To demonstrate prognostic utility of left atrial strain (LAS) in adult patients with repaired Tetralogy of Fallot (rTOF). Adults patients with rTOF were prospectively enrolled in this study between years 2011 and 2015. Left atrium (LA) phasic functions were assessed using 2D speckle tracking echocardiography. Association of LA strain (LAS) with primary (any cardiovascular event) and secondary (death, heart failure or arrhythmia) composite endpoints was assessed using Cox regression analysis. Hundred-and-twelve rTOF patients, in whom LAS was feasible and were in sinus rhythm, were included in the final analysis (age 33 ± 10 years, 68[61

Aim To explore whether left atrial (LA) strain with speckle tracking echocardiography (STE) can contribute to prognostication in patients with congenital aortic stenosis (CAS). Methods and results In this prospective study, consecutive outpatients with stable CAS and healthy adults were enrolled between 2011 and 2015. Left atrial function was analysed with STE using Tomtec software. Associations between LA strain (LAS) measurements and primary composite outcome (any adverse cardiovascular event, hospitalization, or re-intervention) and secondary outcome (re-interventions) were assessed with Cox regression analysis. In total, 98 patients with CAS (mean age: 35.0 +/- 11.9 year, female: 59.2%) and 121 controls (age: 43.9 +/- 13.8 year, female: 55.4%) were included. The majority of patients were in NYHA class I: 97 (99%) at baseline. At baseline, LA conduit strain (LAS-cd) and strain rate (LASR-cd) were significantly lower in patients than in controls when corrected for age and sex (-18.1 +/- 8.7 vs. -23.5 +/- 9.9%, P = 0.001 and -0.73 +/- 0.31 vs. -1.02 +/- 0.43/s, P < 0.001). During a median follow-up of 6.4 years (5.7-7.1), the primary composite outcome occurred in 48 (39.6%) patients. Kaplan-Meier analysis showed that decreased LAS-cd (<21%) was associated with a higher occurrence of the primary outcome (log-rank: P = 0.008). Depressed LAS-cd and LASR-cd were both associated with the primary composite outcome [univariable hazard ratio (HR) = 0.64(0.46-0.88), P = 0.005 and HR = 0.68(0.55-0.83), P < 0.001, respectively]; adjusted HR (for LAS-cd and LASR-cd, respectively): 0.31(0.09-1.04), P = 0.06 and 0.49(0.26-0.89), P = 0.02. Conclusion Impairment in LA conduit function assessed with STE carries prognostic value in patients with CAS and can be implemented in clinical management.

Aims: To assess the prognostic value of left ventricular (LV) global longitudinal strain (GLS) and global longitudinal early diastolic strain rate (GLSre) with regard to cardiovascular events, as congenital aortic stenosis (AoS) is associated with significant mortality and morbidity but predictors for clinical outcome are scarce. Strain analysis provides a robust and reproducible method for early detection of LV dysfunction, which might be of prognostic value. Methods: This prospective study, included clinically stable patients with congenital AoS between 2011-2013. LV GLS and GLSre was performed in the apical 4, 3 and 2-chamber views using Tomtec software. The endpoint was a composite of death, heart failure, hospitalization, arrhythmia, thrombo-embolic events and re-intervention. Results: In total 138 patients were included (33[26-43] years, 86(62%) male), NYHA class I: 134(97%). Mean LV GLS was -15.3 +/- 3.2%, GLSre 0.66 +/- 0.18 s(-1). Both correlated with NT-proBNP, LV volumes and ejection fraction (strongest LV GLS with LV EF: r -0.539, p < 0.001, strongest LV GLSre with age: r -0.376, p < 0.001). During median follow-up of 5.9[5.5-6.2] years, the endpoint occurred in 53(38%) patients: 4 patients died, 9 developed heart failure, 22 arrhythmias, 8 thrombo-embolic events and 35 re-interventions. Both LV GLS (standardized HR (sHR 0.62(95%CI 0.47-0.81) and GLSre (sHR 0.62(95%CI 0.47-0.83) were associated with the endpoint. Additional multivariable analysis showed that both GLS and GLSre were associated independent of left atrial volume, NT-proBNP and prior re-interventions. Conclusion: Left ventricular GLS and GLSre are reduced in adult patients with congenital AoS. Both markers are associated with adverse cardiac events and have clear clinical relevance.

Aim: This study aimed to describe the systolic left ventricular global longitudinal strain (LvGLS) and left ventricular peak early diastolic strain rate (Sre) in adult women with Turner syndrome (TS) and to determine its relationship with exercise capacity and clinical parameters. Methods: In this cross-sectional cohort study, consecutively included adult TS women underwent an electrocardiogram, transthoracic echocardiogram (TTE) and cardiopulmonary exercise test (CPET) on the same day. LvGLS and Sre were measured using 2D speckle tracking analysis (STE) and compared with age-matched healthy female controls. Results: Ninety-four adult women (age 36 ± 13 years) with TS and 32 healthy age-matched female controls were included. Women with TS had a signi fi cantly impaired/reduced systolic LvGLS ( – 17.82 ± 2.98% vs . – 21.80 ± 1.85%, p < 0.001) and Sre (0.98 ± 0.32 s-1 vs . 1.27 ± 0.19 s-1, p > 0.001), compared to healthy female controls. Furthermore, TS women had reduced diastolic function as measured by conventional echocardiographic parameters: A higher A-wave ( p < 0.001), lower E/A-ratio ( p = 0.001), longer deceleration time ( p = 0.006), and a higher E/E ’ -ratio ( p < 0.001). Women with TS also had a signi fi cantly reduced maximal workload ( p = 0.033), reduced oxygen uptake ( p < 0.001) and a reduced maximal heart rate ( p < 0.001) during exercise. Multivariable linear regression analysis revealed that Age, karyotype and QT-duration were signi fi cantly associated with Sre, but not with LvGLS, in the TS population. Conclusion: Systolic and diastolic strain and exercise capacity were signi fi cantly reduced in TS women compared to healthy women. No correlation between strain itself and exercise capacity could be demonstrated, but correlations with conventional TTE parameters and baseline characteristics were found.

There is abundant evidence of the prognostic and diagnostic value of global longitudinal strain (GLS). However, despite multiple reports, uncertainty persists about the variance in normal GLS. The difficulties in defining the lower limit of normality (LLN) have provided 1 reason for slow uptake of

Left ventricular global longitudinal strain (LVGLS) analysis is a sensitive measurement of myocardial deformation most often done using speckle-tracking transthoracic echocardiography (TTE). We propose a novel approach to measure LVGLS using feature-tracking software on the magnitude dataset of 4D flow cardiovascular magnetic resonance (CMR) and compare it to dynamic computed tomography (CT) and speckle tracking TTE derived measurements. In this prospective cohort study 59 consecutive adult patients with a bicuspid aortic valve (BAV) were included. The study protocol consisted of TTE, CT, and CMR on the same day. Image analysis was done using dedicated feature-tracking (4D flow CMR and CT) and speckle-tracking (TTE) software, on apical 2-, 3-, and 4-chamber long-axis multiplanar reconstructions (4D flow CMR and CT) or standard apical 2-, 3-, and 4-chamber acquisitions (TTE). CMR and CT GLS analysis was feasible in all patients. Good correlations were observed for GLS measured by CMR (− 21 ± 3%) and CT (− 20 ± 3%) versus TTE (− 20 ± 3%, Pearson’s r: 0.67 and 0.65, p < 0.001). CMR also correlated well with CT (Pearson’s r 0.62, p < 0.001). The inter-observer analysis showed moderate to good reproducibility of GLS measurement by CMR, CT and TTE (Pearsons’s r: 0.51, 0.77, 0.70 respectively; p < 0.05). Additionally, ejection fraction (EF), end-diastolic and end-systolic volume measurements (EDV and ESV) correlated well between all modalities (Pearson’s r > 0.61, p < 0.001). Feature-tracking GLS analysis is feasible using the magnitude images acquired with 4D flow CMR. GLS measurement by CMR correlates well with CT and speckle-tracking 2D TTE. GLS analysis on 4D flow CMR allows for an integrative approach, integrating flow and functional data in a single sequence. Not applicable, observational study.

Three dimensional speckle tracking echocardiography (3D-STE) is a novel modality for the assessment of left ventricular strain (LVS). The aim of our study is to provide single vendor normative strain values measured with 3D-STE in healthy adult caucasians. One hundred fifty-five healthy subjects aged 20 to 72 years (≥ 28 subjects per decile) were prospectively included and examined with 2D and 3D transthoracic echocardiography. In 105 both 3D and 2D-STE were feasible (71%, mean age 44 ± 14 years, 51% female). Mean 3D tangential strain (3D-TS) was − 32 ± 2.9%. 3D global longitudinal strain (3D-GLS) demonstrated a significant but not very strong correlation with 2D-GLS values (− 19.7 ± 1.8% vs − 20.4 ± 2.2%, r = 0.462, p < 0.001). No gender difference was observed in 3D strain parameters. 3D-GLS decreased with increasing age stratum (p = 0.024). LVEF was associated with 3D-TS and 3D-GLS (r = − 0.819, p ≤ 0.001 for 3D-TS, p = − 0.477, r < 0.001, p = 0.001 for 3D-GLS). In this single vendor study age and gender-specific normative LV 3D-TS values were reported for healthy adult caucasians. In a significant proportion of the subjects 3D-STE was not feasible, but when feasible, 3D-STE shows excellent association with LVEF, and is therefore a promising novel modality for the assessment of the myocardial function, provided that issues of limited feasibility and temporal resolution are addressed.

Background Adults with a systemic right ventricle (sRV) have a high risk of cardiac complications. This study aimed to identify prognostic markers in adults with sRV based on clinical evaluation, echocardiography, and blood biomarkers. Methods and Results In this prospective cohort study, consecutive clinically stable adults with sRV caused by Mustard‐ or congenitally corrected transposition of the great arteries were included (2011–2013). Eighty‐six patients were included (age 37±9 years, 65% male, 83% New York Heart Association functional class I, 76% Mustard transposition of the great arteries, 24% congenitally corrected transposition of the great arteries). Venous blood sampling was performed including N‐terminal pro B‐type natriuretic peptide, high‐sensitive‐troponin‐T, high‐sensitivity C‐reactive protein, growth differentiation factor‐15, galectin‐3, red cell distribution width, estimated glomerular filtration rate, and hemoglobin. Besides conventional echocardiographic measurements, longitudinal, circumferential, and radial strain were assessed using strain analysis. During a median follow‐up of 5.9 (interquartile range 5.3–6.3) years, 19 (22%) patients died or had heart failure (primary end point) and 29 (34%) patients died or had arrhythmia (secondary end point). Univariable Cox regression analysis was performed using dichotomous or standardized continuous variables. New York Heart Association functional class >I, systolic blood pressure, and most blood biomarkers were associated with the primary and secondary end point (galectin‐3 not for primary, N‐terminal pro B‐type natriuretic peptide and high‐sensitivity C‐reactive protein not for secondary end point). Growth differentiation factor‐15 showed the strongest association with both end points (hazard ratios; 2.44 [95% CI 1.67–3.57, P<0.001], 2.00 [95% CI 1.46–2.73, P<0.001], respectively). End‐diastolic basal dimension of the subpulmonary ventricle was associated with both end points (hazard ratio: 1.95 [95% CI 1.34–2.85], P<0.001, 1.70 [95% CI 1.21–2.38, P=0.002], respectively). Concerning strain analysis, only sRV septal strain was associated with the secondary end point (hazard ratio 0.58 [95% CI 0.39–0.86], P=0.006). Conclusions Clinical, conventional echocardiographic, and blood measurements are important markers for risk stratification in adults with a sRV. The value of novel echocardiographic strain analysis seems limited.

Background: Adult patients with repaired tetralogy of Fallot (ToF) are at risk for complications such as heart failure and sudden cardiac death, and identifying high-risk patients is important. Reduced left ventricular (LV) and right ventricular (RV) function has been identified as a predictor of outcomes. However, LV ejection fraction is often preserved, and RV function is difficult to assess. With the introduction of strain analysis, an easy and more sensitive parameter became available. The aim of this study was to investigate the association between strain variables and cardiovascular events in patients with ToF. Methods: Stable adult patients with repaired ToF were consecutively included in a prospective observational study between 2011 and 2013 (N = 151; median age, 33.2 years [interquartile range, 25.5-42.0 years]; 61.6% men). For the left ventricle, global longitudinal strain and apical and basal rotation were measured, and longitudinal strain was measured for the right ventricle. The primary endpoint was a composite of death or heart failure. The secondary endpoint was a composite of death, heart failure, arrhythmia, reintervention, or hospitalization for cardiac reasons. Results: During a median follow-up period of 71.5 months (interquartile range, 64.0-75.3 months), the primary and secondary endpoints occurred in 14 (9%) and 62 (41%) patients, respectively. After adjusting for LV ejection fraction and LV global longitudinal strain, RV longitudinal strain remained independently associated with the primary endpoint in a ridge regression analysis. LV apical rotation remained independently associated with the secondary end point (adjusted hazard ratio, 0.72; 95% CI, 0.52-0.98; P = .035) after adjusting for age, New York Heart Association functional class, QRS duration, LV ejection fraction, RV longitudinal strain, and LV global longitudinal strain. Conclusions: Myocardial deformation variables of both the left and right ventricles were associated with cardiovascular events in patients with ToF. LV and RV longitudinal strain and LV rotation should become part of the routine assessment of patients with ToF.

AimsReliable evaluation of the severity and consequences of pulmonary regurgitation (PR) in patients with repaired tetralogy of Fallot (TOF) is crucial to timely identify the need for pulmonary valve intervention. We aimed to identify the accuracy of echocardiographic parameters to differentiate between moderate and severe PR, using phase contrast cardiac magnetic resonance imaging (CMR) as gold standard. Methods and resultsIn this cross-sectional study, 45 TOF patients with both echocardiographic and CMR measurements of PR were enrolled. All quantitative and semiquantitative echocardiographic measurements such as pressure half time (PHT), Color flow jet width (CFJW), ratio CFJW/right ventricle outflow tract (RVOT) diameter, PR index and the presence of early termination of the PR jet, end-diastolic antegrade flow and diastolic backflow in main pulmonary artery (MPA), and PA branches correlated significantly with PR fraction on CMR. Qualitative assessment with color flow on echocardiography overestimated PR Multivariate linear regression analysis identified the ratio of CFJW/RVOT diameter and PHT as independent predictors of PR fraction. Accuracy of echo parameters was tested to differentiate between mild-to-moderate and severe PR Combining different echocardiographic parameters increased sensitivity and specificity. The addition of diastolic flow reversal in the PA branches to PHT below 167milliseconds increased the NPV from 87% to 89% and PPV from 62% to 76%. ConclusionsComparison with CMR confirms that echocardiographic parameters are reliable in predicting PR severity. Combined measurement of diastolic flow reversal in the pulmonary artery branches and PHT is reliable in the detection of severe PR in the follow-up of TOF patients.

PurposeLeft atrial (LA) dilatation is predictive for complications in a multitude of cardiac diseases; therefore, adequate assessment is essential. Technological advances have made it possible to quantify LA function with Speckle Tracking Echocardiography (STE); however, there are currently no recommendations for normal values with regard to LA function. We aimed to assess LA myocardial and volumetric function in a healthy cohort and investigate correlations with baseline characteristics.MethodsThis prospective cohort study included 147 (aged 20–72) healthy individuals and assessed LA volumetric function using maximum, minimum and pre‐a‐wave volumes and myocardial function using reservoir function using peak strain in LA relaxation (LA‐strain), conduit function using peak strain rate in early LA contraction (LA‐SRe) and pump function using peak strain rate in late LA contraction (LA‐SRa).ResultsMean LA‐strain was 39.7 ± 6.2%, LA‐SRe −2.78 ± 0.62 s−1 and LA‐SRa −2.56 ± 0.62 s−1. Subjects were divided into 5 age decades (each 50% female). LA‐strain and LA‐SRe were lower in the oldest groups, whereas LA‐SRa was higher. LA‐SRa was higher in males(−2.69 ± 0.68 s−1 vs −2.42 ± 0.52 s−1). Age‐specific values are provided. Age proved to be an independent predictor for LA‐SRa after correction for blood pressure and heart rate. LA expansion index and passive emptying fraction decreased with age, while active emptying fraction increased with age. LA maximum volume did not increase with age.ConclusionThis study provides normal values for the three phasic functions of the LA, assessed with STE and volumetric function. Our results suggest the need for age‐specific reference ranges, and normal values for this cohort have been calculated.

Despite successful aortic coarctation (CoA) repair, systemic hypertension often recurs which may influence left ventricular (LV) function. We aimed to detect early LV dysfunction using LV global longitudinal strain (GLS) in adults with repaired CoA, and to identify associations with patient and echocardiographic characteristics. In this cross-sectional study, patients with repaired CoA and healthy controls were recruited prospectively. All subjects underwent echocardiography, ECG and blood sampling within 1 day. With speckle-tracking echocardiography, we assessed LV GLS on the apical four-, three- and two-chamber views. We included 150 subjects: 75 patients (57 % male, age 33.4 ± 12.8 years, age at repair 2.5 [IQR: 0.1–11.1] years) and 75 healthy controls of similar sex and age. LV GLS was lower in patients than in controls (−17.1 ± 2.3 vs. −20.2 ± 1.6 %, P < 0.001). Eighty percent of the patients had a normal LV ejection fraction, but GLS was still lower than in controls (P < 0.001). In patients, GLS correlated with systolic and diastolic blood pressure (r = 0.32, P = 0.009; r = 0.31, P = 0.009), QRS duration (r = 0.34, P = 0.005), left atrial dimension (r = 0.27, P = 0.029), LV mass (r = 0.30, P = 0.014) and LV ejection fraction (r = −0.48, P < 0.001). Patients with either associated cardiac lesions, multiple cardiac interventions or aortic valve replacement had lower GLS than patients without. Although the majority of adults with repaired CoA seem to have a normal systolic LV function, LV GLS was decreased. Higher blood pressure, associated cardiac lesions, and larger left atrial dimension are related with lower GLS. Therefore, LV GLS may be used as objective criterion for early detection of ventricular dysfunction.