Left ventricular (LV) global longitudinal strain (GLS) can detect subclinical myocardial systolic dysfunction in individuals with diabetes. The present study investigates the clinical usefulness... Show moreLeft ventricular (LV) global longitudinal strain (GLS) can detect subclinical myocardial systolic dysfunction in individuals with diabetes. The present study investigates the clinical usefulness and incremental net benefit of identifying subclinical myocardial systolic dysfunction in individuals with diabetes. A cohort of 397 type 2 diabetic individuals was followed up for the occurrence of all-cause mortality. Clinical and echocardiographic data of diabetic patients were assessed retrospectively. LV GLS was evaluated on transthoracic echocardiography using speckle tracking imaging. Subclinical LV systolic dysfunction was defined as LV GLS > -17.0% from 104 healthy volunteers recruited from the community. A total of 178 (44.8%) diabetic individuals had evidence of subclinical LV systolic dysfunction and 46 (11.6%) died during follow-up. The presence of subclinical LV systolic dysfunction was independently associated with all-cause mortality on follow-up (hazard ratio [HR] 2.83, 95% confidence interval [CI] 1.40 to 5.71, p = 0.004). Diabetic individuals without subclinical LV systolic dysfunction had similar survival as the general population (standardized mortality ratio 0.94, 95% CI 0.52 to 1.58). Decision curve analysis showed identification of subclinical LV systolic dysfunction and quantification of LV GLS provided an incremental net clinical benefit at risk stratifying patients for risk of death at 5 years. In conclusion, subclinical LV systolic dysfunction is independently associated with all-cause mortality in diabetic patients. Decision curve analyses suggest use of LV GLS and identification of subclinical LV systolic dysfunction is clinically useful, and provided incremental net clinical benefit for diabetic individuals. (C) 2019 The Authors. Published by Elsevier Inc. Show less
The general introduction of the thesis outlines the role of cardiac mechanics assessment in the evaluation and risk stratification of HF patients. Part I This part of the thesis summarizes current... Show moreThe general introduction of the thesis outlines the role of cardiac mechanics assessment in the evaluation and risk stratification of HF patients. Part I This part of the thesis summarizes current imaging techniques to assess various aspects of LV mechanics in HF patients (Chapter 2), differentiating between ischemic and non-ischemic HF (Chapter 3) and investigating its role in the selection of HF patients who are candidates to CRT (Chapters 4-6). Furthermore, the role of imaging techniques to optimize the results of CRT is summarized in Chapter 7. Part II The final part focuses on long-term prognosis of advanced HF patients. Novel echocardiographic techniques provide several parameters that have incremental prognostic value over well-recognized echocardiographic and clinical parameters (Chapters 8-11). CONCLUSIONS The study of cardiac mechanics is crucial in advanced HF patients. Particularly, using imagine techniques as speckle-tracking echocardiography, important information on the effects of CRT in heart failure patients may be derived. Moreover, studying LV mechanics may be helpful for understanding the differences in pathophysiological mechanisms of different HF aetiologies. Finally, the role of non-invasive imaging techniques for the study of LV mechanics may be paramount for the definition of long-term prognosis in advanced HF patients. Show less
BACKGROUND: Clinical or echocardiographic mid-term responses to cardiac resynchronization therapy (CRT) may have a different influence on a long-term prognosis of heart failure patients treated... Show moreBACKGROUND: Clinical or echocardiographic mid-term responses to cardiac resynchronization therapy (CRT) may have a different influence on a long-term prognosis of heart failure patients treated with CRT. The aim of the evaluation was to establish which definition of response to CRT, clinical or echocardiographic, best predicts long-term prognosis. METHODS AND RESULTS: A total of 679 heart failure patients treated with CRT were included. All the patients underwent a complete history and physical examination and transthoracic echocardiogram prior to CRT implantation and at 6-month follow-up. The clinical and echocardiographic responses to CRT were defined based on clinical improvement (≥1 NYHA class) and LV reverse remodelling (reduction in LV end-systolic volume ≥15%) at 6-month follow-up, respectively. All the patients were prospectively followed up for the occurrence of death. The mean age was 65 ± 11 years and 79% of the patients were male. At 6-month follow-up, 510 (77%) patients showed clinical response to CRT and 412 (62%) patients showed echocardiographic response to CRT. During a mean follow-up of 37 ± 22 months, 140 (21%) patients died. Clinical and echocardiographic responses to CRT were both significantly related to all-cause mortality on univariable analysis. However, on multivariable Cox-regression analysis only echocardiographic response to CRT was independently associated with superior survival (hazard ratio: 0.38; 95% CI: 0.27-0.50; P < 0.001). CONCLUSION: In a large population of heart failure patients treated with CRT, the reduction in LV end-systolic volume at the mid-term follow-up demonstrated to be a better predictor of long-term survival than improvement in the clinical status. Show less
Bertini, M.; Schalij, M.J.; Bax, J.J.; Delgado, V. 2012
BACKGROUND Left ventricular (LV) global longitudinal strain (GLS) is a measure of the active shortening of the LV in the longitudinal direction, which can be assessed with speckle-tracking... Show moreBACKGROUND Left ventricular (LV) global longitudinal strain (GLS) is a measure of the active shortening of the LV in the longitudinal direction, which can be assessed with speckle-tracking echocardiography. The aims of this evaluation were to validate the prognostic value of GLS as a new index of LV systolic function in a large cohort of patients with chronic ischemic cardiomyopathy and to determine the incremental value of GLS to predict long-term outcome over other strong and well-established prognostic factors. METHODS AND RESULTS A total of 1060 patients underwent baseline clinical evaluation and transthoracic echocardiography. Median age was 66.9 years (interquartile range, 58.4, 74.2 years); 739 (70%) were men. The median follow-up duration for the entire patient population was 31 months. During the follow-up, 270 patients died and 309 patients reached the combined end point (all-cause mortality and heart failure hospitalization). Compared with survivors, patients who died (270, [25%]) had larger LV volumes (P<0.05), lower LV ejection fraction (P=0.004), higher wall motion score index (P=0.001), and greater impairment of LV GLS (P<0.001). After dichotomizing the population on the basis of the median value of LV GLS (-11.5%), patients with an LV GLS ≤-11.5% had superior outcome compared with patients with an LV GLS >-11.5% (log-rank χ(2), 13.86 and 14.16 for all-cause mortality and combined end point, respectively, P<0.001 for both). On multivariate analysis, GLS was independently related to all-cause mortality (hazard ratio per 5% increase, 1.69; 95% confidence interval, 1.33-2.15; P<0.001) and combined end point (1.64; 95% confidence interval, 1.32-2.04; P<0.001). CONCLUSIONS The assessment of LV GLS with speckle-tracking echocardiography is significantly related to long-term outcome in patients with chronic ischemic cardiomyopathy. Show less
BACKGROUND Diabetic patients have increased interstitial myocardial fibrosis on histological examination. Magnetic resonance imaging (MRI) T(1) mapping is a previously validated imaging technique... Show moreBACKGROUND Diabetic patients have increased interstitial myocardial fibrosis on histological examination. Magnetic resonance imaging (MRI) T(1) mapping is a previously validated imaging technique that can quantify the burden of global and regional interstitial fibrosis. However, the association between MRI T(1) mapping and subtle left ventricular (LV) dysfunction in diabetic patients is unknown. METHODS AND RESULTS Fifty diabetic patients with normal LV ejection fraction (EF) and no underlying coronary artery disease or regional macroscopic scar on MRI delayed enhancement were prospectively recruited. Diabetic patients were compared with 19 healthy controls who were frequency matched in age, sex and body mass index. There were no significant differences in mean LV end-diastolic volume index, end-systolic volume index and LVEF between diabetic patients and healthy controls. Diabetic patients had significantly shorter global contrast-enhanced myocardial T(1) time (425±72 ms vs. 504±34 ms, P<0.001). There was no correlation between global contrast-enhanced myocardial T(1) time and LVEF (r=0.14, P=0.32) in the diabetic patients. However, there was good correlation between global contrast-enhanced myocardial T(1) time and global longitudinal strain (r=-0.73, P<0.001). Global contrast-enhanced myocardial T(1) time was the strongest independent determinant of global longitudinal strain on multivariate analysis (standardized β=-0.626, P<0.001). Similarly, there was good correlation between global contrast-enhanced myocardial T(1) time and septal E' (r=0.54, P<0.001). Global contrast-enhanced myocardial T(1) time was also the strongest independent determinant of septal E' (standardized β=0.432, P<0.001). CONCLUSIONS A shorter global contrast-enhanced myocardial T(1) time was associated with more impaired longitudinal myocardial systolic and diastolic function in diabetic patients. Show less
Auger, D.; Bleeker, G.B.; Bertini, M.; Ewe, S.H.; Bommel, R.J. van; Witkowski, T.G.; ... ; Delgado, V. 2012
AimsTo evaluate the effects of cardiac resynchronization therapy (CRT) on long-term survival of patients without baseline left ventricular (LV) mechanical dyssynchrony.Methods and resultsA total of... Show moreAimsTo evaluate the effects of cardiac resynchronization therapy (CRT) on long-term survival of patients without baseline left ventricular (LV) mechanical dyssynchrony.Methods and resultsA total of 290 heart failure patients (age 67 ± 10 years, 77% males) without significant baseline LV dyssynchrony (<60 ms as assessed with tissue Doppler imaging) were treated with CRT. Patients were divided according to the median LV dyssynchrony measured after 48 h of CRT into two groups. All-cause mortality was compared between the subgroups. In addition, the all-cause mortality rates of these subgroups were compared with the all-cause mortality of 290 heart failure patients treated with CRT who showed significant LV dyssynchrony (≥60 ms) at baseline. In the group of patients without significant LV dyssynchrony, median LV dyssynchrony increased from 22 ms (inter-quartile range 16-34 ms) at baseline to 40 ms (24-56 ms) 48 h after CRT. The cumulative mortality rates at 1-, 2-, and 3-year follow-up of patients with LV dyssynchrony ≥40 ms 48 h after CRT implantation were significantly higher when compared with patients with LV dyssynchrony <40 ms (10, 17, and 23 vs. 3, 8, and 10%, respectively; log-rank P< 0.001). Finally, the cumulative mortality rates at 1-, 2-, and 3-year follow-up of patients with baseline LV dyssynchrony were 3, 8, and 11%, respectively (log-rank P= 0.375 vs. patients with LV dyssynchrony <40 ms). Induction of LV dyssynchrony after CRT was an independent predictor of mortality (hazard ratio: 1.247; P= 0.009).ConclusionIn patients without significant LV dyssynchrony, the induction of LV dyssynchrony after CRT may be related to a less favourable long-term outcome. Show less
Ng, A.C.T.; Yiu, K.H.; Ewe, S.H.; Kley, F. van der; Bertini, M.; Weger, A. de; ... ; Delgado, V. 2011
