© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12569

Echocardiography

Evaluation of Human Immunodeficiency Virus Infection-Related Left Ventricular Systolic Dysfunction by Tissue Doppler Strain Echocardiography Imran Onur, M.D.,* Baris Ikitimur, M.D.,† Fahrettin Oz, M.D.,* Ahmet Ekmekci, M.D.,‡ Ali Elitok, M.D.,* Arif Atahan Cagatay, M.D.,§ Kamil Adalet, M.D.,* Ahmet Kaya Bilge, M.D.,* and Mehmet Gungor Kaya, M.D., F.E.S.C.¶ *Department of Cardiology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey; †Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey; ‡Department of Internal Medicine, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey; §Department of Infectious Diseases and Clinical Microbiology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey; and ¶Department of Cardiology, Erciyes University School of Medicine Kayseri, Istanbul, Turkey

Objective: Cardiovascular involvement causes significant morbidity and mortality among patients with human immunodeficiency virus (HIV) infection. Since the introduction of highly active antiretroviral treatment (HAART), subtle changes in left ventricular (LV) function, which may be clinically silent, have become more pronounced in HIV patients. Echocardiographic strain imaging (SI) may detect subclinical myocardial dysfunction at an earlier stage compared with conventional echocardiography. The aim of this study was to evaluate tissue Doppler–derived LV strain and strain rate (SR) along with conventional measures of LV function in asymptomatic, stable adult HIV patients on HAART. Methods: Twenty-one patients with HIV infection (mean age: 37.8  11.9 years, 11 males) who had no cardiovascular complaints and 27 healthy volunteers (mean age: 40.9  5.8 years, 14 males) were enrolled. Traditional parameters including LV ejection fraction (EF) were measured along with tissue velocity imaging (TVI) and tissue Doppler SI parameters using transthoracic echocardiography. Results: The mean duration of HIV infection was 30.8  25.1 (3–120) months. The mean LVEF in HIV group was within normal limits but lower than controls (64.5%  10.2% vs. 72.2%  6.4%, P = 0.003). There were no differences in other major traditional measures, as well as TVI parameters between groups. LV systolic strain and SR parameters were impaired indicating subtle LV systolic dysfunction in HIV group. No difference in diastolic function was observed between groups. Conclusion: Left ventricular systolic strain parameters may be utilized to demonstrate subtle LV systolic dysfunction in asymptomatic HIV patients. (Echocardiography 2014;31:1199–1204) Key words: human immunodeficiency virus infection, left ventricular dysfunction, echocardiography, strain, strain rate Cardiovascular involvement has long been recognized as a clinical entity causing significant morbidity and mortality among patients with human immunodeficiency virus (HIV) infection.1 Left ventricular (LV) systolic dysfunction presenting as dilated cardiomyopathy has been reported to be one of the most common cardiovascular consequences of HIV infection and early echocardiographic investigations conducted before the highly active antiretroviral treatment (HAART) era have demonstrated cardiomyopathy to be present in about one-third of cohorts studied.1–3 Address for correspondence and reprint requests: Mehmet Gungor Kaya, M.D., F.E.S.C., Department of Cardiology, Erciyes University School of Medicine, 38039 Kayseri, Turkey. Fax: +90 352 4376327; E-mail: [email protected]

The pathogenesis of LV dysfunction in HIV patients includes direct effects of the HIV virus on the heart, the presence of autoantibodies, the inflammatory response of the host myocardium to the virus, other infections depending on the immune status of patients and side effects of antiretroviral and other drugs used for management of HIV.4–6 Since the introduction of HAART, HIV-associated morbidity and mortality have decreased substantially, together with changing clinical presentation of cardiovascular disease in HIV patients.7,8 The decreasing prevalence of overt LV systolic dysfunction in HIV patients has shifted the focus to more subtle changes in LV systolic and diastolic function which may be clinically silent and present throughout the early stages of disease process. LV function has been studied 1199

Onur, et al.

using various imaging techniques like standard echocardiography utilizing M-mode, two-dimensional (2D) and Doppler ultrasound, radionuclide ventriculography, pulsed-wave tissue Doppler echocardiography, and cardiac magnetic resonance imaging (MRI) in HIV-infected patients.9–13 Strain (S) is a measure of myocardial deformation and strain rate (SR) is used to measure the rate of this deformation.14 Measurement of strain and SR by echocardiography has been demonstrated to be both accurate and reliable in assessing myocardial function.15–17 Strain imaging (SI) has been able to detect subclinical myocardial dysfunction at an earlier stage compared with conventional imaging in a number of diseases.18–23 Together with tissue velocity imaging (TVI), SI have been used to detect right and LV involvement in various systemic diseases, demonstrating impaired longitudinal fiber motion to be a sensitive marker of early myocardial dysfunction.19–23 SI has also been used to assess myocardial function in children and young adults with HIV acquired early in life.24 In pediatric HIV population, impaired LV strain and SR were demonstrated to be present despite normal LV ejection fractions (EFs). The aim of this study was to evaluate tissue Doppler-derived LV strain and SR along with conventional measures of LV function in asymptomatic adult HIV patients. Material and Methods: A total of 21 consecutive patients with HIV infection (mean age: 37.8  11.9 years, 11 males) who were referred to the Cardiology Department of a University Hospital for routine cardiovascular evaluation were enrolled. All the patients were stable in terms of HIV infection, and had no cardiovascular symptoms, as well as no history of cardiac or other systemic chronic illnesses besides HIV infection. None of the subjects were receiving medications like b-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, diuretics or any other cardiovascular drugs. All the patients were followed in the infectious diseases outpatient department and were on HAART. Control group consisted of 27 age- and sex-matched healthy volunteers (mean age: 40.9  5.8 years, 14 males). Informed consent was obtained from all patients. The study complies with the Declaration of Helsinki and trial protocol was approved by the local Ethics Committee. Echocardiographic Examination: Traditional echocardiographic and strain measurements of both the patients with HIV and the controls were performed by 2 cardiologists, who were blinded to the clinical characteristics of the 1200

subjects. The examinations were carried out using a General Electric Vivid 7 Expert (GE Vingmed Ultrasound, Horten, Norway) echocardiography machine and a 2.5 MHz transducer. All patients were in sinus rhythm at the time of examination. Measurements were performed on 3 consecutive heart beats and an average of the 3 measurements was calculated. Echocardiograms were recorded in supine position with patients turned 30° on their left sides, and digitally stored to be analyzed later. Septal and posterior wall thickness and left ventricle chamber dimensions were measured according to the American Society of Echocardiography (ASE) guidelines.25 The left ventricle mass index (LVMI) was determined by the ASE-recommended formula: “LVMI (g/m2) = (1.04[(IVST + LVID + PWT)3  LVID3]  13.6)/body surface area”. LVEF was calculated using the Teichholz method.26 Conventional Doppler echocardiography was performed to obtain early and late transmitral diastolic velocities (E and A velocities) and their ratio (E/A), and deceleration time of the early transmitral diastolic flow (DT). In addition to conventional echocardiographic parameters, TVI and SI parameters were also evaluated from offline analysis of stored loops by using custom software (Echopac, GE Systems, Oslo, Norway). TVI analysis of the mitral annulus was performed in the apical four-chamber view. A 5-mm sample volume was placed at the septal and lateral sides of the annulus. Tissue velocity imaging measures included peak systolic myocardial velocity (S), early (E0 ), and late (A0 ) diastolic myocardial velocities, and their ratio at the basal segments of the LV and septal walls. As Doppler measures are angle dependent, care was taken to obtain an ultrasound beam parallel to the direction of mitral annulus motion. Color-coded tissue Doppler data were acquired and stored as cine loops. SI measures included peak systolic strain and SR, peak early and late diastolic SR which were evaluated at the basal segments of the LV lateral and septal walls. These sites were chosen because SI imaging is angle dependent and longitudinal velocities are highest in the basal segments of the LV and diminish toward the apex. During the measurement of strain parameters, an oval-shaped sample volume, 6 9 12 mm in size, was placed in the basal inner half of the LV myocardium at the septum and the lateral wall to keep the angle between the Doppler beam and the endocardium

Evaluation of human immunodeficiency virus infection-related left ventricular systolic dysfunction by tissue Doppler strain echocardiography.

Cardiovascular involvement causes significant morbidity and mortality among patients with human immunodeficiency virus (HIV) infection. Since the intr...
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