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Imaging in renal failure
P3838 | SPOTLIGHT 2013
Improvement of left ventricular mechanics after hemodialysis in
patients with end-stage renal disease: a three-dimensional speckle
tracking study
A. Kovacs 1 , K. Solymossy 1 , A. Apor 1 , A. Nagy 1 , M. Faludi 2 , V. Reti 2 ,
P. Studinger 3 , A. Tisler 3 , K. Berta 2 , B. Merkely 1 . 1 Semmelweis University
Heart and Vascular Center, Budapest, 2 Fresenius Medical Care, Budapest,
3 Semmelweis University, 1st Dept. of Internal Medicine, Budapest, Hungary
Background: Cardiovascular diseases are the leading causes of morbidity and
mortality in patients with chronic renal insufficiency. We sought to investigate the
chronic renocardiac syndrome and the immediate effects of hemodialysis (HD) on
myocardial mechanics using three-dimensional (3D) speckle tracking echocardiography.
Methods: Forty-four patients (mean age 48±13 years, 54% men) with end-stage
renal disease on three times per week maintenance HD, without diabetes and any
significant cardiac disease were investigated just before and immediately after
HD, and compared to 46 normal controls (NC; 48±12 years, 48% men). Beyond
conventional transthoracic echocardiographic examination, 3D recordings were
obtained using multi-beat reconstruction from 6 consecutive cardiac cycles (GE
Vivid E9). Ejection fraction (EF) and left ventricular mass indexed to body surface
area (LVMi) were measured, and 3D speckle tracking analysis was performed to
assess global longitudinal-, circumferential-, area- and radial peak systolic strain
values (GE 4D Auto LVQ). For statistical analysis, Wilcoxon signed-rank, MannWhitney U, Spearman correlation tests and multivariate linear regression were
used. Data are presented as median (interquartile range).
Results: LVMi was remarkably increased in patients compared to NC [136 (46)
vs. 71 (8) g/m2 , p<0.001]. EF and strain values in all directions improved after
HD [pre- vs. post-HD; EF: 63 (9.5) vs. 66 (10), longitudinal: -20 (3) vs. -21 (6),
circumferential: -20 (4) vs. -22 (7), area: -33 (5) vs. -35 (10), radial: 50 (12) vs.
53.5 (20) %, all p<0.01]. While there was no difference in longitudinal strain, the
patients’ pre-HD circumferential, area and radial strains were reduced, and after
HD only the circumferential strain increased enough to be similar compared to
NC [NC longitudinal: -20.5 (3), circumferential: -21 (3), area -36 (3), radial 61 (8)
%, p<0.05]. LVMi correlated inversely with post-HD circumferential strain (ρ=0.34,
p<0.05), and even stronger with area (ρ=0.54) and radial strains (ρ=-0.58, both
p<0.001). In a multivariate linear regression model, circumferential strain was
found to be an independent predictor of EF both before (β=-0.88, p<0.001) and
after HD (β=-0.96, p<0.001).
Conclusions: In chronic renocardiac syndrome the left ventricle can be characterized by increased mass and reduced 3D strain values measured by speckle
tracking echocardiography. The increase of LVMi correlates strongly with the reduction of area and radial strains. HD results in immediate improvement of left
ventricular function indicated by EF and 3D strain, as well.
P3839 | BEDSIDE
Emerging predictive power of myocardial deformation in chronic
kidney disease
G. Valocik 1 , I. Valocikova 2 , M. Vachalcova 1 , J. Ignac 1 , S. Juhas 1 , P. Mitro 1 .
1
East-Slovak Institute of Cardiovascular Diseases (VUSCH), Kosice, Slovak
Republic; 2 Safarik University Medical School, Kosice, Slovak Republic
Introduction: Cardiovascular disease is the major cause of morbidity and mortality in patients with advanced chronic kidney disease (CKD). In the last decade a
growing number of cardiac biomarkers have been identified as risk factors linked
to adverse cardiovascular outcomes in patients with renal failure. Moreover, several cardiac structural abnormalities, identified mainly by echocardiography, were
also found in relation to CKD. Echocardiography continuously provides new imaging modalities, which are characterized by increasing ability to identify subtle functional or structural changes of the heart. In the present study we evaluated the
prognostic information that can be gained from traditional and novel echocardiographic parameters in combination with selected biomarkers in two groups of
patients, predialysis and dialysis.
Methods: The study cohort consisted of 50 predialysis and 45 dialysis patients
(mean age 60.6±15.8 years) followed-up between September 2006 and January
2013 (76 months, 6.3 years). The association of selected humoral biomarkers
(BNP, C-reactive protein, and fibrinogen), and echocardiographic parameters to
survival in both groups of patients was assessed. A comprehensive list of quantitative parameters of left-sided chamber size, geometry, systolic and diastolic
function, and valvular function were measured from the echocardiogram. Global
longitudinal strain (GLS), strain rate (GLSR), circumferential strain (CS) and strain
rate (CSR) were assessed from two-dimensional images using speckle tracking
based velocity vector imaging. The primary outcome was all-cause mortality. To
test the appropriateness of the humoral and echocardiographic parameters for
survival analysis, a multivariable logistic regression model was used. The variables with a p value <0.05 were selected for further Cox proportional hazards
regression analysis which was used to identify the optimal parameters to predict
all-cause mortality. The optimal variables identified in the above model were then
entered in a subsequent Kaplan-Meier method.
Results: Comparison of survival curves using log-rank test revealed that significant predictors of all-cause mortality were GLS (p=0.008), CSR (p=0.006) and
LV EF (p=0.04) in predialysis patients (Figures 1-3) and CRP (p=0.02) and E/Em
(p=0.02) in the group of dialysis patients.
Conclusion: The results of our study suggest that the predictive power of LV EF
was outweighed by deformation indexes, such as GLS and CSR in predialysis
patients. In hemodialysis patients the most powerful predictors of survival were
C-reactive protein and E/Em.
P3840 | BEDSIDE
Noninvasive estimation of left ventricular diastolic function using
three-dimensional speckle tracking echocardiography in patients
with hemodialysis
H. Satou 1 , M. Kawasaki 2 , T. Watanabe 2 , A. Furuta 1 , T. Kariya 1 , S. Sawada 1 ,
K. Goto 1 , T. Noda 3 , S. Watanabe 3 , S. Minatoguchi 2 . 1 Sawada Hospital,
Department of Internal Medicine, Gifu, Japan; 2 Gifu University Graduate School
of Medicine, Department of Cardiology, Gifu, Japan; 3 Gifu Prefectural General
Medical Center, Department of Cardiology, Gifu, Japan
Purpose: Many dialysis patients have left ventricular (LV) hypertrophy and high
plasma B-type natriuretic peptide concentrations. Although the evaluation of LV
diastolic function is helpful in treatment of patients with dialysis, noninvasive
estimation of LV diastolic function has not yet been established. We have recently developed a novel index to estimate pulmonary capillary wedge pressure (ePCWP) using left atrial (LA) emptying function (EF) and volume (LAV)
by speckle tracking echocardiography (STE) and named it kinetics-tracking (KT)
index: log (LAEF/LAV index). The ePCWP was estimated as 10.7 – 12.4 × KT index. We sought to noninvasively evaluate diastolic properties in dialysis patients
using 3-dimensional speckle tracking echocardiography (3D-STE) and to compare them with those in normal subjects.
Methods: Phasic left atrial (LA) volume (LAV) and emptying function (EF) were
measured in 43 patients with dialysis (age; 60±14, 26 men) and 20 normal subjects (age; 61±15, 15 men) by 3D-STE. Time constant of LV pressure decline
(Tau) was estimated as Tau = isovolumic relaxation time/(ln 0.9 × systolic blood
pressure – ln ePCWP). Isovolumic relaxation time was obtained by Doppler echo.
LV stiffness was estimated due to linear elastic theory as stiffness = thickness
at end systole/(thickness at end systole – thickness at end diastole). ePCWP,
Tau and LV stiffness in dialysis patients were compared with normal subjects. LV
mass, E/e’ and LV ejection fraction as a systolic function were also compared.
Results: There was no significant difference in LV ejection fraction between normal and dialysis patients (67±8 vs. 66±6%, respectively). LV mass index in dialysis patients was larger than normal (126±31 vs. 87±16g/m2 , respectively). Tau
and LV stiffness in dialysis patients were significantly higher than normal (38±8
vs. 20±6 and 3.3±0.7 vs. 2.6±0.5, respectively). The ePCWP and E/e’ in dialysis patients were higher before dialysis than normal (8.6±2.9 vs. 6.5±2.8mmHg
and 13.0±4.1 vs. 7.1±1.3, respectively) and significantly decreased after dialysis (6.1±2.2mmHg and 10.5±3.3, respectively). There were good correlations
between the ePCWP and Tau or LV stiffness (r=0.88 and r=0.69, p<0.05, respectively).
Conclusions: Diastolic properties such as PCWP, Tau and LV stiffness could be
noninvasively estimated by 3D-STE. Diastolic function was impaired in dialysis
patients associated with increased LV mass. Noninvasive estimation of diastolic
properties using 3D-STE may be useful and have incremental value in evaluation
of diastolic function and treatment of heart failure in dialysis patients.
P3841 | BEDSIDE
Prognostic value of coronary flow reserve on long-term
cardiovascular outcomes in patients with chronic kidney disease
K. Nakanishi 1 , S. Fukuda 2 , K. Shimada 1 , C. Miyazaki 3 , K. Otsuka 1 ,
T. Kawarabayashi 3 , H. Watanabe 4 , J. Yoshikawa 5 , M. Yoshiyama 1 . 1 Osaka
City University Graduate School of Medicine, Osaka, Japan; 2 Osaka Ekisaikai
Hospital, Osaka, Japan; 3 Higashi Sumiyoshi Morimoto Hospital, Osaka, Japan;
4 Heart Center, Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan;
5 Nishinomiya Watanabe, Cardiovascular Center, Nishinomiya, Japan
Purpose: Cardiovascular (CV) diseases and chronic kidney disease (CKD) have
the common predisposing factors, which subsequently cause microvascular dysfunction. In the absence of obstructive coronary artery disease, coronary flow reserve (CFR) represents the status of coronary microcirculation. This study aimed
to investigate the prognostic importance of impaired CFR, as a maker of microvascular dysfunction, on long-term CV outcomes in patients with CKD.
Methods: This study consisted of 139 patients with estimated glomerular filtration
rate less than 60 ml/min/1.73m2 who had no obstructive narrowing in the left an-