively, p < 0.0001). After 6 months, a further increase in LA and RA size was observed (p < 0.0001 and p = 0.002, respectively). Neither athletes nor controls fulfilled the ECG criteria for RA enlargement and no differences were found for LA enlargement criteria between athletes and controls (2/35, 6% vs. 0/23, 0%, p = 0.23). This percentage remained unchanged after training. Biatrial stiffness remained normal in athletes also after training. Training causes an increase in biatrial volumes, with normal filling pressures and normal stiffness. These changes in atrial morphology are not associated with respective electrical changes, suggesting that P-wave morphology is unaffected by training-induced biatrial dilatation in young healthy athletes.

Functional mitral regurgitation (FMR) is a common complication of left ventricle (LV) dysfunction and remodelling. Recently, it has been recognized as an independent prognostic factor in both ischaemic and non-ischaemic LV dysfunctions. In this review article, we discuss the mechanisms through which cardiac dyssynchrony is involved in FMR pathophysiologic cascade and how cardiac resynchronization therapy (CRT) can have therapeutic effects on FMR by reverting specific dyssynchrony pathways. We analyse recent clinical trials focusing on CRT impact on FMR in 'real-world' patients, the limits and future perspectives that could eventually generate new predictors of CRT response in terms of FMR reduction. Finally, we propose a practical diagnostic and therapeutic strategy for the management of symptomatic patients with severe LV dysfunction and concomitant 'prognostic' FMR.

Left atrial (LA) function is a determinant of left ventricular (LV) filling. It carries out three main functions: reservoir, conduit, contractile. Aim of this study was to evaluate the role of LA and its deformation properties on LV filling at rest (R) and immediately after a maximal exercise (ME) through the speckle tracking echocardiography. Population enrolled was composed by 23 water polo athletes who performed a ME of six repeats of 100 m freestyle swim sets. At ME peak atrial longitudinal strain was reduced but all strain rate (SR) parameters increased, respectively positive peak SR at reservoir phase, SR negative peak at rapid ventricular filling (SRep) and SR negative peak at late ventricular filling (SRlp), that corresponds to atrial contraction phase. We showed a parallel increase in E and A pulsed Doppler wave and SRep and SRlp; particularly at ME, A wave and SRlp increased more respectively than E wave and SRep. SRlp was related to ejection fraction (EF) (r = -0.47; p

In order to obtain accurate diagnosis, treatment and prognostication in many cardiac conditions, there is a need for assessment of left ventricular (LV) filling pressure. While systole depends on ejection function of LV, diastole and its disturbances influence filling function and pressures. The commonest condition that represents the latter is heart failure with preserved ejection fraction in which LV ejection is maintained, but diastole is disturbed and hence filling pressures are raised. Significant diastolic dysfunction results in raised LV end-diastolic pressure, mean left atrial (LA) pressure and pulmonary capillary wedge pressure, all referred to as LV filling pressures. Left and right heart catheterization has traditionally been used as the gold standard investigation for assessing these pressures. More recently, Doppler echocardiography has taken over such application because of its noninvasive nature and for being patient friendly. A number of indices are used to achieve accurate assessment of filling pressures including: LV pulsed-wave filling velocities (E/A ratio, E wave deceleration time), pulmonary venous flow (S wave and D wave), tissue Doppler imaging (E' wave and E/E' ratio) and LA volume index. LA longitudinal strain derived from speckle tracking echocardiography (STE) is also sensitive in estimating intracavitary pressures. It is angle-independent, thus overcomes Doppler limitations and provides highly reproducible measures of LA deformation. This review examines the application of various Doppler echocardiographic techniques in assessing LV filling pressures, in particular the emerging role of STE in assessing LA pressures in various conditions, e.g., HF, arterial hypertension and atrial fibrillation.

To evaluate potential relationships between different components of left ventricular (LV) function and histopathological evidence for myocardial fibrosis in patients undergoing heart transplantation.The study population included patients with advanced heart failure, referred for an echocardiographic examination before heart transplantation. Traditional LV function measurements and global longitudinal strain (GLS) by speckle tracking echocardiography, averaging all LV segments in 4-, 2-, and 3-chamber views were obtained in all subjects. LV tissue samples were obtained from all patients who underwent heart transplantation. Myocardial fibrosis was assessed using Masson's staining.Of 106 patients referred for cardiac transplantation, 47 underwent cardiac transplantation and were enrolled in the study. LV myocardial fibrosis and its grade strongly correlated with GLS (r = 0.75, P = .0001), modestly with global circumferential strain and LV torsion (r = 0.61, P = .001 and r = 0.52, P = .01, respectively) and weakly with mitral S' wave (r = -0.41; P = .01) and mitral annular plane systolic excursion (r = -0.35; P = .05) but did not correlate with LV ejection fraction (r = -0.12; P = NS). GLS had the strongest accuracy for detecting LV fibrosis (area under the curve, 0.92). None of the echo parameters correlated with patient's exercise capacity.Global longitudinal strain is the most accurate LV global function measure that correlates with the extent of myocardial fibrosis in patients with advanced systolic HF requiring heart transplantation.

Left atrial (LA) strain is a speckle tracking echocardiography (STE)-derived parameter applied to the analysis of chamber function that provides highly reproducible measures of LA deformation by a non-Doppler, angle-independent quantification. In recent years, data regarding accuracy and clinical application of LA strain are rapidly increasing. This review describes the main features of LA strain and examines the role of STE in the evaluation of various aspects of AF, as the risk of developing the arrhythmia in general population, the evaluation of LA fibrosis and LA impairment, the quantification of cardioembolic risk and of recurrence after cardioversion or ablation therapies.

The left ventricular (LV) long axis (Lax) function is very sensitive in documenting myocardial abnormalities in aortic stenosis (AS). We hypothesized that Lax recovery after aortic valve replacement (AVR) is related to the extent of cavity dyssynchrony measured by total isovolumic time (t-IVT).A consecutive 107 patients (aged 70 ± 7 years, 70 male) with severe AS and Lax impairment were studied. T-IVT was measured before and after AVR. Reduced Lax function and its post-operative recovery were defined as mitral annular plane systolic excursion (MAPSE) ≦10 mm and an increase of MAPSE10%, respectively.LV function improved (EF: 43 ± 8 to 48 ± 10%; MAPSE: 7.9 ± 1.0 to 11.0 ± 2.4 mm) and t-IVT shortened (9.7 ± 3.7 to 7.0 ± 2.8s/min, p0.01 for all) after AVR. Sixty-five (61%) patients had Lax recovery after a median of 32-month follow-up. Univariate predictors were LV size, LA dimensions, the presence of restrictive LV filling and prolonged t-IVT. Only LV end-systolic dimension, restrictive filling and t-IVT (OR 0.61, 95% CI 0.47-0.79, p0.01) were independent predictors. A pre-operative t-IVT ≦ 9.3s/min was 81% sensitive and 63% specific in predicting Lax recovery (AUC 0.81, p0.001). The prevalence of CAD or concomitant CABG were similar in 2 patient groups with different t-IVT.Lax recovery was evident in the majority of AS patients after AVR. The lower prevalence of Lax recovery seen in patients with prolonged t-IVT suggests that dyssynchrony may play an important role in the process of adverse LV remodeling.

Left ventricular (LV) torsion is a fundamental component of wall motion and plays an important role to optimize ventricular ejection fraction. The aim of our study was to calculate by speckle tracking echocardiography LV twist angle in patients with hypertension and LV remodeling, analyzing torsional indices in all patterns of hypertrophy, in comparison to torsional dynamics of age-matched healthy subjects. Hypertensive patients (n = 202) were divided in three groups, patients with concentric remodeling (n = 70), concentric hypertrophy (n = 68) and eccentric hypertrophy (n = 64), in relation to the echocardiographic measurements of relative wall thickness and LV mass, analyzing their torsional patterns by speckle tracking in comparison to age-matched control group. Compared to healthy controls, LV twist angle was increased in patients with hypertension and concentric remodeling (15.2° ± 1.9° vs. 11.0° ± 1.6°; p

The occurrence of atrial fibrillation (AF), especially in patients with mitral regurgitation (MR), is related to the degree of left atrial (LA) myopathy, remodeling and fibrosis, that are responsible of LA electrical inhomogeneity and abnormal conduction velocities. Speckle tracking echocardiography (STE) has recently enabled the quantification of longitudinal myocardial LA deformation dynamics. Our aim was to investigate by STE the effects of the occurrence of paroxysmal AF on LA myocardial deformation, in a population of patients with asymptomatic chronic MR. We compared two groups of a total of 197 patients with MR: 54 with history of paroxysmal AF and 143 with MR alone. Subgroups were created according to MR degree. Peak atrial longitudinal strain (PALS) was measured in all subjects. Values were obtained by averaging all segments (global PALS), measured in the 4-chamber and 2-chamber views. Compared to the mild MR group (46.1 +/- A 4.9%), global PALS was lower in moderate MR group (22.1 +/- A 5.8%) and further reduced in the severe MR group (13.9 +/- A 4.2%; overall P < 0.0001 by ANOVA, P < 0.05 for all pair-wise comparisons). Besides, in each MR group, patients with history of paroxysmal AF presented a global PALS significantly reduced (overall P < 0.0001 by ANOVA). After multivariate analysis, global PALS was significantly and independently associated with paroxysmal AF. STE enables noninvasive quantification of LA dysfunction due to MR and paroxysmal AF. MR have a major negative impact on LA function. In patients with MR, the history of paroxysmal AF is associated to a further impair of LA myocardial reservoir function.

Background: The role of speckle tracking in the assessment of right atrial (RA) deformation dynamics has not been established yet. The reference ranges of RA longitudinal strain indices were measured by speckle tracking in a population of normal subjects. Methods: In 84 healthy individuals, peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and time to peak longitudinal strain (TPLS) were measured using a six-segment model for the RA. Strain rate (SR) was also measured starting from the QRS-wave onset, peak positive (x-wave), first peak negative (y-wave), and second negative peak (z-wave). The time from the QRS onset was measured to each wave peak. Results: Adequate tracking quality was achieved in 64% of segments analyzed. Inter- and intraobserver variability coefficients of measurements ranged between 6% and 11%. Global PALS was 49 ± 13%, global TPLS was 363 ± 59 msec, x-wave was 2.12 ± 0.58 sec−1, y-wave was −1.91 ± 0.63 sec−1, and z-wave was −2.18 ± 0.78 sec−1. Conclusion: Speckle tracking is a feasible technique for the assessment of longitudinal myocardial RA deformation. Reference ranges of strain indices were reported. (Echocardiography 2012;29:147-152)

Background: Levosimendan (L) is used in clinical practice for the treatment of severe heart failure (HF); it has inotropic and vasodilatory effects, without increasing myocardial oxygen consumption. In acute HF, levosimendan improves hemodynamic parameters; previous stu- dies have demonstrated that it has favorable effects on left ventricular (LV) diastolic function. The aim of our study was to evaluate the effect of on LV long-axis function that represents the earlier marker of diastolic dysfunction. Methods: We enrolled 41 patients (age 62 ± 12 years) admitted to our Department for acute HF, NYHA class IV and severe LV dysfunction. Twenty-six patients were treated with L (0.1 µg/kg/min ev for 24 h without loading dose) and 15 patients were treated with standard therapy (C). We evaluated clinical, blood exams and echocardiographic parameters at baseline and one week after L or C treatment. Results: Baseline demographic, clinical and biochemical data were similar in both groups. After one week, the L group had shown a significant improvement in NYHA class and a redu- ction of pro-B-type natriuretic peptide (pro-BNP). In echocardiographic study, we observed an improvement in LV longitudinal function (p < 0.05) and LV ejection fraction (p < 0.05) with a reduction of E/E ' (p < 0.05) in the L group. We divided the L group into ischemic and non- -ischemic patients and we demonstrated a significant increase in systolic function in the for- mer. No differences were found between subgroups in diastolic function. Conclusions: L therapy, without loading dose, improves NYHA class and ventricular func- tion in patients with acute HF; we believe that these prolonged hemodynamic effects are due to active metabolities of L. (Cardiol J 2011; 18, 5: 532-537)

Aims The relative role of multiple determinants of left atrial volume index (LAVi) in athletes and non-athletes is not fully defined. Thus, we decided to prospectively assess the determinants of LAVi in healthy individuals and competitive athletes over a wide age range. Methods and results Four hundred and eighteen healthy individuals (mean age 41.7 ± 15.6 years, range 16–84, 65% males, 38% competitive athletes) underwent Doppler echocardiography including assessment of LAVi by the biplane area-length method and of left ventricular (LV) diastolic function including the ratio of early diastolic peak LV inflow velocity to peak myocardial early diastolic velocity ( E / e ′). Mean LAVi was 32.2 ± 9.0 mL/m2 in the pooled population. LAVi was larger in athletes than in non-athletes (38.9 ± 9.6 mL/m2 vs. 28.4 ± 5.8 mL/m2, P < 0.0001). In the pooled population a stepwise multiple linear regression analysis identified LV end-diastolic volume index (LVEDVi) ( β = 0.378, P < 0.0001), LV mass index (LVMi) ( β = 0.260, P < 0.0001), competitive sport activity ( β = 0.258, P < 0.0001), and age ( β = 0.222, P < 0.0001) as independent determinants of LAVi (model R 2 = 0.54, P < 0.0001). By separate analyses, although LVEDVi, age, and LVMi were predictors of LAVi in both groups, body mass index and the E / e ′ ratio were additional predictors of LAVi only in non-athletes. Conclusions In healthy individuals LV size, competitive sport, age, and LV mass are independent determinants of LAVi. Body mass index and the E / e ′ ratio affect LAVi only in non-athletes. These findings may have practical implications when assessing normalcy of LA size in the clinical setting.

Purpose: Left ventricular hypertrophy (LVH) can develop in response to training with morphological changes in the heart and to pathological increase in afterload such as in essential hypertension. Deformation analysis using two-dimensional (2D) strain echocardiography can detect early systolic function abnormalities in patients with LVH. The aim of this study was to characterize left ventricular twisting (LVT) modifications, in professional athletes, compared with control subjects and with patients with hypertensive cardiopathy. Methods: Seventy-six patients were enrolled: 37 professional athletes with cardiac hypertrophy (group A), 22 patients with early hypertensive cardiopathy (group B) cross-matched for LV mass index, and 17 healthy controls (group C), with no evidence of cardiac hypertrophy. All patients had no concomitant cardiac disease. All patients were investigated at rest using transthoracic echocardiography. LVT was obtained with speckle tracking analysis, using dedicated software. Results: LVT was reduced in group A compared to group B and C (group A: 8.0°± 2.4°; group C: 10.3°± 2.3°; group B: 16.0°± 4.2°; P < 0.01). In overall population, LVT showed a significant correlation with transmitral flow pattern (r =–0.58, P < 0.01) and with age (r =–0.57, P < 0.01). LVT showed the best predictive value to diagnose diastolic dysfunction (AUC: 0.86, P < 0.0001). Conclusions: 2D strain can identify specific patterns of myocardial deformation in professional athletes, controls, and patients with early hypertensive cardiopathy. In our study LVT showed a parallel trend with modifications of diastolic function and could represent a promising tool to differentiate functional cardiac hypertrophy from hypertensive cardiac hypertrophy. (Echocardiography 2011;28:892-898)

Background: Moderate-to-high blood concentrations of ethanol acutely impair conventional echocardiographic measures of left ventricular (LV) performance, but the effects of low concentrations are unclear. This study explored the acute effects of low blood concentrations of ethanol on sensitive and load-independent indices of LV and right ventricular (RV) function. Methods: This is a crossover experimental study conducted in 64 young healthy volunteers. Participants were asked to drink a light dose of Italian red wine equivalent to 0.5 mg/kg of ethanol, and an equal volume of fruit juice in separate experiments. The following measurements were taken at baseline and 60 minutes after the challenges: tissue Doppler mitral annulus systolic velocity (S’) and excursion (MAPSE), early diastolic velocity (E’), its ratio to late diastolic velocity (E’/A’), and the ratio of mitral-to-myocardial early diastolic velocities (E/E’); and tricuspid annulus systolic velocity (tricuspid S’) and amplitude (TAPSE), early diastolic velocity (tricuspid E’), and its ratio to late diastolic velocity (tricuspid E’/A’). Results: Blood ethanol concentration after wine intake was 0.48 ± 0.06 g/l. Compared with the control challenge, ethanol yielded a decrease in all measures of LV function (S’, −9.7%; E’, −11.2%; E’/A’, −13.4%; MAPSE, −8.8%; p

Background: The associations of left ventricular (LV) systolic torsion with clinical and echocardiographic variables in physiological conditions have not been fully investigated. We explored the independent determinants of LV systolic torsion in a population of normal subjects. Methods: In 119 healthy subjects, peak twist angle (LVtw) and torsion (LVtor) during ejection, and the QRS-LVtw interval (time-to-peak LVtw) were measured by speckle tracking. LV twisting rate and rotational deformation delay were also determined. Results: Stepwise multiple regression showed that LVtw was independently associated with indexed end-systolic volume (β=–0.200, P < 0.0001), peak early diastolic mitral annulus velocity (β=–0.186, P = 0.0001), heart rate (β= 0.178, P = 0.0003), and male gender (β=–0.174, P = 0.0004). Similar results were found for LVtor. Age was the only parameter, which has demonstrated an independent correlation with time-to-peak LVtw (β= 0.329, P < 0.0001). Despite significance of these associations, the proportions of variability explained by regression models were relatively low (range 11–26%), and no accurate predictive models were identifiable for LV twisting rate and rotational deformation delay. Conclusion: In normal individuals, indexed end-systolic LV volume, LV relaxation, heart rate, gender, and age correlate independently with LV torsion mechanics. However, conventional echocardiographic and clinical variables are not able to predict LV torsion mechanics. (Echocardiography 2011;28:641-648)

Background: The right atrium (RA) plays multiple roles in the cardiac cycle. The reservoir phase of the RA is a dynamic rather than a static phase of cardiac cycle and RA deformation is dependent on pulmonary pressures exerted on the right ventricle and, therefore, backwards on the RA. The purpose of this study was to assess the accuracy and the clinical applicability of the speckle tracking echocardiography (STE) evaluation of the RA in predicting the invasive systolic pulmonary artery pressure (SPAP) in patients with systolic heart failure (HF) undergoing right heart catheterization (RHC). Methods: Thirty-one hemodynamically stable, in-clinic HF patients who were undergoing RHC were included. Doppler echocardiography and RHC catheterization were simultaneously performed. Echocardiographic measures and STE where obtained as peak atrial longitudinal strain (PALS), RA strain rate, and time to peak longitudinal strain (TPLS). RA PALS was inversely correlated with invasively assessed SPAP (r =–0.81; P 50 mmHg were for RA PALS 10.3% (AUC:0.93, sensitivity: 100%, specificity: 78%). Conclusion: RA STE showed a significant correlation with pulmonary pressure. RA assessment with STE can predict pulmonary artery hypertension in HF patients. This result is consistent with nitroprusside challenge test. Although RA STE is not routinely used, its evaluation may implement right heart evaluation in HF patients. (Echocardiography 2011;28:658-664)

A 41-year-old male asymptomatic athlete with unremarkable personal and family history of heart disease underwent annual preparticipation screening. No abnormalities were noted on prior testing. On this occasion, a 12-lead electrocardiogram showed diffused and marked repolarization abnormalities. He was therefore referred for echocardiography, which showed moderate asymmetric hypertrophy localized at the mid-apical portions of the left ventricular anterolateral wall. Cardiac magnetic resonance confirmed the diagnosis of hypertrophic cardiomyopathy. Re-evaluation of the electrocardiogram performed the previous year revealed a completely normal tracing.

OBJECTIVES Cardiac resynchronization therapy (CRT) elicits more beneficial effects on left-ventricular (LV) structure and function, and long-term clinical outcomes in nonischemic heart failure patients. Rates of β-blocker use in recent heart failure trials are higher than in CRT trials and this may influence the response to CRT. This study examined the long-term effects of CRT on LV structure and function in New York Heart Association class III-IV β-blocker-treated patients. METHODS One hundred and four (41 ischemic and 63 nonischemic) CRT patients, who were receiving β-blockers before and throughout 12 months following device implantation, were retrospectively selected. Variations in echocardiographic parameters recorded before, and 6 and 12 months after CRT were analyzed. RESULTS Selected patients were all stable on β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (97%) and diuretics (97%) before implantation. CRT was associated with significant improvements in LV morphological and systo-diastolic functional parameters at 6 months, with further improvements between 6 and 12 months seen in nonischemic patients only. Accordingly, rates of echocardiographic response to CRT were similar at 6 months but significantly higher in nonischemic patients after 1 year. The degree of reduction in LV diameters and volumes, and of increase in ejection fraction, was significantly larger in nonischemic patients at both 6 and 12 months. In addition, a significant reduction in LV mass and severity of mitral regurgitation was more evident in nonischemic patients both 6 and 12 months following CRT. CONCLUSIONS Ischemic aetiology of heart failure is associated with less favorable long-term effects of CRT on LV structure and function despite the systematic use of β-blockers.

Background: Speckle tracking echocardiography (STE) is a novel method for the angle-independent and objective quantification of myocardial deformation; it has recently evolved, enabling the quantification of longitudinal myocardial left atrial (LA) deformation dynamics. To investigate the effects of chronic mitral regurgitation (MR) on these functional atrial indices, we analyzed LA function by STE in a group of asymptomatic patients with chronic degenerative MR. Methods: The study population included 36 patients with mild MR, 38 with moderate MR, and 42 with severe MR. 52 age-matched controls were also recruited. Global peak atrial longitudinal strain (global PALS) was measured in all subjects by averaging all atrial segments. Results: Age, gender, and LV ejection fraction in all pathological groups were comparable to those in the controls. Global PALS was higher in the mild MR group (46.7 ± 9.1%) in comparison with the controls (40.5 ± 6.2%; P < 0.001); instead global PALS was lower in the moderate MR group (25.7 ± 7.1%) and further reduced in the severe MR group (13.2 ± 5.2%) in comparison with the controls (40.5 ± 6.2%; overall P < 0.0001 by ANOVA, P < 0.05 for all pairwise comparisons). In multivariate analysis, E/Em ratio emerged as the principal independent determinant of global PALS. Conclusions: Our study provides new insight for the LA function analysis in response to different degrees of MR, showing that STE measurements of LA longitudinal strain may be considered a promising tool for the early detection of impairment of LA compliance in patients with asymptomatic chronic MR. (Echocardiography 2011;28:327-334)

We report on the successful treatment with sildenafil of a unique case of severe chronic thromboembolic pulmonary hypertension which developed as a late complication in a 71-year-old heart transplant recipient, with focus on the potential therapeutic challenges encountered in the management of such a peculiar association of clinical conditions.

Background The assessment of the longitudinal component of left ventricular (LV) function is of major clinical importance for the early detection of LV contractile impairment. The aim of this study was to compare the impact of isolated type-2 diabetes, isolated hypertension, and co-existence of both on LV longitudinal systolic performance, with particular focus on their potential interaction effect. Methods The study population included 163 consecutive patients: 84 patients with hypertension, 36 with diabetes, and 43 who have both hypertension and diabetes; 70 healthy controls were also recruited. Systolic mitral annulus velocity (Sm) by Tissue Doppler and left atrioventricular plane displacement (AVPD) by M-mode were measured in all subjects. Results AVPD was similarly reduced in hypertensives (13.2 ± 2.2 mm) and diabetics (13.5 ± 2.3 mm) when compared with the controls (15.1 ± 2.4 mm), and further depressed in diabetic hypertensives (11.5 ± 3.0 mm). Similar results were found for Sm. General linear model analysis revealed no significant interaction terms between diabetes and hypertension. Conclusions Normotensive diabetics and nondiabetic hypertensives show comparable depression in LV longitudinal systolic indices when compared with age- and gender-matched healthy controls; the co-existence of diabetes and hypertension leads to further impairment in LV longitudinal systolic function in an additive manner.

Background: Moderate to high blood concentrations of ethanol have been shown to yield acute changes in cardiac electrophysiological properties, but the effect of low concentrations have never been assessed. The role of concomitant changes in clinical variables or cardiac dimensions is also still unknown. This study aimed at exploring the acute effects of low doses of ethanol, administered as Italian red wine, on conduction, depolarization, and repolarization electrocardiographic (ECG) intervals in a population of healthy subjects. Methods: Forty healthy young volunteers drank a low quantity of red wine (5 ml/kg), and an equal volume of fruit juice in separate experiments. Heart rate, P-wave duration, PR interval, QRS duration, QT interval, corrected QT interval, QT dispersion, and corrected QT dispersion were assessed at baseline and after 60 minutes from challenge. Results: Mean blood ethanol concentration after drinking was 0.48 ± 0.06 g/l. Compared to the control challenge, significant changes after red wine intake were observed in P-wave duration (from 101 ± 11 to 108 ± 14 milliseconds, p = 0.0006), PR interval (from 153 ± 15 to 167 ± 17 milliseconds, p

The main objective of this study is to determine the prevalence of left ventricular systolic and diastolic dysfunction in patients with chronic sarcoidosis without clinical evidence of heart disease. The study includes 69 chronic sarcoidosis patients, 30 diagnosed by organ biopsy and 39 by clinical history, chest X-ray, high resolution computerized tomography (HRCT) and bronchoalveolar lavage (BAL), without suspected cardiac involvement. The control group consisted of 26 subjects selected from a population of hospital workers. The examination includes 12-lead ECG and echocardiographic examination. The results show that there were no differences in atrial size, left ventricular diameters, wall thickness, left ventricular ejection fraction or endocardial fractional shortening between the sarcoid group and controls. Signs of diastolic dysfunction were found in 33 (55%) patients, however, this group was significantly older than the others and had marginally higher blood pressure. Sarcoid patients had lower midwall fractional shortening (mFS) than controls; patients with diastolic dysfunction also had lower mFS but the difference was not significant. In conclusion, the results demonstrated an absence of left ventricular systolic dysfunction, evaluated by traditional echocardiographic methods, in our chronic sarcoidosis patients and an apparent absence of any relation between left ventricular diastolic dysfunction and sarcoidosis. Lower mFS was found among patients, particularly those with a long history of sarcoidosis. Further analysis is required to evaluate the significance of this index as a potential marker of heart involvement in chronic sarcoidosis.

SummaryLevels of circulating endothelial progenitor cells (EPCs) and CXCR4-positive cells are decreased in patients with coronary artery disease (CAD); however, their ability to change in response to acute vascular injury remains to be elucidated. Progenitor and CXCR4-positive cells were analysed by flow cytometry from the peripheral blood of 23 healthy controls and 23 patients with CAD, of which 13 patients underwent angiogram and 10 patients received percutaneous coronary intervention (PCI) with stent implantation. Baseline levels of progenitor and CXCR4-positive cells were substantially reduced in CAD patients compared to controls, although they were still capable of increasing in response to vascular injury. Levels of progenitor and CXCR4-positive cells were increased to a greater extent in the PCI group compared to angiogram patients. At presentation, levels of putative endothelial progenitor and CXCR4-positive cells were found to be negatively correlated with disease severity. A one-year follow-up revealed that out of the cell populations examined, only levels of CXCR4-positive cells were positively correlated with angina frequency in the PCI group, but not in patients receiving angiogram. Baseline levels of progenitor cells are differentially increased depending upon the severity of vascular injury incurred, regardless of a significant deficit in baseline levels in CAD patients. Levels of putative EPCs and CXCR4-positive cells were negatively correlated with disease severity at presentation, however, only CXCR4-positive cells were associated with patient condition in a one-year follow-up.

We report the case of a 51-year old man with symptoms of heart failure due to severe cardiac amyloidosis, in whom treatment with melphalan and dexamethasone yielded significant improvement in clinical status and both systolic and diastolic left ventricular (LV) function over a 12-week follow-up. The improvement in LV performance was detected by Tissue Doppler (TD) and strain analysis, despite no changes in standard indices such as ejection fraction and Doppler pattern of mitral inflow. Color TD-derived myocardial velocity and deformation indices also revealed a reduction in intra-ventricular early diastolic asynchrony after therapy. In addition, an improvement in intra-ventricular systolic synchrony was detected by strain rate and strain, but not by color TD velocity imaging. These findings suggest that treatment with melphalan and dexamethasone may improve symptoms of heart failure and LV performance in subjects with cardiac amylodosis, and that TD and particularly strain imaging could represent useful techniques to monitor the effect of therapy on LV function in the follow-up of these patients.

Functional mitral regurgitation (FMR) is a common finding in patients with ischemic or nonischemic dilated cardiomyopathy as a complication of left ventricular (LV) dysfunction and remodeling associated with a fibrotic remodeling response of mitral leaflets to abnormal valvular loading. Although mitral valve tenting is the main determinant of FMR, clinical and experimental observations suggest that intraventricular delay could be a potential co-determinant of FMR. LV dyssynchrony can potentially contribute to FMR by several mechanisms, such as creating an uncoordinated regional LV mechanical activation in segments supporting the papillary muscles, determining diastolic mitral regurgitation, reducing the sphincteric function of the mitral annulus, and decreasing the efficiency of LV contraction and closing forces. Cardiac resynchronization therapy has been demonstrated to reduce FMR with correction of some of the underlying pathophysiological mechanisms. The present review article focuses on the role of mechanical dyssynchrony as a pathophysiological determinant of FMR, and on the potential role of cardiac resynchronization therapy as a therapeutic option for treatment of FMR in patients with severe heart failure and advanced LV dysfunction.

Background Assessment of left ventricular circumferential (LV circ ) systolic function by standard echocardiography can be performed by estimating midwall fractional shortening (mFS) and stress-corrected mFS (ScmFS). Their determination is based on spherical or cylindrical LV geometric models, which often yield discrepant values. We developed a new model based on a more realistic truncated ellipsoid (TE) LV shape, and explored the concordance between models among hypertensive patients. We also compared the relationships of different mFS and ScmFS estimates with indexes of LV circ systolic strain. Methods In 364 hypertensive subjects, mFS was determined using the spherical (mFS spher ), cylindrical (mFS cyl ), and TE model (mFS TE ). Corresponding values of ScmFS spher , ScmFS cyl , and ScmFS TE were obtained. Global circumferential strain (GCS) and systolic strain rate (GCSR) were also measured by speckle tracking. Results The three models showed poor concordance for the estimation of mFS, with average differences ranging between 11% and 30% and wide limits of agreement. Similar results were found for ScmFS, where reclassification rates for the identification of abnormal LV circ systolic function ranged between 18% and 29%. When tested against strain indexes, mFS TE and ScmFS TE showed the best correlations (R=0.81 and R=0.51, p TE and ScmFS TE showed the strongest independent associations with LV circ strain measures. Conclusions Substantial discrepancies in LV circ midwall systolic indexes exist between different models, supporting the need of model-specific normative data. The use of the TE model might provide indexes that show the best associations with established strain measures of LV circ systolic function.

In last month, an intriguing discussion has been raised by Dr Khayyal on the EACVI Club 35 LinkedIn platform ‘Young Network of Cardiovascular Imaging’ about the new ASE/EACVI recommendations for chamber quantification,1 particularly concerning the evaluation of the right ventricle, the range values for defining it as normal and the severity grading of dilatation. In summary, in the new guidelines the RV basal diameter is normal up to 41 mm, mid-diameter up to 35 mm. Actually there is not a distinction in severity grades, so we could distinct only normal and abnormal RV. Conversely, in the 2005 guidelines,2 the …

Aims Conflicting evidence exists concerning right ventricular (RV) morphological and functional remodelling in trained athletes, with a very few longitudinal data prospectively investigating the RV changes. The aim of this study was to assess the morphological and functional RV changes occurring during the competitive season in young athletes engaged in the most popular team sports. Methods and results Twenty-nine top-level athletes (age: 20.9 ± 6.7 years), practicing basketball and volleyball, were evaluated at pre-season, mid-season, and end-season time-points, using tissue Doppler imaging and 2D speckle-tracking echocardiography. RV basal and mid-cavity end-diastolic diameters (EDDs; overall P = 0.011 and P < 0.0001, respectively), and RV diastolic area (overall P < 0.0001) increased during the season. Conversely, RV outflow tract did not vary (overall P = 0.96). During the season, no significant differences were observed in RV diastolic functional indexes and in RV fractional area change (overall P = 0.35). Global RV longitudinal strain did not significantly change (overall P = 0.52), although apical longitudinal strain significantly increased (overall P = 0.017). In association, left ventricular (LV) volume and mass increased during the season (overall P = 0.007). On multivariate analysis, LV mass was the only independent predictor of RVEDD at pre-season ( β = 0.69, P < 0.0001) and at end-season (β = 0.82, P < 0.0001). Conclusions Right ventricular chamber size increases during the competitive season in top-level athletes, with no significant changes in the outflow tract. RV morphological adaptation in top-level athletes practicing team sports is not associated with a reduction in RV function or in myocardial deformation and occurs in close association with changes on the left ventricle, suggesting a physiological remodelling of the right ventricle.

The development and rapid dissemination of two-dimensional echocardiography led to important further advances in our understanding of athletes' heart that has been the subject of several echocardiographic studies involving many thousands of athletes. The description of ventricular chamber enlargement, myocardial hypertrophy and atrial dilatation has led to a more comprehensive understanding of cardiac adaptation to exercise conditioning. Most recently, advanced echocardiographic techniques have begun to clarify significant functional adaptations of the myocardium that accompany previously reported morphological features of athletes' heart. In particular, speckle-tracking echocardiography (STE) has recently provided further insights into the characterisation of myocardial properties.STE is a relatively new, largely angle-independent, non-invasive imaging technique that allows for an objective and quantitative evaluation of global and regional myocardial function. STE has enhanced our understanding of athletes' heart through a comprehensive characterisation of biventricular and biatrial function, providing novel insights into the investigation of physiological adaptation of the heart to exercise conditioning. These peculiarities can provide further useful data to distinguish between athletes' heart and cardiomyopathies. Furthermore, STE represents a promising tool to address new concerns on right ventricular function and to increase understanding of the complexity of the non-systemic circulation, especially in the athletic population.This review article analyses new data on cardiac function in athletes by novel echocardiographic techniques with a particular attention to the application of STE to characterise biventricular and biatrial function in athletes.

Aim Exertional angina in patients with no coronary flow limiting lesions remains a clinical puzzle. We aimed to assess the extent of coronary artery calcification (CAC) and its relationship to ventricular wall motion function using stress echocardiography in a group of patients limited by exertional angina, but no obstructive lesions. Methods We compared CT coronary calcium score (CACS) and dobutamine stress echocardiography in 55 patients (age 64.7 ± 7.7 years), divided into Group 1 (CACS ≤ 100) and Group 2 (CACS > 100). No patient had LV ejection fraction-EF

Atrial septal defect (ASD) is the most common congenital heart disease in adults. When right heart dilation occurs, prompt closure should be considered. In the athletic population, however, the management of ASD can be challenging. Indeed, while the training-induced haemodynamic effects on the right heart of an athlete with open ASD are not well known, possible device-related consequences may occur after percutaneous closure. We report the case of a competitive athlete with secundum ASD in which changes in the training regime significantly affected the right heart. Prompt normalisation of right ventricular size and of pulmonary artery pressures was demonstrated 2 months after percutaneous ASD closure.

Previous cross-sectional studies have demonstrated that fat-free mass (FFM) is an important determinant of left ventricular mass (LVM) in athletes. However, cross-sectional investigations have not the ability to detect the dynamic adaptation occurring with training. We hypothesized that LVM adapts concurrently with the increase of FFM induced by exercise conditioning. We sought to study the relationship between the variations of LVM and of FFM occurring in top-level soccer players during the season.Twenty-three male top-level athletes were recruited. LVM was assessed by echocardiography and FFM by dual-energy X-ray absorptiometry. Serial measurements were performed pre-season, after 1 month, at mid- and end-season, and after 2 months of detraining.LVM significantly increased at mid-season versus pre-season values, reaching the highest value at the end of the season (p0.05). While body weight did not vary during the study period, FFM significantly increased (p0.05 for mid-/end-season vs. pre-season data). After the detraining, no significant differences were observed between pre-season and detraining echocardiographic data. The only independent predictors of LVM were left ventricular stroke volume and FFM (R = 0.36, p = 0.005; R = 0.35, p = 0.005, respectively). When ΔLVM index was set as dependent variable, the only independent predictor was ΔFFM (R = 0.87, p = 0.002).Changes in LVM occur in close association with changes in FFM, suggesting that the left ventricle adapts concurrently with the increase of the metabolically active tissue induced by training, i.e. the FFM. Therefore, the dynamic changes in FFM and LVM may reflect a physiological adaptation induced by intensive training.

We read with interest the letter by Stollberger and Finsterer [1] inresponse to our article [2] and we wish to thank the authors for givingus the opportunity to provide further considerations, based on theircomments.The possibility to correctly identify left ventricular non-compaction(LVNC) is fundamental in the context of pre-participation screening,given that cardiomyopathies are known as a primary cause for suddencardiac death in young athletes. However, at the present time, thereare uncertainties on the correct classification of LVNC, particularlywhenseeninathleteswherephysiologicalLVremodelingmaymorpho-logically mimic true myocardial disease.An interesting observation reported by Stollberg questionedwhether LV hypertrabeculation was present before training in ourcase series [2]. While 1 athlete fulfilled both the echocardiographicChin and Jenni criteria for LVNC [3,4] before the training, 3 of them ful-filled the Chin criteria and all the Jenni criteria after training. As a re-sponse to training stimulus, new trabeculae were identified and theyweremoreevidentascomparedwiththepre-trainingevaluation.Nota-bly, training was able to induce anincrease in both the non-compactedand compacted layers. The better visualization of LV trabeculae aftertraining can be explained not only by the direct stimulus related totraining, but also by the increase in LV cavity size induced by changesin hemodynamics.AssuggestedbyStollberg,thepresenceoffamilyhistoryiscrucialfortheclinicalevaluation,suchasthepresenceofsymptoms.Inourcasese-ries, none of the athletes had family history for cardiomyopathies, sud-dencardiacdeath,orheartfailure.Furthermore,nonewassymptomaticorpresentedsyncopeorarrhythmiasandnonehadsigns,symptoms,orbiochemical abnormalities related to neuromuscular disorders.Stollberg states that the intake of doping drugs is able to influencemuscular growth and could influence the pattern of LV hypertrophy.However, none of the athletes took drugs and this was confirmed byantidoping controls performed during the agonistic season, accordingto current regulation for the Italian Basketball League.Theexercise-inducedincreaseinLVtrabeculationwasaccompaniedalsobychangesat12-leadrestingECG[2].Thesechangeswerefoundin3 athletes after training, all of them of afro-Caribbean origin, and werenot interpreted as pathological, being a possible normal, race-relatedvariant,assuggestedbycurrentrecommendations[5,6].Notably,thelo-calization of negative T waves differs between patients suffering fromLVNC and athletes presenting with LV hypertrabeculation [7]: indeed,while the latter normally show anterior T-wave inversion, as found inour case series, the former have a high prevalence of T-wave inversionin the inferior and lateral leads [7]. However, we cannot negate thatthe contemporary presence of both LV hypertrabeculation and T-waveinversion in the precordial leads represents a challenge for clinicianswhen evaluating an athlete.In conclusion, our observation does not challenge the hypothesis thatLVNC is due to a disturbed compactionprocess of the embryogenic heart.Conversely,itsuggeststhatexercisecouldrepresentastimulusforthede-velopment of a LV hypertrabeculation pattern in certain subjects. Thus,according to this experience and to previous observations in athletes byother research groups [7–9], we suggest distinguishing between“hypertrabeculation” and “LVNC”. We believe that these two terms de-scribe a different phenomenon: indeed, isolated “hypertrabeculation”does potentially indicate the consequence of physiological adaptation ofthe LV to intensive training in predisposed individuals; it can be foundin the absence of pathological fidings, symptoms, or family history ofncardiomyopathies. Therefore, the optimization of echocardiographic im-aging in the last years should have at least in part in fluenced the recogni-tion of this entity. Conversely, “LVNC” represents a cardiomyopathy ableto induce life-threatening arrhythmias, LV dilatation and dysfunction

Levosimendan is a calcium sensitizer and K(+)-ATP channel opener with inotropic and vasodilatatory effects irrespective of myocardial oxygen consumption, used for treatment of heart failure (HF). A loading dose is usually given by infusion for 12 h; however, profound lowering of blood pressure often disrupts or prolongs the infusion. The aim of this study was to assess clinical, biochemical and myocardial differences between different regimes of levosimendan therapy, with or without loading dose, and compared to standard therapy in heart failure.Fifty-seven patients (mean age ± SD: 60.9 ± 9.3 years, 45 males) with HF, New York Heart Association (NYHA) III-IV, reduced left ventricular ejection fraction (LVEF) were included. Twenty patients (NB group) were given levosimendan without loading dose, 14 patients (B group) were given levosimendan with loading dose, and 23 patients (C group) were given standard therapy. Clinical, biochemical and echocardiographic characteristics at baseline and one week after treatment were evaluated.Groups were similar at baseline. After one week NHYA class (P0.001), NT pro-BNP (P0.001), LVEF (P = 0.045), E/A (P = 0.048) E/e' (P0.001), and PAPs (P0.001) decreased. DT (P = 0.011) and TAPSE (P = 0.035) increased in all groups.Levosimendan, as well as standard therapy, improves myocardial function and symptoms of HF, irrespective of the loading dose administration. Treatment options for patients with end-stage heart failure refractory to conventional medical therapy are limited. Inotropic drugs play an important role in heart failure (HF).

Diastolic function get worse with increasing age. Aim of this study was to investigate the impact of aerobic training on diastolic function with increasing age with speckle tracking echocardiography. We enrolled 125 amateur swimmers (AG), divided in three groups at increasing age: young athletes, adult athletes (AG2), old athletes (AG3). We enrolled 95 sedentary controls (SG) age-matched with athletes and divided into three groups: young sedentary group, adult sedentary group (SG2) and old sedentary group (SG3). AG had better diastolic function than SG. AG showed lower left ventricular twist than controls. E/A ratio got worse at increasing of age in all population (r = -0.34; p < 0.001); particularly in SG2 and SG3 there was a worsening of diastolic function respect to diastolic function of AG2 and AG3; in fact E/A ratio decreased with aging. Furthermore in SG E/A ratio showed a linear correlation with age (r = -0.54; p < 0.001); in AG this correlation was lost. Therefore the training and age were independent predictor of E/A (respectively β = -0.27; p = 0.004; β = -0.24, p = 0.008). Regular and aerobic training may minimize aging changes of diastolic function. This training-effect may play a key role to preserve diastolic filling in older athletes.

Purpose The increase in systolic indexes from rest (R) to exercise is achieved by combination of enhanced heart rate (HR) and stroke volume (SV). Aim of this study was to evaluate left ventricular (LV) longitudinal, circumferential, and torsional components immediately after a maximal intensity exercise (ME) by speckle tracking echocardiography (STE). Methods Twenty-seven male water polo players performed an ME that consisted of 6 repeats of 100 m freestyle swim sets. An echocardiographic examination was performed before and after ME. STE was performed to obtain the analysis of LV myocardial deformation. Results There were no differences between R and ME regarding LV longitudinal strains (PVLS). Apical circumferential LV strain (AVCS) and LV longitudinal strain rate (SR) increased at ME with respect to R (R: −23.1 ± 4.9%; ME: −28.4 ± 7.6%, P

Impact of physical training on normal age-related changes in left ventricular longitudinal function

Background Speckle tracking echocardiography analysis (STE) has recently allowed an in-depth analysis of right ventricular (RV) performance. The aim of the study was to observe RV function by STE in patients with advanced heart failure before and after left ventricular assist device (LVAD) implantation. Methods A transthoracic echocardiogram was performed in 19 patients referred for LVAD implant at baseline and with serial echocardiograms after LVAD implantation (Jarvik 2000). All echocardiographic images were analyzed off line by an independent operator to calculate with STE the RV free wall longitudinal strain (RVLS). Results All the patients, except 4, showed a progressive increase of RVLS after LVAD implant. However, 4 patients, who presented the lowest RVLS values at baseline, presented a further RV failure in the postoperative. The value of −11% represented the empirical preoperative cutoff able to identify patients at greater risk of postimplant RV failure. Conclusions RV myocardial deformation may have important clinical implications for the selection and management of LVAD patients. It can be used to evaluate RV function before LVAD implantation, to drive decisional strategy regarding the management of this type of patients, and after LVAD implant for the follow-up.

Pulse pressure variation (PPV) is a dynamic index of fluid responsiveness. This parameter helps clinicians in improving haemodynamic status while avoiding potential fluid overload. Echocardiographic indices, such as E/E' ratio and left atrial (LA) strain by speckle tracking echocardiography (STE), are used to estimate left ventricular (LV) filling pressures. This study aimed at exploring the relationship between PPV and echocardiographic indices of LV filling pressures in critically ill patients.Twenty-two patients (mean age of 50.9 ± 21.6, male/female = 15/7) admitted to intensive care unit, and requiring mechanical ventilation and invasive arterial pressure monitoring, were studied. In all patients, two independent operators assessed simultaneously PPV, using a pulse contour method, mean E/E' ratio and peak atrial longitudinal strain (PALS) by means of STE. PALS values were obtained by averaging LA segments measured in the 4-chamber and 2-chamber views (global PALS).A significant negative correlation was found between mean E/E' ratio and PPV (R(2) = -0.76; P0.001). A positive correlation between global PALS and PPV was found (R(2) = 0.80, P0.001). Mean global PALS of 26.2% demonstrated excellent accuracy (Area Under Roc Curve = 0.86, P0.001), and good sensitivity (92%) and specificity (86%) in predicting a PPV15%.In a group of mechanically ventilated patients PPV, derived from pulse contour analysis, and echocardiographic preload parameters were well correlated. Global PALS by STE provided better estimation of PPV than mean E/E' ratio. PALS seems a potential alternative to PPV in assessing fluid responsiveness in critically ill patients.

The presence of left ventricular (LV) diastolic dysfunction (DD) as characterized by Doppler echocardiography is associated with worse overall mortality both in symptomatic and asymptomatic patients. However, available data on this topic come from referral centers and have been obtained by different, validated algorithms for each single study. Thus, we aimed at determining the feasibility of comprehensive evaluation of LVDD in a primary care outpatient setting and at testing the concordance of different methodological approaches in grading diastolic dysfunction. Eight hundred eighty-five consecutive outpatients, in sinus rhythm, prospectively underwent Doppler echocardiography according to a predetermined protocol. Feasibility of each LV diastolic index and concordance between 3 methods to determine the degree of LVDD, namely the American Society of Echocardiography/European Association of Echocardiography (ASE/EAE) recommendations, the Olmstead County, and the Canberra Study protocols, were tested. Feasibility of all diastolic indexes was high, ranging from 93% of Valsalva maneuver to ≥99% for mitral inflow and tissue Doppler parameters. Diastolic function was not classifiable in 6% to 19% of patients. The concordance for LV diastolic dysfunction degree was fair when comparing the classification of the ASE/EAE with those from Olmstead County (κ = 0.25; reclassification rate 51%) and Canberra Study (κ = 0.27; reclassification rate 43.7%), and was good for the comparison between the Olmstead County and Canberra classifications (κ = 0.68, reclassification rate 27%). In conclusion, feasibility of LV diastolic function measurements is very high and grading diastolic dysfunction is possible in most patients in primary care settings. Substantial differences, however, exist when concordance is tested among 3 documented criteria, resulting in poor concordance of data interpretation and hence patient stratification and clinical management.

Assessment of left ventricular (LV) systolic function is the cornerstone of the echocardiographic examination. There are many echocardiographic parameters that can be used for clinical and research purposes, each one with its pros and cons. The LV ejection fraction is the most used one due to its feasibility and predictability, but it also has many limits, related to both the imaging technique used for calculation and to the definition itself. LV longitudinal function is expression of subendocardial fibers contraction. Because the subendocardium is often involved early in many pathological processes, its analysis has been a fertile field for the development of sensitive parameters. Longitudinal function can be evaluated in many ways, such as M-mode echocardiography, tissue Doppler imaging, and speckle tracking echocardiography. This latter is a relatively new tool to assess LV function through measurement of myocardial strain, with a high temporal and spatial resolution and a better inter- and intra-observer reproducibility compared to Doppler strain. It is angle independent, not affected by translation cardiac movements, and can assess simultaneously the entire myocardium along all the three-dimensional geometrical (longitudinal, circumferential, and radial) axes. Speckle tracking echocardiography also allows the analysis of LV torsion. The aim of this paper was to review the main echocardiographic parameters of LV systolic function and to describe its pros and cons.