Determinants of functional capacity in patients with chronic heart failure: Role of filling pressure and systolic and diastolic function

Background Previous work suggesting a better correlation of diastolic than systolic function with exercise capacity in heart failure may reflect the -relative insensitivity and load-dependence of ejection fraction (EF). We sought the correlation of new and more sensitive methods of quantifying systolic and diastolic function and filling pressure with functional capacity. Methods We studied 155 consecutive exercise tests on 95 patients with congestive heart failure (81 male, aged 62 +/- 10 years), who underwent resting 2-climensional echocardiography and tissue Doppler imaging before and after measurement of maximum oxygen uptake (peak VO2)Results The resting EF was 3 1 % 10% and a peak VO(2)was 13 +/- 5 mL/kg/min; the majority of these patients (80%) had an ischemic cardiornyopathy. Resting EF (r 0.14, P =.09) correlated poorly with peak VO2 and mean systolic (r = 0.23, P =.004) and diastolic tissue velocities (r 0.18, P =.02). Peak EF was weakly correlated with the mean systolic (r = 0.18, P =.02) and diastolic velocities (r = 0.16, P <.04). The mean sum of systolic and diastolic velocities in both annuli (r = 0.30, P <.001) and E/Ea ratio (r 0.31, P <.001) were better correlated with peak VO2 Prediction of peak VO2 was similar with models based on models of filling pressure (R = 0.61), systolic factors (R = 0.63), and diastolic factors (R 0.59), although a composite model of filling pressure, systolic and diastolic function was a superior predictor of peak VO2 (R 0.69; all P<.001). Conclusions The reported association of diastolic rather than systolic function with functional capacity may have reflected the limitations of EF. Functional capacity appears related not only to diastolic function, but also to systolic function and filling pressure, and is most closely associated with a combination of these factors.

Measurement of strain and strain rate by echocardiography - Ready for prime time?

Strain and strain rate (SR) are measures of deformation that are basic descriptors of both the nature and the function of cardiac tissue. These properties may now be measured using either Doppler or two-dimensional ultrasound techniques. Although these measurements are feasible in routine clinical echocardiography, their acquisition and analysis nonetheless presents a number of technical challenges and complexities. Echocardiographic strain and SR imaging has been applied to the assessment of resting ventricular function, the assessment of myocardial viability using low-dose dobutamine infusion, and stress testing for ischemia. Resting function assessment has been applied in both the left and the fight ventricles, and may prove particularly valuable for identifying myocardial diseases and following up the treatment response. Although the evidence base is limited, SR imaging seems to be feasible and effective for the assessment of myocardial viability. The use of the technique for the detection of ischemia during stress echocardiography is technically challenging and likely to evolve further. The clinical availability of strain and SR measurement may offer a solution to the ongoing need for quantification of regional and global cardiac function. Nonetheless, these techniques are susceptible to artifact, and further technical development is necessary.

Association of subclinical right ventricular dysfunction with obesity

OBJECTIVES The purpose of this research was to identify the determinants of right ventricular (RV) dysfunction in overweight and obese subjects. BACKGROUND Right ventricular dysfunction in obese subjects is usually ascribed to comorbid diseases, especially obstructive sleep apnea. We used tissue Doppler imaging to identify the determinants of RV dysfunction in overweight and obese subjects. METHODS Standard and tissue Doppler echocardiography was performed in 112 overweight (body mass index [BMI] 25 to 29.9 kg/m(2)) or obese (BMI >30 kg/m(1)) subjects and 36 referents (BMI 35 kg/m(2) had reduced RV function compared with referent subjects, evidenced by reduced s(m) (6.5 +/- 2.4 cm/s vs. 10.2 +/- 1.5 cm/s, p < 0.001), peak strain (-21 +/- 4% vs. -28 +/- 4%, p < 0.001), peak strain rate (-1.4 +/- 0.4 s(-1) vs. -2.0 +/- 0.5 s(-1), p < 0.001), and e(m) (6.8 +/- 2.4 cm/s vs. -10.3 +/- 2.5 cm/s, p < 0.001), irrespective of the presence of sleep apnea. Similar but lesser degrees of reduced systolic function (p < 0.05) were present in overweight (BMI 25 to 29.9 kg/m(2)) and mildly obese (BMI 30 to 35 kg/m(2)) groups. Differences in RV e(m), s(m), and strain indexes were demonstrated between the severely versus overweight and mildly obese groups (p < 0.05). Body mass index remained independently related to RV changes after adjusting for age, log insulin, and mean arterial pressures. In obese patients, these changes were associated with reduced exercise capacity but not the duration of obesity and presence of sleep apnea or its severity. CONCLUSIONS Increasing BMI is associated with increasing severity of RV dysfunction in overweight and obese subjects without overt heart disease, independent of sleep apnea.

Cardiac contributions to exercise training responses in patients with chronic heart failure: A strain imaging study

The improvement of exercise capacity due to exercise training in heart failure has been associated with peripheral adaptation, but the contribution of cardiac responses is less clear. We sought the extent to which the improvement of functional capacity in patients undergoing exercise training for heart failure was related to myocardial performance. Thirty-seven patients (35 men, age 64 +/- 11) with symptomatic heart failure and left ventricular ejection fraction

Comparison between myocardial integrated backscatter and strain rate imaging in the quantitative assessment of subepicardial function post-myocardial infarction

Transmural extent of infarction (TME) may be an important determinant of functional recovery and remodeling. Recent animal data suggest that strain rate imaging (SRI) maybe able to identify subendocardial ischemia.We compared SRI and cyclic variation of integrated backscatter (CVIB) for predicting TME in the quantitative assessment of regional subepicardial function. Forty-nine (n = 49) postmyocardial infarct patients (61±10 years, EF 41±10%) underwent tissue Doppler echocardiography (TDE) and contrast enhanced magnetic resonance imaging (CMR). A15 mm×2mm sampling volume (tracked to wall motion) was placed over the long axis subepicardial region of each segment during TDE offline analysis to measure peak longitudinal systolic strain rate (SR), peak longitudinal systolic strain (PS), and CVIB. Findingswere compared with TME classified into two categories of scar thickness by CMR: Non-transmural (TME≤50%), and transmural (TME > 50%). Of 213 segments identified with resting wall motion abnormalities, 145 segments showed delayed hyperenhancement on CMR. SR, PS and CVIB were similar with no significant differences between transmural and non-transmural infarcts regardless of the echo modality.

Hydrologic measurements and implications for tree island formation within Everglades National Park

Tree islands in the Shark River Slough of the Everglades National Park (ENP), in the southern state of Florida in the United States, are part of a wetland system of densely vegetated ridges interspersed within relatively open sloughs. Human alteration of this system has had dramatic negative effects on the landscape of the region and restoration efforts will require adjusting the hydrology of the region to assure the preservation of these important ecologic features. The primary objectives of this study were to document the hydrology in the vicinity of tree islands in ENP by measuring velocities in time and space and by characterizing suspended sediments. The results of such measurements were interpreted with respect to factors that may limit tree island growth. The measurements were conducted in the vicinity of three tree islands known as Black Hammock (BH), Gumbo Limbo (GL), and an unnamed island that was named for this study as Satin Leaf (SL). Acoustical Doppler Velocity (ADV) meters were used for measuring the low velocities of the Everglades water flow. Properties of suspended sediments were characterized through measurements of particle size distribution, turbidity, concentration and particle density. Mean velocities observed at each of the tree islands varied from 0.9 to 1.4 cm/s. Slightly higher mean velocities were observed during the wet season (1.2–1.6 cm/s) versus the dry season (0.8–1.3 cm/s). Maximum velocities of more than 4 cm/s were measured in areas of Cladium jamaicense die-off and at the hardwood hammock (head) of the islands. At the island’s head, water is channelized around obstructions such as tree trunks in relatively rapid flow, which may limit the lateral extent of tree island growth. Channelization is facilitated by shade from the tree canopy, which limits the growth of underwater vegetation thereby minimizing the resistance to flow and limiting sediment deposition. Suspended sediment concentrations were low (0.5–1.5 mg/L) at all study sites and were primarily of organic origin. The mean particle size of the suspended sediments was 3 μm with a distribution that was exponential. Critical velocities needed to cause re-suspension of these particles were estimated to be above the actual velocities observed. Sediment transport within the water column appears to be at a near steady state during the conditions evaluated with low rates of sediment loss balanced by presumably the release of equivalent quantities of particles of organic origin. Existing hydrologic conditions do not appear to transport sufficient suspended sediments to result in the formation of tree islands. Of interest would be to collect hydrologic and sediment transport data during extreme hydrologic events to determine if enough sediment is transported under these conditions to promote sufficient sediment accumulations.

Natural history of markers of collagen turnover in patients with early diastolic dysfunction and impact of eplerenone

OBJECTIVES: This study was designed to evaluate the impact of eplerenone on collagen turnover in preserved systolic function heart failure (HFPSF).

BACKGROUND: Despite growing interest in abnormal collagen metabolism as a feature of HFPSF with diastolic dysfunction, the natural history of markers of collagen turnover and the impact of selective aldosterone antagonism on this natural history remains unknown.

METHODS: We evaluated 44 patients with HFPSF, randomly assigned to control (n = 20) or eplerenone 25 mg daily (n = 24) for 6 months, increased to 50 mg daily from 6 to 12 months. Serum markers of collagen turnover and inflammation were analyzed at baseline and at 6 and 12 months and included pro-collagen type-I and -III aminoterminal peptides, matrix metalloproteinase type-2, interleukin-6 and -8, and tumor necrosis factor-alpha. Doppler-echocardiographic assessment of diastolic filling indexes and tissue Doppler analyses were also obtained.

RESULTS: The mean age of the patients was 80 +/- 7.8 years; 46% were male; 64% were receiving an angiotensin-converting enzyme inhibitor, 34% an angiotensin-II receptor blocker, and 68% were receiving beta-blocker therapy. Pro-collagen type-III and -I aminoterminal peptides, matrix metalloproteinase type-2, interleukin-6 and -8, and tumor necrosis factor-alpha increased with time in the control group. Eplerenone treatment had no significant impact on any biomarker at 6 months but attenuated the increase in pro-collagen type-III aminoterminal peptide at 12 months (p = 0.006). Eplerenone therapy was associated with modest effects on diastolic function without any impact on clinical variables or brain natriuretic peptide.

CONCLUSIONS: This study demonstrates progressive increases in markers of collagen turnover and inflammation in HFPSF with diastolic dysfunction. Despite high background utilization of renin-angiotensin-aldosterone modulators, eplerenone therapy prevents a progressive increase in pro-collagen type-III aminoterminal peptide and may have a role in management of this disease. (The Effect of Eplerenone and Atorvastatin on Markers of Collagen Turnover in Diastolic Heart Failure; NCT00505336).

The impact of mechanical compression on cortical microtubules in Arabidopsis: a quantitative pipeline

Exogenous mechanical perturbations on living tissues are commonly used to investigate whether cell effectors can respond to mechanical cues. However, in most of these experiments, the applied mechanical stress and/or the biological response are described only qualitatively. We developed a quantitative pipeline based on microindentation and image analysis to investigate the impact of a controlled and prolonged compression on microtubule behaviour in the Arabidopsis shoot apical meristem, using microtubule fluorescent marker lines. We found that a compressive stress, in the order of magnitude of turgor pressure, induced apparent microtubule bundling. Importantly, that response could be reversed several hours after the release of compression. Next, we tested the contribution of microtubule severing to compression-induced bundling: microtubule bundling seemed less pronounced in the katanin mutant, in which microtubule severing is dramatically reduced. Conversely, some microtubule bundles could still be observed 16 hours after the release of compression in the spiral2 mutant, in which severing rate is instead increased. To quantify the impact of mechanical stress on anisotropy and orientation of microtubule arrays, we used the nematic tensor based FibrilTool ImageJ/Fiji plugin. To assess the degree of apparent bundling of the network, we developed several methods, some of which were borrowed from geostatistics. The final microtubule bundling response could notably be related to tissue growth velocity that was recorded by the indenter during compression. Because both input and output are quantified, this pipeline is an initial step towards correlating more precisely the cytoskeleton response to mechanical stress in living tissues.

SIMULATIONS OF NEWTONIAN AND NON-NEWTONIAN FLOWS IN DEFORMABLE TUBES

Computational models for the investigation of flows in deformable tubes are developed and implemented in the open source computing environment OpenFOAM. Various simulations for Newtonian and non-Newtonian fluids under various flow conditions are carried out and analyzed. First, simulations are performed to investigate the flow of a shear-thinning, non-Newtonian fluid in a collapsed elastic tube and comparisons are made with experimental data. The fluid is modeled by means of the Bird-Carreau viscosity law. The computational domain of the deformed tube is constructed from data obtained via computer tomography imaging. Comparison of the computed velocity fields with the ultrasound Doppler velocity profile measurements show good agreement, as does the adjusted pressure drop along the tube's axis. Analysis of the shear rates show that the shear-thinning effect of the fluid becomes relevant in the cross-sections with the biggest deformation. The peristaltic motion is simulated by means of upper and lower rollers squeezing the fluid along a tube. Two frames of reference are considered. In the moving frame the computational domain is fixed and the coordinate system is moving with the roller speed, and in the fixed frame the roller is represented by a deforming mesh. Several two-dimensional simulations are carried out for Newtonian and non-Newtonian fluids. The effect of the shear-thinning behavior of the fluid on the transport efficiency is examined. In addition, the influence of the roller speed and the gap width between the rollers on the xxvii transport efficiency is discussed. Comparison with experimental data is also presented and different types of moving waves are implemented. In addition, the influence of the roller speed and the gap width between the rollers on the transport efficiency is discussed. Comparison with experimental data is also presented and different types of moving waves are implemented.

Alterazioni strutturali e funzionali nelle diverse eziologie di amiloidosi cardiaca: analisi dei parametri ecocardiografici ed emodinamici invasivi e loro ruolo prognostico

Background e scopo: Tradizionalmente la cardiomiopatia amiloidotica (CA) è stata considerata una cardiomiopatia restrittiva, ma studi recenti hanno evidenziato il ruolo anche della disfuzione sistolica nella sua fisiopatologia. In questo contesto recente, raramente è stato indagato il profilo emodinamico invasivo. Lo scopo dello studio è stato quello di caratterizzare il profilo emodinamico, strutturale e funzionale della CA nelle tre principali eziologie (amiloidosi da catene leggere (AL), amiloidosi transtiretino-relata (ATTR) mutata (ATTRm) e ‘wild-type’ (ATTRwt)), valutare le differenze del profilo ecocardiografico ed emodinamico nelle fasi diverse di malattia ed esplorare il ruolo prognostico delle principali variabili cliniche e strumentali nella CA. Metodi e risultati: Abbiamo analizzato retrospettivamente i dati di 224 pazienti con CA (AL, n=93; ATTRm, n=66; ATTRwt, n=65). Rispetto all'ATTRwt, i pazienti con AL presentano un minor interessamento morfologico cardiaco, ma dati emodinamici paragonabili, caratterizzati da elevate pressioni di riempimento biventricolari e riduzione della gittata sistolica. L’ATTRm, nonostante il profilo ecocardiografico analogo all’ATTRwt, mostra un quadro emodinamico migliore. Gli indici di funzione diastolica e sistolica longitudinale del ventricolo sinistro (Vsn) sono alterati fin dagli stadi iniziali della malattia, mentre la frazione di eiezione (FEVsn) rimane preservata nella maggior parte dei pazienti, anche nelle fasi avanzate (FEVsn 50 [37-60]%; FEVsn <40% nel 28% dei pazienti NYHA III / IV). All'analisi multivariata, età, NYHA III/I, eziologia AL, frazione di contrazione miocardica (MCF), indice cardiaco (CI) e pressione atriale destra (RAP) sono indipendentemente associati a eventi clinici avversi. Conclusioni Questo studio conferma la complessa fisiopatologia della CA, in cui la disfunzione diastolica è accompagnata da una funzione sistolica longitudinale anormale sin dalle fasi iniziali della malattia. L'AL e l'ATTRwt, nonostante diversi gradi di alterazioni morfologiche, hanno un profilo emodinamico simile; l'ATTRm, invece, presenta un quadro emodinamico migliore. Tra i parametri strumentali, MCF, CI e RAP emergono come predittori significativi di eventi avversi.

Ecocardiografia 3D real-time: principi fisici, tecnologia e applicazioni fetali per diagnosi prenatale

La diagnosi clinica, definita come un giudizio clinico espresso da un esperto sulla salute di un individuo, dopo aver effettuato degli esami obiettivi attraverso la strumentazione adeguata allo specifico caso clinico, rappresenta un elemento fondamentale nel paradigma Prevenzione – Diagnosi – Cura – Riabilitazione, che ha come fine ultimo la salute del paziente. In questo elaborato viene presentata una tecnica di imaging che permette di fare diagnosi in uno degli organi più importanti e delicati del corpo umano, cioè il cuore, sia degli adulti, sia dei feti: l’ecocardiografia 3D Real-Time. L’elaborato si sviluppa in tre capitoli, come di seguito presentato. - Capitolo 1: si descrive la tecnologia su cui si fonda l’ecocardiografia volumetrica Real-Time attraverso le varie fasi di realizzazione dello scanner, il quale consente sia l’acquisizione sia la visualizzazione dei volumi in tempo reale; - Capitolo 2: il sistema di imaging presentato nel capitolo precedente, viene contestualizzato in un organo specifico, ovvero il cuore, illustrandone le caratteristiche, le differenze rispetto a tecniche ritenute meno performanti nella valutazione di patologie cardiache, oltre che alcune particolari evoluzioni, quali Strain Rate Imaging e Tissue Doppler Imaging; - Capitolo 3: si descrive in cosa consiste l’ecocardiografia 3D Real-Time fetale, qual è la sua finalità e quali potrebbero essere alcune applicazioni cliniche tramite cui fare una diagnosi prenatale; inoltre, si evidenzia l’importanza dell’ecocardiografia per studiare le modifiche a cui è soggetto l’apparato cardiovascolare di una donna durante i mesi di gestazione e, quindi, sottoporla alle cure opportune.

The role of Doppler left ventricular filling indexes and Doppler tissue echocardiography in the assessment of cardiac involvement in hereditary hemochromatosis

Although cardiac dysfunction in hereditary hemochromatosis (HHC) can be evaluated by conventional echocardiography, findings are often not specific. To test the hypothesis that the assessment of (1) conventional Doppler left ventricular filling indexes and (2) intrinsic elastic properties of the myocardium by Doppler tissue echocardiography can both enhance the accuracy of echocardiographic diagnosis of cardiac involvement in HHC, a group of 18 patients with HHC (mean age 50+/-7 years) and 22 age-matched healthy subjects were studied. The following indexes were characteristic for HHC: (1) the duration of atrial reversal measured from pulmonary venous flow (ms) was longer(118+/-20 vs 90+/-16; P

Study of the Myocardial Contraction and Relaxation Velocities through Doppler Tissue Imaging Echocardiography: A New Alternative in the Assessment of the Segmental Ventricular Function

OBJECTIVE: Doppler tissue imaging (DTI) enables the study of the velocity of contraction and relaxation of myocardial segments. We established standards for the peak velocity of the different myocardial segments of the left ventricle in systole and diastole, and correlated them with the electrocardiogram. METHODS: We studied 35 healthy individuals (27 were male) with ages ranging from 12 to 59 years (32.9 ± 10.6). Systolic and diastolic peak velocities were assessed by Doppler tissue imaging in 12 segments of the left ventricle, establishing their mean values and the temporal correlation with the cardiac cycle. RESULTS: The means (and standard deviation) of the peak velocities in the basal, medial, and apical regions (of the septal, anterior, lateral, and posterior left ventricle walls) were respectively, in cm/s, 7.35(1.64), 5.26(1.88), and 3.33(1.58) in systole and 10.56(2.34), 7.92(2.37), and 3.98(1.64) in diastole. The mean time in which systolic peak velocity was recorded was 131.59ms (±19.12ms), and diastolic was 459.18ms (±18.13ms) based on the peak of the R wave of the electrocardiogram. CONCLUSION: In healthy individuals, maximum left ventricle segment velocities decreased from the bases to the ventricular apex, with certain proportionality between contraction and relaxation (P<0.05). The use of Doppler tissue imaging may be very helpful in detecting early alterations in ventricular contraction and relaxation.

Doppler tissue imaging to assess systolic function in Chagas' disease

OBJECTIVE: To assess the usefulness of Doppler tissue imaging (DTI) for evaluating the systolic function of chagasic patients with and without electrocardiographic abnormalities, in comparision with echocardiographic study. METHODS: We studied 77 patients divided into 3 groups as follows: group 1 - control; group 2 - chagasic patients with normal electrocardiographic findings; and group 3 - chagasic patients with abnormal electrocardiographic findings. The following parameters were assessed: left ventricular dimensions and ejection fraction, left atrial dimensions and diastolic function on echocardiography. Systolic velocity and regional isovolumic contraction time (IVCTr) of the septal, anterior, lateral, posterior and inferior left ventricular walls were assessed on DTI. RESULTS: Left ventricular cavitary dimensions, ejection fraction and DTI systolic wave showed significant differences between groups 1 and 3 and between groups 2 and 3, which were not found between groups 1 and 2. IVCTr allowed a statistically significant discrimination among the 3 groups. CONCLUSION: DTI allowed discrimination among the different groups assessed, being superior to echocardiography in identifying early abnormalities of contractility, and, therefore, potentially useful for detecting incipient myocardial alterations in chagasic patients with normal electrocardiographic findings.