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THEORETICAL LESSON PROGRAMME

Inferior petrosal sinus sampling was performed in all cases of microadenomas smaller than 6 mm, equivocal MRI findings, or inconsistent dynamic test results. Glycemic status data were recorded in the CD group, with the patients qualified as diabetic, pre-diabetic, or individuals with normal glucose tolerance. In all patients with CD, the standard hormonal assessment of gonadotroph and thyrotroph function was performed. It should be emphasized that the evaluated CD patients took no medications affecting the pituitary—adrenal axis function, and the pituitary thyrotroph function was either preserved 21 cases or well-controlled with l -thyroxin therapy 1 case.

Associated Data

Therefore, neither steroidogenesis inhibitors nor estrogen therapy nor pituitary deficiency interfered with echocardiography results. The transsphenoidal surgery was curative in 19 out of 22 patients with CD The studies were conducted according to Good Clinical Practice guidelines and the Declaration of Helsinki. Written informed consents were obtained from all the patients. The clinical examination focused mainly on cardiovascular risk factors, such as family history of cardiovascular disease or nicotinism, and BMI.

Office systolic blood pressure SBP and office diastolic blood pressure DBP measurements were performed in the presence of a trained physician or nurse, in a quiet room, in a sitting position after a minimum of 5 min of rest, with the arm supported and legs uncrossed. Subjects were instructed not to smoke; drink alcohol, coffee, or other fluids potentially increasing BP; or take drugs potentially affecting BP e.

Standard parasternal, apical, and subcostal views were used in two-dimensional echocardiography 2. The parasternal long-axis view was used to measure the left atrial LA diameter, left ventricular end diastolic diameter LVEDD , and interventricular septum thickness at end-diastole IVSd. Simultaneous registration of the flow pattern through the aortic and mitral valves and the calculation of isovolumic diastolic time were performed in the apical 5-chamber view. Mitral annular velocity was measured in apical views by tissue Doppler imaging TDI with the sample volume positioned at or 1 cm within the septal insertion site of the mitral leaflets to cover the longitudinal excursion of the mitral annulus in diastole.

Left ventricular diastolic dysfunction LVDD was diagnosed according to current guidelines 7.


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Left ventricular GLS was assessed with the use of automated function imaging software. The analysis involved ECG-gated digital images in the apical long-axis 2-chamber and apical 4-chamber views. With two basal points selected at the level of the mitral annulus and the third point at the apex detection of the tracked area was carried out semi-automatically, with the possibility of manual adjustments. LV walls were divided into six segments in each apical view, and tracking quality and the value of strain were assessed for each LV segment.

The mean global longitudinal peak systolic strain was calculated for each view. The mean of these values was the value of GLS. Statistical analyses were performed for the entire study population and for men and women separately. Statistical analyses were performed using Statistica Data distribution and normality were assessed by visual inspection and the Kolmogorov—Smirnov test. Basic characteristic of three groups was presented in Table 1. Seventeen patients None of them has taken more than three antihypertensive medications.

Most of the patients have taken 1 or 2 medications. In the group of patients with diabetes five were treated with metformin only and two with metformin and insulin. Twenty-one out of 22 CD patients had preserved anterior pituitary function. One patient with an invasive corticotroph tumor had been diagnosed with thyrotropin deficiency, but it was well-controlled on a stable dose of l -thyroxin. Figure 1. Our results revealed that patients with CD exhibited a more pronounced LV systolic and diastolic dysfunction than hypertensive patients and healthy individuals, with similar basic clinical presentation.

These observations are clinically important as cardiovascular complications of cortisol excess strongly affect the prognosis in patients with CD. Population studies and clinical observations suggest that CD is associated with a higher mortality in comparison to that in general population. Death in CD is typically due to myocardial infarction or stroke, especially in patients receiving inadequate treatment 8 — Therefore, identifying subclinical cardiac dysfunction before any clinical symptoms emerge is important for early initiation of cardioprotective treatment.

GLS is the most commonly evaluated strain parameter, reported to be a more sensitive measure of systolic function than LVEF Thus, GLS assessments may be used to identify subclinical LV dysfunction at early stages of many diseases. GLS is a sensitive indicator of myocardial dysfunction due to factors, such as ischemia 13 , 14 , hypertrophy 15 , hypoxia 16 , cardiotoxic drugs 17 , and several systemic illnesses Furthermore, recent studies have shown that GLS abnormalities are independently associated with adverse cardiovascular outcomes 15 , Their LV systolic depression coexisted with LV diastolic dysfunction.

Toja et al. Chronically increased cardiac load seems to be the main cause of accelerated LV dysfunction. Increased arterial stiffness may play the crucial role. Bayram et al. However, elevated BP is not the only factor that may lead to cardiac damage in CD. Myocardial fibrosis is an important ultrastructural abnormality directly related to the effects of cortisol, independent from AH Yiu et al.

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As mentioned above, treatment of hypertensive patients with CD is difficult due to hypercortisolism. These patients usually need more intensive therapy. Moreover, hypertensive patients with CD had a higher risk of cardiovascular disease, even in low-grade HA. These medications are known to have cardioprotective effects and an early treatment may be beneficial for these patients.

A more detailed analysis of our results suggested that men with CD had a more impaired cardiac function than matched hypertensives and healthy individuals. Both LV systolic and diastolic dysfunction rates were higher in CD males, whereas impaired LV systolic function was only characteristic for females. The clinical value of these observations should be further investigated.

It is possible that young and middle-aged men with CD demand special and careful long-term follow-up. Our results confirm that subclinical heart disease is present in CD, even with well-controlled BP. Thus, the issue of early preventive pharmacotherapy emerges. Patients with CD and symptomatic heart disease are usually treated with standard guideline-based therapy. However, there is no sufficient evidence to give reliable therapeutic recommendations for those with asymptomatic LV dysfunction.

By the time LVEF decline is detected it may be too late for effective treatment and complete restoration of LV function.

Strain Echocardiography part II: General concept

Early cardioprotection may offer some benefits. In fact, those with the most explicit impairment of GLS at baseline improved the most in the end.

Japanese Circulation Society

Moreover, detection of impaired cardiac function may prompt a more intensive therapeutic approach in patients previously treated with cardiovascular drugs. In view of our previous observations 20 impaired GLS is associated with higher afterload systemic vascular resistance index , and its reduction may be an additional goal of antihypertensive therapy. Regular clinical and echocardiographic screening should include early signs of heart failure that demand specific therapeutic approach. We realize that the small sample size and a retrospective design are limitations of this study.

Our study mainly involved young and middle-aged patients and our results should not be extrapolated to the general population. On the other hand, the strength of our results lay in the fact that we recruited subjects with no other serious chronic diseases apart from CD and AH. Thus, our observations were specific to these populations and deprived of potential bias related to additional alterations of cardiovascular function.

Our previous study 30 demonstrated no evidence that the administered medical treatment had any significant influence on GLS. The current study was not aimed at verifying the effects of different medications on the evaluated echocardiographic parameters.

Thus, although our previous analysis showed no inter-drug differences, we cannot exclude diverse effects of different medications on LV performance. Finally, the duration of hypertension, which was not investigated in detail, might potentially confound the results. These hemodynamic abnormalities can be detected by modern non-invasive diagnostic tools and may become potential therapeutic objectives. All the authors approved the final version.

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Early detection of left ventricular wall motion alterations in heart allografts with coronary artery disease: Diagnostic value of tissue Doppler and two dimensional 2D strain echocardiography. Eur J Echocardiogr ;7:S Echocardiographic quantification of myocardial function using tissue deformation imaging, a guide to image acquisition and analysis using tissue Doppler and speckle tracking. Cardiovasc Ultrasound ; Mechanical dyssynchrony in children with systolic dysfunction secondary to cardiomyopathy: A Doppler tissue and vector velocity imaging study.

Impact of left ventricular lead position on the efficacy of cardiac resynchronisation therapy: A two-dimensional strain echocardiography study. Usefulness of three-dimensional speckle tracking strain to quantify dyssynchrony and the site of latest mechanical activation.

Utility of strain echocardiography at rest and after stress testing in arrhythmogenic right ventricular dysplasia. Right ventricular regional and global systolic function is diminished in patients with pulmonary arterial hypertension: A 2-dimensional ultrasound speckle tracking echocardiography study. Discrimination of nonobstructive hypertrophic cardiomyopathy from hypertensive left ventricular hypertrophy on the basis of strain rate imaging by tissue Doppler ultrasonography. Distinguishing focal fibrotic lesions and non-fibrotic lesions in hypertrophic cardiomyopathy by assessment of regional myocardial strain using two-dimensional speckle tracking echocardiography: Comparison with multislice CT.

Int J Cardiol ; Application of 3-dimensional speckle tracking imaging to the assessment of right ventricular regional deformation. Circ J ; Moderated Poster Presentation at Euroecho Abstract; P Advanced search. Related articles Speckle tracking; Strain; Strain rate. Cardiac computed Basic principle Understanding of Color tissue doppler. Tissue doppler i Limitations of t Speckle tracking Strain and strai Clinical applica Ischemic heart d Assessment of my Strain imaging a Miscellaneous ap The right ventri Article Figures. Article Tables.

Strain and strain rate: An emerging technology in the perioperative period. Ann Card Anaesth ; Cardiac computed tomography and magnetic resonance imaging. Figure 1: The three components of normal strain often referred to as principal strains, diagrammatically represented in this figure.

Three perpendicular axes - longitudinal, circumferential, and radial represent the geometric coordinates of the left ventricle Click here to view. Basic principle of tissue doppler imaging. Figure 2: Velocity range Click here to view. Figure 3: Understanding of the normal pattern of myocardial movement is necessary for comprehensive assessment of tissue Doppler imaging data Click here to view.

Understanding of the normal pattern of myocardial movement is necessary for comprehensive assessment of tissue doppler imaging data. Figure 4: Tissue Doppler imaging of a midesophageal four-chamber view acquired as a full-sector view; frame rate is Hz Click here to view. Figure 5: Same images are acquired, but the sector is narrowed down to improve frame rates. Note that frame rates have increased from Hz to Hz Click here to view. Table 1: Factors affecting tissue Doppler imaging velocity measurements Click here to view. Figure 6: Color tissue Doppler Click here to view.

Assessment of Fetal Myocardial Deformation Using Speckle Tracking Techniques

Tissue doppler imaging and strain. Limitations of tissue doppler imaging. Speckle tracking and strain calculation. Figure 7: Myocardial fibers in the subepicardium helically run in a left-handed direction, fibers in the mid layer run circumferentially, and fibers in the subendocardium helically run in a right-handed direction Click here to view. Strain and strain rate. Table 2: Normal strain and strain rate patterns in different segments Click here to view.


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Clinical applications of strain and strain rate in cardiac diseases. Ischemic heart disease and strain imaging. Figure 8: a How to estimate strain rate, stepwise in a 2-chamber. Figure 9: Left anterior descending occlusion in 3 different strain types Click here to view. Assessment of myocardial viability. Strain imaging and valvular heart disease. Strain imaging and cardiac dyssynchrony. Miscellaneous applications of strain imaging. The right ventricular function.

Figure Illustration of a segment of the left ventricle with tracking results from all areas through the heart wall from endocardium to epicardium. The arrows indicate the estimated displacement from one frame to the next. The arrow in red illustrates an outlier caused by an erroneous match Click here to view. This article has been cited by. Simulation for transthoracic echocardiography of aortic valve.