Risk Assessment of Ventricular Arrhythmias in Patients with Nonischemic Dilated Cardiomyopathy by Strain Echocardiography

doi:10.1016/j.echo.2012.02.004

Journal of the American Society of Echocardiography

Volume 25, Issue 6, June 2012, Pages 667-673

https://doi.org/10.1016/j.echo.2012.02.004 Get rights and content

Background

Indications for prophylactic implantable cardioverter-defibrillator implantation in patients with nonischemic dilated cardiomyopathy (DCM) are based on left ventricular (LV) ejection fraction (LVEF), although LVEF has limited ability to predict arrhythmias. It has recently been shown that strain echocardiography can predict ventricular arrhythmias in patients after myocardial infarction. The aim of this study was to evaluate whether strain echocardiography may help in the risk stratification of ventricular arrhythmias in patients with DCM.

Methods

Ninety-four patients with nonischemic DCM were prospectively included. By speckle-tracking strain echocardiography, global longitudinal strain was calculated as the average of peak longitudinal strain from a 16-segment LV model. The time interval from electrocardiographic peak R to peak negative strain was assessed in each LV segment. Mechanical dispersion was defined as the standard deviation of time to peak negative strain from 16 LV segments.

Results

After a median of 22 months of follow-up (range, 1–46 months), 12 patients (13%) had experienced arrhythmic events, defined as sustained ventricular tachycardia or cardiac arrest. LVEF and global longitudinal strain were reduced in patients with DCM with arrhythmic events compared with those without (28 ± 10% vs 38 ± 13%, P = .01, and −6.4 ± 3.3% vs −12.3 ± 5.2%, P < .001, respectively). Global longitudinal strain showed greater area under the curve than LVEF to identify arrhythmic events in receiver operating characteristic curve analyses (P = .05). Patients with arrhythmic events had increased mechanical dispersion (98 ± 43 vs 56 ± 18 ms, P < .001). Mechanical dispersion predicted arrhythmias independently of LVEF (hazard ratio, 1.28; 95% confidence interval, 1.11–1.49; P = .001).

Conclusions

Global longitudinal strain is a promising marker of arrhythmias. Mechanical dispersion predicted arrhythmic events in patients with DCM independently of LVEF. Strain echocardiography may help in the risk stratification of patients with DCM not fulfilling current implantable cardioverter-defibrillator indications.

Section snippets

Study Population

We prospectively included 94 patients with nonischemic DCM at two different centers: the University Hospital of Jena (Jena, Germany) and Oslo University Hospital, Rikshospitalet (Oslo, Norway).

Inclusion criteria were LVEF < 50% and a dilated left ventricle, with LV end-diastolic diameter > 30 mm/m² (indexed to body surface area). The date of the echocardiographic examination was defined as the study start. Patients were followed for ≥6 months or to the date of a defined end point. End points

Study Population

Clinical characteristics are presented in Table 1. During a median of 22 months of follow-up (range, 1–46 months), 12 patients (14%) experienced severe arrhythmic events. Of these, one patient died of electrical storm, two were resuscitated from ventricular fibrillation, six received appropriate therapies for ventricular tachycardia from a cardiac resynchronization therapy (CRT) with a defibrillator (CRT-D) device/primary-prophylaxis ICD, and two had repetitive sustained ventricular tachycardia

Discussion

This study shows that strain echocardiography may add important information about the risk for ventricular arrhythmias in patients with DCM. Global longitudinal strain is a promising marker of arrhythmias. Furthermore, we introduce a new arrhythmic risk stratification parameter in DCM. We used mechanical dispersion as a marker of arrhythmic risk, a parameter that is similar although not identical to previous markers of dyssynchrony. Mechanical dispersion predicted arrhythmic events in patients

Conclusions

Global longitudinal strain is a promising marker of arrhythmias in patients with DCM. Mechanical dispersion predicted arrhythmic events in patients with DCM independently of LVEF. Mechanical dispersion may be of help in risk-stratifying patients with DCM not fulfilling current ICD indications. Strain echocardiography may therefore serve as an additional tool for assessing LV function in patients with DCM and improve the risk assessment of ventricular arrhythmias.

Acknowledgments

We thank all the patients participating in this study.

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Speckle tracking strain echocardiography allows one to visualize the timing of maximum regional strain and quantifies left ventricular–mechanical dispersion (LV-MD). Whether LV-MD and LV-global longitudinal strain (LV-GLS) provide similar or complementary information in mortality risk stratification in patients with severe aortic stenosis (SAS) remains unknown.
The authors hypothesized that LV mechanical dyssynchrony assessed by LV-MD is associated with an increased risk of mortality and provides additional prognostic information on top of LV-GLS in patients with SAS.
A total of 364 patients with SAS (aortic valve area indexed ≤0.6 cm²/m² and/or aortic valve area ≤1 cm²), LV ejection fraction ≥50% and no or mild symptoms were enrolled. The endpoint was overall mortality.
During a median follow-up period of 41 months, 149 patients died. After adjustment, LV-MD ≥68 ms was significantly associated with an increased risk of mortality (adjusted HR: 1.41; 95% CI: 1.01-1.96; P = 0.044). Adding LV-MD ≥68 ms to a multivariable Cox regression model including LV-GLS ≥−15% improved predictive performance in terms of overall mortality, with improved global model fit, reclassification, and better discrimination. Patients with both criteria had an important increase in mortality compared to patients with none or one criterion (adjusted HR: 2.02; 95% CI: 1.34-3.03; P = 0.001). Interobserver reproducibility of LV-MD was good with an intraclass correlation coefficient of 0.90 (95% CI: 0.72-0.97).
LV-MD is a reproducible parameter independently associated with an increased risk of mortality in SAS. Increased LV-MD associated with depressed LV-GLS identifies a subgroup of patients with an increased mortality risk. Whether early aortic valve replacement improves the outcome of these patients deserves further studies.
The Uncertain Benefit from Implantable Cardioverter-Defibrillators in Nonischemic Cardiomyopathy: How to Guide Clinical Decision-Making?
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Cardiac imaging for the prediction of sudden cardiac arrest in patients with heart failure
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The identification of heart failure (HF) patients at risk for arrhythmic sudden cardiac arrest (SCA) is a major challenge in the cardiovascular field. In addition to optimal medical treatment for HF, implantable cardioverter defibrillator (ICD) is currently recommended to prevent SCA in patients with reduced left ventricular ejection fraction (LVEF). The indication for an ICD implantation, in addition to HF etiology, New York Health Association (NYHA) class and life expectancy, mainly depends on LVEF value at echocardiography. However, the actual role of LVEF in the prediction of SCA has recently been debated, while newer multimodality imaging techniques with increased prognostic accuracy have been developed. Speckle tracking imaging allows the quantification of mechanical dispersion, a marker of electrophysiological heterogeneity predisposing to malignant arrhythmias, while advanced cardiac magnetic resonance techniques such as myocardial T1-mapping and extracellular volume fraction assessment allow the evaluation of interstitial diffuse fibrosis. Nuclear imaging is helpful for the appraisal of sympathetic nervous system dysfunction, while newer computed tomography techniques assessing myocardial delayed enhancement allow the identification of focal myocardial scar.
This review will focus on the most modern advances in the field of cardiovascular imaging along with its applications for the prediction of SCA in patients with HF. Modern artificial intelligence applications in cardiovascular imaging will also be discussed.
Peak exercise myocardial deformation indices during cardiopulmonary exercise testing are associated with exercise capacity and ventilatory efficiency in patients with dilated cardiomyopathy
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Citation Excerpt :
These new indices are also influenced by loading conditions and LV geometry but nevertheless to a lesser degree than LVEF [7]. Global longitudinal strain (GLS) is as a sensitive marker of LV function and an important predictor of morbidity and mortality [8-9]. Since the longitudinal fibers in the sub-endocardium are the first anatomical components affected in DCM, GLS is one of the early findings that may emerge early alterations even in subclinical stages [10].
Little is known about the exercise-induced changes in the multidimensional mechanical properties of the heart. We aimed to evaluate the myocardial deformation indices (MDI) at rest and their response at peak exercise during the same cardiopulmonary exercise testing (CPET) session, investigating their relationship to exercise capacity and ventilatory sufficiency in dilated cardiomyopathy (DCM) patients.
We evaluated left ventricular (LV) function using speckle tracking imaging (STI) at rest and peak exercise during the same CPET session in 57 idiopathic DCM patients in New York Heart Association (NYHA) I–II class [54 ± 12 years, 42 males, ejection fraction (EF) 33 ± 9%]. We measured global longitudinal strain (GLS), longitudinal strain rate at systole (LSRS) and diastole (LSRD), and circumferential strain rate (CircS).
Resting GLS, LSRS, and LSRD were impaired compared with the predicted values but were improved at peak exercise (p < 0.001). All MDI at rest and/or at peak exercise were related to several CPET-derived parameters, including peak VO₂, load, O₂ pulse, and VE/VCO₂ slope. Peak exercise LSRS > −1.10 sec⁻¹ (AUC = 0.80, p < 0.001) and GLS > −13% (AUC = 0.81, p = 0.002) predicted impaired exercise capacity (peak VO₂ < 20 ml/min/kg) and ventilatory inefficiency (VE/VCO₂ slope>34). In multiple regression analysis, peak exercise LSRS and GLS were independently related to the peak VO₂ (Beta = −0.39, p = 0.003) and VE/VCO₂ slope (Beta = 0.35, p = 0.02), respectively.
Peak exercise LSRS and GLS in NYHA I–II DCM patients subjected to CPET were associated with aerobic exercise capacity and ventilatory efficiency. Consequently, LSRS and GLS at peak exercise, through their association with CPET-derived CV risk indices, may underline the severity of heart failure and predict future CV events in this DCM population.
Impaired cardiac mechanical synchrony revealed with increased myocardial work in women with advanced age
2023, Experimental Gerontology
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Automated ECG-guided imaging was performed in all LV myocardial A4C segments (basal anterolateral, basal inferoseptal, mid anterolateral, mid inferoseptal, apical lateral, apical septal, apex). LVMD was assessed via the dispersion (standard deviation) of the time to peak (TPSD) of LS (%) and TS (%), and their respective strain rates (s−1) (LSR, TSR) (Haugaa et al., 2012). Among potential techniques to quantify LVMD, TPSD of LV longitudinal and transverse axes via STI—a method independent of cardiac translation and insonation angle (Langeland et al., 2005)—has demonstrated superior prognostic power in previous clinical studies (Haugaa et al., 2010; Lim et al., 2008; Miyazaki et al., 2008; Modin et al., 2018).
Whether the synchronous nature of the myocardium is sex-dependent or affected by the aging process remains unknown. This study aimed to determine the influence of sex and age on cardiac mechanical synchrony during controlled hemodynamic stress.
Transthoracic speckle-tracking echocardiography analyses and central hemodynamics were assessed at rest and during moderate- to high-intensity exercise in healthy young (<45 yr) and older (≥45 yr) women (n = 32) and men (n = 34) matched by age, physical activity and exercise capacity. Left ventricular mechanical dyssynchrony (LVMD) was determined as the time to peak standard deviation (TPSD) of longitudinal and transverse strain and strain rates (LSR, TSR).
Physical activity, aerobic capacity, heart rate, blood pressure and LVMD at rest were similar between women and men in each age group (P > 0.05). The rate pressure product, an index of myocardial work, did not differ between sex and age groups at rest and during exercise at a given percentage of peak heart rate (P > 0.05). A consistent age effect was observed for transverse LVMD (P-for-age ≤ 0.011). Specifically, older women presented with marked increments (≥42 %) in TSR TPSD at all exercise levels compared with younger women (P ≤ 0.005). Sex per se did not generally affect LVMD.
A prevailing impairment of cardiac mechanical synchrony in the transverse axis of the left ventricle is revealed during conditions of elevated hemodynamic stress in women with advanced age.

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: This work was supported by Inger and John Fredriksen's foundation and the South-Eastern Norway Regional Health Authority. Oslo University Hospital, Rikshospitalet, has filed patent application 61/306,678 regarding the method of mechanical dispersion described in this report; Drs. Haugaa and Edvardsen are the patent applicants. Drs. Haugaa and Goebel contributed equally to this report.

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Clinical InvestigationVentricular MechanicsRisk Assessment of Ventricular Arrhythmias in Patients with Nonischemic Dilated Cardiomyopathy by Strain Echocardiography

Background

Methods

Results

Conclusions

Section snippets

Study Population

Study Population

Discussion

Conclusions

Acknowledgments

JACC Cardiovasc Imaging

J Am Soc Echocardiogr

J Am Soc Echocardiogr

JACC Cardiovasc Imaging

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

Am Heart J

Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy

N Engl J Med

Clinical trials update from the European Society of Cardiology Congress 2007: 3CPO, ALOFT, PROSPECT and statins for heart failure

Eur J Heart Fail

Clinical Investigation
Ventricular Mechanics
Risk Assessment of Ventricular Arrhythmias in Patients with Nonischemic Dilated Cardiomyopathy by Strain Echocardiography