Screening of Myocardial Cardiotoxicity Induced by Anticancer Chemotherapy and the Importance of Global Longitudinal Strain

Introduction: The improvement of survival in patients with cancer and the expansion of therapeutic options have led to the emergence of a new profile of cardiotoxicity, specifically associated with antimitotic agents. Our study aimed to assess the incidence of chemotherapy-induced myocardial toxicity in patients with cancer. Patients and Methods: We conducted a looking-forward longitudinal cohort study including all patients admitted to the Cardiology departments of Aristide le Dantec Hospital and Dalal Jamm National Hospital Centre for apre-chemotherapy check-up. The included patients did not undergo any pre-existing cardiopathy. Results: Over a period of two years ranging from January 2019 to December 2021, a total of 37 patients were included in the study. Notably, there was a female predominance (92%) with an average age of 49.7 years ± 13.69. Breast cancer accounted for 70% of the neoplasms. Laboratory findings revealed moderate anemia in 19 patients (51%). At inclusion, the left ventricle (LV) was of normal size (LV diastole at 44.46 ± 4.97 mm). The systolic function of the left ventricle was normal in all patients, with an average ejection fraction (EF) of 63.1% ± 5.80 and a mean global longitudinal strain (GLS) of −20.4% ± 2.58. The most commonly used agents were anthracyclines. During follow-up, 3 patients (8.1%) developed clinical symptoms of left heart failure, and LV dysfunction on echocardiography was observed in 5 (13.5%) patients, with a significant decrease in EF Conclusion: The incidence of cardiac toxicity is not negligible, hence the importance of early screening. Strain imaging is an essential tool that should be performed as part of the assessment before chemotherapy and re-evaluated during treatment.

Global Longitudinal Strain at Rest for Detection of Coronary Artery Disease in Patients without Diabetes Mellitus

Global longitudinal strain （GLS） at rest on two-dimensional speckle tracking echocardiography （2D STE） was demonstrated to help detect coronary artery disease （CAD）. However, the optimal cut-off point of GLS and its diagnostic power for detecting critical CAD in non-diabetes mellitus （DM） patients are unknown. In the present study, 211 patients with suspected CAD were prospectively included, with DM patients excluded. All patients underwent echocardiography and subsequently coronary angiography within 3 days. Left ventricular （LV） GLSs were quantified by 2D STE. Territorial peak systolic longitudinal strains （TLSs） were calculated based on the perfusion territories of the 3-epicardial coronary arteries in a 17-segment LV model. Critical CAD was defined as an area stenosis _〉70% in _〉1 epicardial coronary artery （_〉50% in left main coronary artery）. Totally 145 patients were diagnosed as having critical CAD by coronary angiography. Significant differences were observed in all strain parameters between patients with and without critical CAD. The area under the receiver operating charcteristic （ROC） curve （AUC） for GLS in the detection of left main （LM） or threevessel CAD was 0.875 at a cut-off value of-19.05% with sensitivity of 78.1% and specificity of 72.7%, which increased to 0.926 after exclusion of apical segments （cut-off value -18.66%; sensitivity 84.4% and specificity 81.8%）. The values of TLSs were significantly lower in regions supplied by stenotic arteries than in those by non-stenotic arteries. The AUC for the TLSs to identify critical stenosis of left circumflex （LCX） artery, left anterior descending （LAD） artery and right coronary artery （RCA）, in order of diagnostic accuracy, was 0.818 for LCX, 0.764 for LAD and 0.723 for RCA, respectively. In conclusion, in non-DM patients with suspected CAD, GLS assessed by 2D STE is an excellent predictor for LM or three-vessel CAD with high diagnostic accuracy, and a higher cut-off point than reported before should be used. Excluding apical segments in the calculation of GLS can further improve the predictive accuracy of GLS. It is unsatisfactory for TLSs to be used to identify stenotic coronary arteries.

Change and impact of left ventricular global longitudinal strain during transcatheter aortic valve implantation

BACKGROUND Although transcatheter aortic valve implantation(TAVI)is a safe and effective treatment for aortic stenosis,it still carries some risks,such as valve leaks,stroke,and even death.The left ventricular global longitudinal strain(LVGLS)measurement may be useful for the prediction of adverse events during this operation.AIM To explore the change of LVGLS during TAVI procedure and the relationship between LVGLS and perioperative adverse events.METHODS In this study,61 patients who had undergone percutaneous transfemoral TAVI were evaluated by transthoracic echocardiography.Before surgery,data on left ventricular ejection fraction(LVEF)and LVGLS were collected separately following balloon expansion and stent implantation.Difference in values of LVGLS and LVEF during preoperative balloon expansion(pre-ex),preoperative stent implantation(pre-im)and balloon expansion-stent implantation(ex-im)were also examined.Adverse events were defined as perioperative death,cardiac rupture,heart arrest,moderate or severe perivalvular leakage,significant mitral regurgitation during TAVI,perioperative moderate or severe mitral regurgitation,perioperative left ventricular outflow tract obstruction,reoperation,and acute heart failure.RESULTS The occurrence of perioperative adverse events was associated with differences in pre-ex LVGLS,but not with difference in pre-ex LVEF.There were significant differences between pre-LVGLS and ex-LVGLS,and between pre-LVGLS and im-LVGLS(P=0.037 and P=0.020,respectively).However,differences in LVEF were not significant(P=0.358,P=0.254);however differences in pre-ex LVGLS were associated with pre-LVGLS(P=0.045).Compared to LVEF,LVGLS is more sensitive as a measure of left heart function during TAVI and the perioperative period.Moreover,the differences in LVGLS were associated with the occurrence of perioperative adverse events,and changes in LVGLS were apparent in patients with undesirable LVGLS before the surgery.Furthermore,LVGLS is useful to predict changes in cardiac function during TAVI.CONCLUSION Greater attention should be paid to the patients who plan to undergo TAVI with normal LVEF but poor LVGLS.

Global longitudinal strain is superior to ejection fraction for detecting myocardial dysfunction in end-stage renal disease with hyperparathyroidism

BACKGROUND The estimation of left ventricular ejection fraction(LVEF)by 2D echocardiography(2D-ECHO)is the most used tool to assess LV systolic function(LVSF).Global longitudinal strain(GLS)has recently been suggested as a superior method for several evaluations.This study explored the association and prevalence of LV systolic dysfunction(LVSD)by using these methods in patients with end-stage renal disease(ESRD)and severe hyperparathyroidism(SHPTH);both associated with cardiovascular events(CEs).AIM To evaluate the myocardial function in patients with ESRD and SHPTH by using the GLS and LVEF measured through conventional 2D-ECHO.METHODS In 62 patients with ESRD and SHPTH,asymptomatic,and without a history of CEs,LVSF was evaluated by 2D-ECHO,obtaining the EF,by the Simpson biplane method,and GLS by speckle tracking.RESULTS The total patients with ESRD had a preserved LVEF(>50%)but abnormal GLS(<13.55%).Additionally,multivariate analysis showed an independent association of GLS and serum parathyroid hormone(PTH),LV mass index,and hemoglobin.Also,PTH was independently associated with lateral e'wave and tricuspid regurgitation velocity.CONCLUSION In patients with SHPTH linked to ESRD,the use of GLS by 2D-ECHO is a more sensitive tool than LVEF for detecting LVSD.

Subclinical impairment of left ventricular myocardium function in type 2 diabetes mellitus patients with or without hypertension

BACKGROUND Cardiovascular disease has been the leading cause of morbidity and mortality for type 2 diabetes mellitus(T2DM)patients over the last decade.AIM To determine whether layer-specific global longitudinal strain(GLS)combined with peak strain dispersion(PSD)can be used to assess left ventricle(LV)myocardium systolic dysfunction in T2DM patients or without hypertension(HP).METHODS We enrolled 97 T2DM patients,70 T2DM+HP patients and 101 healthy subjects.Layer-specific GLS and PSD were calculated by EchoPAC software in apical three-,four-and two-chamber views.GLS of the epimyocardial,middle-layer and endomyocardial(GLSepi,GLSmid,and GLSendo)were measured and recorded.Receiver operating characteristic analysis was performed to detect LV myocardium systolic dysfunction in T2DM patients.RESULTS There were significant differences in GLSepi,GLSmid,GLSendo,and PSD between healthy subjects,T2DM patients and T2DM patients with HP(P<0.001).Trend tests yielded the ranking of healthy subjects>T2DM patients>T2DM with HP patients in the absolute values of GLSepi,GLSmid and GLSendo(P<0.001),while PSD was ranked healthy subjects<T2DM<T2DM with HP(P<0.001).Layer-specific GLS and PSD had high diagnostic efficiency for detecting LV myocardium systolic dysfunction in T2DM patients,however,the area under the curve(AUC)for layer-specific GLS and PSD combined was significantly higher than the AUCs for the individual indices(P<0.05).CONCLUSION Layer-specific GLS and PSD were associated with LV myocardium systolic dysfunction in T2DM patients,T2DM patients with HP.T2DM patients with HP have more severe LV myocardium systolic dysfunction than T2DM patients without HP and normal control patients.The combination of layer-specific GLS and PSD may provide additional prognostic information for T2DM patients with or without HP.

Evaluation of left ventricular systolic function in type 2 diabetes mellitus patients with and without peripheral vascular disease

BACKGROUND Peripheral vascular disease(PVD)is a common complication of type 2 diabetes mellitus(T2DM).Patients with T2DM have twice the risk of PVD as nondiabetic patients.AIM To evaluate left ventricular(LV)systolic function by layer-specific global longitudinal strain(GLS)and peak strain dispersion(PSD)in T2DM patients with and without PVD.METHODS Sixty-five T2DM patients without PVD,57 T2DM patients with PVD and 63 normal controls were enrolled in the study.Layer-specific GLS[GLS of the epimyocardium(GLSepi),GLS of the middle myocardium(GLSmid)and GLS of the endocardium(GLSendo)]and PSD were calculated.Receiver operating characteristic(ROC)analysis was performed to calculate the sensitivity and specificity of LV systolic dysfunction in T2DM patients with PVD.We calculated Pearson’s correlation coefficients between biochemical data,echocardiographic characteristics,and layer-specific GLS and PSD.RESULTS There were significant differences in GLSepi,GLSmid and GLSendo between normal controls,T2DM patients without PVD and T2DM patients with PVD(P<0.001).Trend tests revealed a ranking of normal controls>T2DM patients without PVD>T2DM patients with PVD in the absolute value of GLS(P<0.001).PSD differed significantly between the three groups,and the trend ranking was as follows:normal controls<T2DM patients without PVD<T2DM patients with PVD(P<0.001).ROC analysis revealed that the combination of layer-specific GLS and PSD had high diagnostic efficiency for detecting LV systolic dysfunction in T2DM patients with PVD.Lowdensity lipoprotein cholesterol was positively correlated with GLSepi,GLSmid and PSD(P<0.05),while LV ejection fraction was negatively correlated with GLSepi,GLSmid and GLSendo in T2DM patients with PVD(P<0.01).CONCLUSION PVD may aggravate the deterioration of LV systolic dysfunction in T2DM patients.Layer-specific GLS and PSD can be used to detect LV systolic dysfunction accurately and conveniently in T2DM patients with or without PVD.

Evaluation of Myocardial Strain and Aortic Elasticity in Patients with Bicuspid Aortic Valve

This study evaluated the myocardial strain and aortic elasticity in patients with bicuspid aortic valve（BAV） and then investigated the relation between them. Thirty-nine patients（30 males; mean age 44±19 years; range 6 to 75 years） with BAV were recruited as BAV group, and 29 age- and sex-matched healthy controls（21 males; mean age 42±11 years; range 20 to 71 years） served as control group. Aortic strain, distensibility and stiffness index were derived using M-mode echocardiography. Left ventricular global myocardial strain was acquired with speckle-tracking echocardiography. Correlation between aortic elasticity and myocardial strain was also analyzed. The results showed that aortic stiffness was higher（17.5±14.0 vs. 5.3±2.7, P〈0.001）, and aortic strain（4.9±4.7 vs. 11.0±4.1, P〈0.001） and distensibility（1.8±2.1 vs. 3.7±1.6, P〈0.001） were lower significantly in BAV group than in control group. Global circumferential strain（–19.1±4.2 vs. –22.5±3.7, P〈0.001）, radial stain（29.8±14.9 vs. 38.0±8.8, P〈0.001） and longitudinal stain（–18.4±3.4 vs. –20.8±3.5, P〈0.001） were significantly lower in BAV group than in control group. There was weak association between aortic elasticity and myocardial strain. These findings indicated BAV patients manifest reduced myocardial strain which had weak relationship with aortic elastic lesion.

Long Term Follow-Up of Cardiotoxicity in Breast Cancer Treatment: A Case Report

Background: Cardiac toxicity is currently defined as a symptomatic decrease in Left Ventricular Ejection Fraction (LVEF) of more than 5% or an asymptomatic decrease of at least 10% to a value of under 50% in repeated evaluations on conventional transthoracic echocardiogram (TTE), as well as a Global Longitudinal Strain (GLS) value Aims: To highlight using GLS rather than modified Simpson 2D-LVEF for the evaluation of long-term cardiotoxicity. Case Presentation: The case concerns a 73-year-old female patient with a history of breast cancer chemotherapy and anthracyclines-based therapy who presented symptoms of late cardiac toxicity related to the chemotherapeutic treatment. In the following years, the patient remained asymptomatic with a 2D-LVEF of 48%, dilation of the left atrium was found, and the reservoir phase strain was severely decreased. Conclusion: The preferred method for evaluating cardiovascular complications associated with chemotherapy is the TTE, which is performed prior to the start of treatment, during therapy, and in the follow-up. Myocardial deformation as a predictor of cardiotoxicity allows the identification of subclinical heart failure.

Speckle-tracking echocardiography for detecting myocardial dysfunction in sepsis and septic shock patients:A single emergency department study

BACKGROUND:Septic cardiomyopathy(SCM)occurs in the early stage of sepsis and septic shock,which has implications for treatment strategies and prognosis.Additionally,myocardial involvement in the early stages of sepsis is difficult to identify.Here,we assess subclinical myocardial function using laboratory tests and speckle-tracking echocardiography(STE).METHODS:Emergency department patients diagnosed with sepsis or septic shock were included for analysis.Those with other causes of acute or pre-existing cardiac dysfunction were excluded.Transthoracic echocardiography(TTE),including conventional echocardiography and STE,were performed for all patients three hours after initial resuscitation.Samples for laboratory tests were taken around the time of TTE.RESULTS:Left ventricular functions of 60 patients were analyzed,including 21 septic shock patients and 39 sepsis patients.There was no significant difference in global longitudinal strain(GLS),global circumferential strain(GCS),or global radical strain(GRS)between patients with sepsis and septic shock(all with P>0.05).However,GLS and GCS were significantly less negative in patients with abnormal troponin levels or in patients with abnormal left ventricular ejection fraction(LVEF)values(all with P<0.05).There were also moderate correlations between GLS and levels of cTnI(r=0.40,P=0.002)or N-terminal pro-B-type natriuretic peptide(NT-proBNP)(r=0.44,P=0.001)in sepsis and septic shock patients.CONCLUSION:Myocardial dysfunction,e.g.,lower LVEF or less negative GLS in patients with sepsis or septic shock,is more affected by myocardial injury.GLS could be incorporated into mainstream clinical practice as a supplementary LVEF parameter,especially for those with elevated troponin levels.

Temporal echocardiography findings in patients with fulminant myocarditis: beyond ejection fraction decline

The features of myocardial strains from speckle-tracking echocardiography (STE) have not been well defined in fulminant myocarditis (FM) patients.In this study,changes in the left ventricular ejection fraction (LVEF) and global and layer-specific myocardial strains over time were monitored.We aimed to determine the echocardiographic patterns of FM and ascertain their significance in FM treatment.Twenty patients who were clinically diagnosed with FM and received mechanical life support were prospectively enrolled.Conventional echocardiographic measurements were obtained,and serial strain echocardiography was performed from admission to hospital discharge until LVEF recovery (> 50%).Global/regional peak systolic longitudinal strains (GLS/RLS) and layer-specific longitudinal strains were quantified,and their changes with time were monitored in 14 FM patients.All patients had severely impaired cardiac function.Steep improvement in LVEF and GLS were observed within 6 days.Layer-specific strain analysis showed that reduction at admission or recovery at discharge in the endocardium and epicardium strains were equal.In conclusion,FM patients who received mechanical circulatory supports exhibited steep improvement in ventricular function within 6 days.The patchy and diffused distribution pattern of reduced RLS and equally and severely impaired strain in the endocardium and epicardium are valuable features in the diagnosis of FM.

Septic cardiomyopathy phenotype in the critically ill may depend on antimicrobial resistance

Background Sepsis is a life-threatening organ dysfunction,and septic cardiomyopathy(SCM)may complicate the course of the disease.Infection with multidrug-resistant(MDR)pathogens has been linked with worse outcomes.This study aims to evaluate SCM in patients with infections caused by different antimicrobial-resistant phenotypes.Method This retrospective study included patients with sepsis/septic shock,hospitalized,and intubated in the intensive care unit of the University Hospital of Larissa between January 2022 and September 2023 with echocardiographic data during the first two days after infection onset.The patients were divided into two groups:non-MDR-SCM group and MDR-SCM group.The cardiac function was compared between the two groups.Result A total of 62 patients were included in the study.Forty-four patients comprised the MDR-SCM and 18 the non-MDR-SCM group.Twenty-six patients(41.9%)presented with left ventricular(LV)systolic dysfunction,and≤35%right ventricular fractional area change(RVFAC)was present in 56.4%.LV systolic function was more severely impaired in the non-MDR-SCM group(left ventricular ejection fraction,35.8%±4.9%vs.45.6%±2.4%,P=0.049;LV outflow tract velocity time integral,[10.1±1.4]cm vs.[15.3±0.74]cm,P=0.001;LV-Strain,–9.02%±0.9%vs.–14.02%±0.7%,P=0.001).The MDR-SCM group presented with more severe right ventricular(RV)dilatation(right ventricular end-diastolic area/left ventricular end-diastolic area,0.81±0.03 vs.0.7±0.05,P=0.042)and worse RV systolic function(RVFAC,32.3%±1.9%vs.39.6%±2.7%,P=0.035;tricuspid annular plane systolic excursion,[15.9±0.9]mm vs.[18.1±0.9]mm,P=0.165;systolic tissue Doppler velocity measured at the lateral tricuspid annulus,[9.9±0.5]cm/s vs.[13.1±0.8]cm/s,P=0.002;RV-strain,–11.1%±0.7%vs.–15.1%±0.9%,P=0.002).Conclusion SCM related to MDR infection presents with RV systolic dysfunction predominance,while non-MDR-SCM is mainly depicted with LV systolic dysfunction impairment.