In this thesis, novel and established imaging techniques have provided new insights into the pathophysiology and outcomes of various cardiac diseases.In part I, a novel method of evaluating RV... Show moreIn this thesis, novel and established imaging techniques have provided new insights into the pathophysiology and outcomes of various cardiac diseases.In part I, a novel method of evaluating RV function is described and validated. Chapter 2 provides a proof of concept for the feasibility of RV myocardial work assessment on 2-dimensional speckle tracking strain echocardiography. This concept was validated in chapter 3 in a population with precapillary pulmonary hypertension.Part II includes six chapters focused on novel insights into the risk stratification of patients with valvular heart disease. Chapter 4 demonstrates the differences and prognostic implications of LV remodeling in different types of bicuspid aortic valve disease, while chapter 5 shows the association between left atrial enlargement and outcome in patients with aortic regurgitation due to a bicuspid aortic valve. Chapter 6 evaluates the prevalence and prognostic relevance of mitral regurgitation in patients with a bicuspid aortic valve and chapter 7 investigates the importance of LV ejection fraction in patients with bicuspid aortic valve disease. Chapter 8 evaluates the mechanisms linking renal function and significant tricuspid regurgitation. Chapter 9 evaluates the prognostic role of the number of secondary outcome determinants on postsurgical survival in patients with degenerative mitral regurgitation. Show less
Meucci, M.C.; Butcher, S.C.; Galloo, X.; Velde, E.T. van der; Marsan, N.A.; Bax, J.J.; Delgado, V. 2022
Background: Left ventricular (LV) global longitudinal strain (GLS) has been proposed as a sensitive marker of myocardial damage in patients with chronic severe aortic regurgitation (AR) and... Show moreBackground: Left ventricular (LV) global longitudinal strain (GLS) has been proposed as a sensitive marker of myocardial damage in patients with chronic severe aortic regurgitation (AR) and preserved LV ejection fraction (LVEF). However, LV GLS does not take into account the afterload. Noninvasive LV myocardial work is a novel parameter of LV myocardial performance, which integrates measurements of myocardial deformation and noninvasive blood pressure (afterload). The aims of this study were (1) to assess noninvasive LV myocardial work in patients with chronic AR and preserved LVEF and its correlation with other echocardiographic parameters, (2) to evaluate changes of LV myocardial work after aortic valve replacement or repair (AVR), and (3) to assess the relationship between LV myocardial work and postoperative LV reverse remodeling. Methods: Fifty-seven patients (53 6 16 years; 67% men) with moderate or severe chronic AR and preserved LVEF treated by AVR were included. Noninvasive LV myocardial work indices were measured at baseline and postoperatively (between 2 and 12 months after surgery) and compared with previously reported normal reference ranges. Results: Based on normal reference values, patients with chronic AR and preserved LVEF had preserved or increased values of LV global work index (GWI; 82% and 18%, respectively) and LV global constructive work (GCW; 74% and 25%, respectively) and preserved LV global work efficiency (GWE). Left ventricular GWI and GCW showed a positive correlation with markers of AR severity and parameters of LV systolic function. Left ventricular GWI, GCW, and GWE decreased after AVR (P <.001), without changes in LV global wasted work (P =.28). The postoperative impairment of LV GWI, observed in 28% of patients, was closely associated with reduced LV reverse remodeling. Conclusions: Noninvasive myocardial work may allow better understanding of myocardial function and energetics than afterload-dependent echocardiographic parameters in chronic AR with preserved LVEF. (J Am Soc Echocardiogr 2022;35:703-11.) Show less
In this thesis, the role of multi-modality imaging in ischemic heart disease, arrhythmias and cardiac mechanics is investigated. Computed tomography (CT) is utilized to evaluate the role of sex on... Show moreIn this thesis, the role of multi-modality imaging in ischemic heart disease, arrhythmias and cardiac mechanics is investigated. Computed tomography (CT) is utilized to evaluate the role of sex on progression of coronary artery disease (CAD) and the relationship between anatomical and functional markers of CAD. Reference values for a novel technique, non-invasive myocardial work, are presented for different cardiac pathologies and its relation with the extent of infarct transmurality following ST-segment elevation myocardial infarction is evaluated. The prognostic value of left ventricular (LV) global longitudinal strain (GLS) on 2-dimensional speckle tracking echocardiography and heart-to-mediastinum ratio on 123I-MIBG scintigraphy on appropriate Implantable Cardioverter Defibrillator (ICD) therapy is evaluated. Furthermore, the predictive value of posterior left atrial adipose tissue attenuation on CT for atrial fibrillation recurrence following ablation is investigated. Show less
In this thesis the prognostic value of the new echocardiographic techniques 'speckle tracking strain' and 'myocardial work' was evaluated in patients with hypertrophic cardiomyopathy and primary... Show moreIn this thesis the prognostic value of the new echocardiographic techniques 'speckle tracking strain' and 'myocardial work' was evaluated in patients with hypertrophic cardiomyopathy and primary mitral regurgitation. These parameters were indenpendently associated with outcome in these patients. Furthermore, the pathophysiology and hereditary component of primary mitral valve disease were discussed. Show less
Fortuni, F.; Butcher, S.C.; Kley, F. van der; Lustosa, R.P.; Karalis, I.; Weger, A. de; ... ; Marsan, N.A. 2021
Background: Left ventricular myocardial work (LVMW) is a novel method to assess left ventricular (LV) function using pressure-strain loops that takes into consideration LV afterload. The estimation... Show moreBackground: Left ventricular myocardial work (LVMW) is a novel method to assess left ventricular (LV) function using pressure-strain loops that takes into consideration LV afterload. The estimation of LV afterload in patients with severe aortic stenosis (AS) may be challenging, and no study so far has investigated LVMW in this setting. The aim of this study was to develop a method to calculate LVMW in patients with severe AS and to analyze its relationship with heart failure symptoms.Methods: Indices of LVMW were calculated in 120 patients with severe AS who underwent transcatheter aortic valve replacement and invasive LV and aortic pressure measurements. LV systolic pressure was also derived by adding the mean aortic valve gradient to the aortic systolic pressure. LV global longitudinal strain and echocardiography-derived LV systolic pressure were then incorporated to construct pressure-strain loops of the left ventricle.Results: An excellent correlation was observed between LVMW indices calculated using the invasive and echocardiography-derived LV systolic pressure. Patients in New York Heart Association functional class III or IV (n = 97 [73%]) had lower LV global longitudinal strain, LV global work index, LV global constructive work, and right ventricular free wall strain compared with those in New York Heart Association functional class I or II. In contrast to LV global longitudinal strain, LV global work index (odds ratio per 100 mm Hg% increase, 0.91; 95% CI, 0.85-0.98; P = .012) and LV global constructive work showed independent associations with New York Heart Association functional class III or IV heart failure symptoms.Conclusions: The calculation of echocardiography-based LVMW indices is feasible in patients with severe AS. In particular, LV global work index and global constructive work showed independent associations with heart failure symptoms and may provide additional information on myocardial remodeling and function in patients with severe AS. Show less
Hiemstra, Y.L.; Bijl, P. van der; Mahdiui, M. el; Bax, J.J.; Delgado, V.; Marsan, N.A. 2020
Background: Noninvasive left ventricular (LV) pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate LV function, integrating longitudinal strain by speckle... Show moreBackground: Noninvasive left ventricular (LV) pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate LV function, integrating longitudinal strain by speckle-tracking analysis and sphygmomanometrically measured blood pressure to estimate myocardial work. The aims of this study were (1) to describe global and segmental myocardial work in patients with hypertrophic cardiomyopathy (HCM), (2) to assess the correlation between myocardial work and other echocardiographic parameters, and (3) to evaluate the association of myocardial work with adverse outcomes.Methods: One hundred ten patients with nonobstructive HCM (mean age, 55 +/- 15 years; 66% men), with different phenotypes (apical, concentric, and septal hypertrophy), and 35 age- and sex-matched healthy control subjects were included. The following myocardial work indices were included: myocardial work index, constructive work (CW), wasted work, and cardiac efficiency. The combined end point included all-cause mortality, heart transplantation, heart failure hospitalization, aborted sudden cardiac death, and appropriate implantable cardioverter-defibrillator therapy.Results: Mean global CW (1,722 +/- 602 vs 2,274 +/- 574 mm Hg%, P < .001), global cardiac efficiency (93% [89%-95%] vs 96% [96%-97%], P < .001), and global MWI (1,534 +/- 551 vs 1,929 +/- 473 mm Hg%) were significantly reduced, while global wasted work (104 mm Hg% [66-137 mm Hg%] vs 71 mm Hg% [49-92 mm Hg%], P < .001) was increased in patients with HCM compared with control subjects. Segmental impairment in CW colocalized with maximal wall thickness (HCM phenotype), and global CW correlated with LV wall thickness (r = -0.41, P < .001), diastolic function (r = -0.27, P = .001), and QRS duration (r = -0.28, P = .001). Patients with global CW > 1,730 mm Hg% (the median value) experienced better event-free survival than those with global CW < 1,730 mm Hg% (P < .001).Conclusions: Myocardial work, assessed noninvasively using echocardiography and blood pressure measurement, is reduced in patients with nonobstructive HCM; it correlates with maximum LV wall thickness and is significantly associated with a worse long-term outcome. Show less
