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      Strain-based discoordination imaging during exercise in heart failure with reduced ejection fraction: Feasibility and reproducibility

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          Abstract

          Purpose

          Various parameters of mechanical dyssynchrony have been proposed to improve patient selection criteria for cardiac resynchronization therapy, but sensitivity and specificity are lacking. However, echocardiographic parameters are consistently investigated at rest, whereas heart failure (HF) symptoms predominately manifest during submaximal exertion. Although strain-based predictors of response are promising, feasibility and reproducibility during exercise has yet to be demonstrated.

          Methods

          Speckle-tracking echocardiography was performed in patients with HF at two separate visits. Echocardiography was performed at rest, during various exercise intensity levels, and during recovery from exercise. Systolic rebound stretch of the septum (SRSsept), systolic shortening, and septal discoordination index (SDI) were calculated.

          Results

          Echocardiography was feasible in about 70–80% of all examinations performed during exercise. Of these acquired views, 84% of the cine-loops were suitable for analysis of strain-based mechanical dyssynchrony. Test–retest variability and intra- and inter-operator reproducibility at 30% and 60% of the ventilatory threshold (VT) were about 2.5%. SDI improved in the majority of patients at 30% and 60% of the VT, with moderate to good agreement between both intensity levels.

          Conclusion

          Although various challenges remain, exercise echocardiography with strain analysis appears to be feasible in the majority of patients with dyssynchronous heart failure. Inter- and intra-observer agreement of SRSsept and SDI up to 60% of the VT were comparable to resting values. During exercise, the extent of SDI was variable, suggesting a heterogeneous response to exercise. Further research is warranted to establish its clinical significance.

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          Most cited references31

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          2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

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            A new method for detecting anaerobic threshold by gas exchange.

            Excess CO2 is generated when lactate is increased during exercise because its [H+] is buffered primarily by HCO-3 (22 ml for each meq of lactic acid). We developed a method to detect the anaerobic threshold (AT), using computerized regression analysis of the slopes of the CO2 uptake (VCO2) vs. O2 uptake (VO2) plot, which detects the beginning of the excess CO2 output generated from the buffering of [H+], termed the V-slope method. From incremental exercise tests on 10 subjects, the point of excess CO2 output (AT) predicted closely the lactate and HCO-3 thresholds. The mean gas exchange AT was found to correspond to a small increment of lactate above the mathematically defined lactate threshold [0.50 +/- 0.34 (SD) meq/l] and not to differ significantly from the estimated HCO-3 threshold. The mean VO2 at AT computed by the V-slope analysis did not differ significantly from the mean value determined by a panel of six experienced reviewers using traditional visual methods, but the AT could be more reliably determined by the V-slope method. The respiratory compensation point, detected separately by examining the minute ventilation vs. VCO2 plot, was consistently higher than the AT (2.51 +/- 0.42 vs. 1.83 +/- 0.30 l/min of VO2). This method for determining the AT has significant advantages over others that depend on regular breathing pattern and respiratory chemosensitivity.
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              Results of the Predictors of Response to CRT (PROSPECT) trial.

              Data from single-center studies suggest that echocardiographic parameters of mechanical dyssynchrony may improve patient selection for cardiac resynchronization therapy (CRT). In a prospective, multicenter setting, the Predictors of Response to CRT (PROSPECT) study tested the performance of these parameters to predict CRT response. Fifty-three centers in Europe, Hong Kong, and the United States enrolled 498 patients with standard CRT indications (New York Heart Association class III or IV heart failure, left ventricular ejection fraction or = 130 ms, stable medical regimen). Twelve echocardiographic parameters of dyssynchrony, based on both conventional and tissue Doppler-based methods, were evaluated after site training in acquisition methods and blinded core laboratory analysis. Indicators of positive CRT response were improved clinical composite score and > or = 15% reduction in left ventricular end-systolic volume at 6 months. Clinical composite score was improved in 69% of 426 patients, whereas left ventricular end-systolic volume decreased > or = 15% in 56% of 286 patients with paired data. The ability of the 12 echocardiographic parameters to predict clinical composite score response varied widely, with sensitivity ranging from 6% to 74% and specificity ranging from 35% to 91%; for predicting left ventricular end-systolic volume response, sensitivity ranged from 9% to 77% and specificity from 31% to 93%. For all the parameters, the area under the receiver-operating characteristics curve for positive clinical or volume response to CRT was < or = 0.62. There was large variability in the analysis of the dyssynchrony parameters. Given the modest sensitivity and specificity in this multicenter setting despite training and central analysis, no single echocardiographic measure of dyssynchrony may be recommended to improve patient selection for CRT beyond current guidelines. Efforts aimed at reducing variability arising from technical and interpretative factors may improve the predictive power of these echocardiographic parameters in a broad clinical setting.
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                Author and article information

                Contributors
                l.s.fixsen@tue.nl
                Journal
                BMC Cardiovasc Disord
                BMC Cardiovasc Disord
                BMC Cardiovascular Disorders
                BioMed Central (London )
                1471-2261
                25 March 2022
                25 March 2022
                2022
                : 22
                : 127
                Affiliations
                [1 ]GRID grid.6852.9, ISNI 0000 0004 0398 8763, Department of Biomedical Engineering, , Eindhoven University of Technology, ; P.O. Box 513, 5600 MB Eindhoven, The Netherlands
                [2 ]GRID grid.7692.a, ISNI 0000000090126352, Department of Cardiology, , University Medical Centre Utrecht, ; Utrecht, The Netherlands
                [3 ]GRID grid.414711.6, ISNI 0000 0004 0477 4812, Department of Cardiology, , Maxima Medical Centre, ; Veldhoven, The Netherlands
                [4 ]GRID grid.6852.9, ISNI 0000 0004 0398 8763, Department of Industrial Design, , Eindhoven University of Technology, ; Eindhoven, The Netherlands
                Article
                2578
                10.1186/s12872-022-02578-w
                8957182
                00810d72-5850-4017-bc94-542ecd1b498e
                © The Author(s) 2022

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 19 July 2021
                : 15 March 2022
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100010665, H2020 Marie Skłodowska-Curie Actions;
                Award ID: 642612
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2022

                Cardiovascular Medicine
                echocardiography,heart failure,cardiac resynchronization therapy,exercise,feasibility,systolic rebound stretch

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