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Left ventricular myocardial work indices in pediatric hypertension: correlations with conventional echocardiographic assessment and subphenotyping

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Abstract

Myocardial work (MW) is a novel parameter that incorporates non-invasive estimates of left ventricular (LV) systolic pressure into the interpretation of strain, thus overcoming the limitations of load dependency traditionally encountered with LV fractional shortening (LVFS), ejection fraction (LVEF), and global longitudinal strain (GLS). However, data on MW in the pediatric population with hypertension are lacking. Conventional markers of LV function and MW indices were obtained from 88 echocardiographic examinations in 76 children with hypertension (47 males, 15.5 ± 2.96 years). When compared with a previously published cohort of 52 healthy controls, global work index (GWI) and global constructive work (GCW) were both significantly elevated while LVEF and GLS were not impaired but rather mildly increased. On multivariable analysis, GWI was correlated with systolic blood pressure (slope =  + 16, p < 0.001) and GLS (slope =  −100, p < 0.001), while GCW was correlated with systolic blood pressure (slope =  + 18, p < 0.001), GLS (slope =  −101, p < 0.001), male sex (slope =  −75, p = 0.016), and LV mass (slope =  −0.93, p < 0.001). Global wasted work (GWW) was correlated with age at echo visit (slope =  −4.5, p = 0.005) and GLS (slope =  + 5.5, p < 0.001). The opposite occurred for global work efficiency (GWE; slope =  + 0.20, p = 0.011, and slope =  −0.48, p < 0.001, respectively). Principal component analysis and k-means clustering revealed 4 subphenotypes which differed in terms of etiology, afterload, and compensation stage of the disease.

    Conclusion: Non-invasive MW shows a good correlation with conventional markers of LV function and may help refine the assessment of hypertensive heart disease in children.

What is Known:

• Myocardial work (MW) is a novel parameter that incorporates non-invasive estimates of left ventricular (LV) systolic pressure into the interpretation of strain, thereby accounting for both deformation and afterload.

• Although the usefulness of MW in the assessment of myocardial function beyond conventional markers has been demonstrated in various clinical populations, data in the pediatric population with hypertension are currently lacking.

What is New:

• Compared to normal values in healthy children, global work index and global constructive work were increased in those with hypertension, while LV ejection fraction and global longitudinal strain were not impaired.

• Machine learning identified 4 subphenotypes which differed in terms of etiology, afterload, and compensation stage of the disease.

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Code availability

The code used for this study will be made available from the corresponding author upon reasonable request.

Abbreviations

AIC:

Akaike Information Criterion

ANOVA:

Analysis of variance

BSA:

Body surface area

DBP:

Diastolic blood pressure

GCW:

Global constructive work

GLS:

Global longitudinal strain

GWE:

Global work efficiency

GWI:

Global work index

GWW:

Global wasted work

IQR:

Interquartile range

LV:

Left ventricle/ventricular

LVEF:

Left ventricular ejection fraction

LVFS:

Left ventricular fractional shortening

LVM:

Left ventricular mass

LVMi:

Left ventricular mass index

MW:

Myocardial work

PCA:

Principal component analysis

SBP:

Systolic blood pressure

SD:

Standard deviation

References

  1. Saito M, Khan F, Stoklosa T, Iannaccone A, Negishi K, Marwick TH (2016) Prognostic implications of LV strain risk score in asymptomatic patients with hypertensive heart disease. JACC Cardiovasc Imaging 9:911–921

    Article  Google Scholar 

  2. Potter E, Marwick TH (2018) Assessment of left ventricular function by echocardiography: the case for routinely adding global longitudinal strain to ejection fraction. JACC Cardiovasc Imaging 11:260–274

    Article  Google Scholar 

  3. Adamo L, Perry A, Novak E, Makan M, Lindman BR, Mann DL (2017) Abnormal global longitudinal strain predicts future deterioration of left ventricular function in heart failure patients with a recovered left ventricular ejection fraction. Circ Heart Fail 10

  4. Tadic M, Sala C, Carugo S, Mancia G, Grassi G, Cuspidi C (2021) Myocardial strain in hypertension: a meta-analysis of two-dimensional speckle tracking echocardiographic studies. J Hypertens 39:2103–2112

    Article  CAS  Google Scholar 

  5. Burns AT, La Gerche A, D’Hooge J, MacIsaac AI, Prior DL (2010) Left ventricular strain and strain rate: characterization of the effect of load in human subjects. Eur J Echocardiogr 11:283–289

    Article  Google Scholar 

  6. Yingchoncharoen T, Agarwal S, Popović ZB, Marwick TH (2013) Normal ranges of left ventricular strain: a meta-analysis. J Am Soc Echocardiogr 26:185–191

    Article  Google Scholar 

  7. Russell K, Eriksen M, Aaberge L, Wilhelmsen N, Skulstad H, Remme EW, Haugaa KH, Opdahl A, Fjeld JG, Gjesdal O, Edvardsen T, Smiseth OA (2012) A novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial work. Eur Heart J 33:724–733

    Article  Google Scholar 

  8. Galli E, Leclercq C, Hubert A, Bernard A, Smiseth OA, Mabo P, Samset E, Hernandez A, Donal E (2018) Role of myocardial constructive work in the identification of responders to CRT. Eur Heart J Cardiovasc Imaging 19:1010–1018

    Article  Google Scholar 

  9. Boe E, Russell K, Eek C, Eriksen M, Remme EW, Smiseth OA, Skulstad H (2015) Non-invasive myocardial work index identifies acute coronary occlusion in patients with non-ST-segment elevation-acute coronary syndrome. Eur Heart J Cardiovasc Imaging 16:1247–1255

    Article  Google Scholar 

  10. Lustosa RP, Butcher SC, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, Kostyukevich MV, Rocha De Lorenzo A, Knuuti J, Ajmone Marsan N, Bax JJ, Delgado V (2021) Global left ventricular myocardial work efficiency and long-term prognosis in patients after ST-segment-elevation myocardial infarction. Circ Cardiovasc Imaging 14:e012072

  11. Galli E, Vitel E, Schnell F, Le Rolle V, Hubert A, Lederlin M, Donal E (2019) Myocardial constructive work is impaired in hypertrophic cardiomyopathy and predicts left ventricular fibrosis. Echocardiography 36:74–82

    Article  Google Scholar 

  12. Chan J, Edwards NFA, Khandheria BK, Shiino K, Sabapathy S, Anderson B, Chamberlain R, Scalia GM (2019) A new approach to assess myocardial work by non-invasive left ventricular pressure-strain relations in hypertension and dilated cardiomyopathy. Eur Heart J Cardiovasc Imaging 20:31–39

    Article  Google Scholar 

  13. Tadic M, Cuspidi C, Saeed S, Lazic JS, Vukomanovic V, Grassi G, Sala C, Celic V (2021) The influence of left ventricular geometry on myocardial work in essential hypertension. J Hum Hypertens

  14. Loncaric F, Marciniak M, Nunno L, Mimbrero M, Fernandes JF, Fabijanovic D, Sanchis L, Doltra A, Montserrat S, Cikes M, Lamata P, Bijnens B, Sitges M (2021) Distribution of myocardial work in arterial hypertension: insights from non-invasive left ventricular pressure-strain relations. Int J Cardiovasc Imaging 37:145–154

    Article  Google Scholar 

  15. Jaglan A, Roemer S, Perez Moreno AC, Khandheria BK (2021) Myocardial work in stage 1 and 2 hypertensive patients. Eur Heart J Cardiovasc Imaging 22:744–750

    Article  Google Scholar 

  16. Flynn JT, Falkner BE (2017) New clinical practice guideline for the management of high blood pressure in children and adolescents. Hypertension 70:683–686

    Article  CAS  Google Scholar 

  17. Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, Horton K, Ogunyankin KO, Palma RA, Velazquez EJ (2019) Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 32:1–64

    Article  Google Scholar 

  18. de Simone G, Daniels SR, Devereux RB, Meyer RA, Roman MJ, de Divitiis O, Alderman MH (1992) Left ventricular mass and body size in normotensive children and adults: assessment of allometric relations and impact of overweight. J Am Coll Cardiol 20:1251–1260

    Article  Google Scholar 

  19. Tretter JT, Pradhan S, Truong VT, Mullikin A, Mazur W, Hill GD, Redington AN, Taylor MD (2021) Non-invasive left ventricular myocardial work indices in healthy adolescents at rest. Int J Cardiovasc Imaging 37:2429–2438

    Article  Google Scholar 

  20. Bogaert J, Rademakers FE (2001) Regional nonuniformity of normal adult human left ventricle. Am J Physiol Heart Circ Physiol 280:H610-620

    Article  CAS  Google Scholar 

  21. Goh VJ, Le TT, Bryant J, Wong JI, Su B, Lee CH, Pua CJ, Sim CPY, Ang B, Aw TC, Cook SA, Chin CWL (2017) Novel index of maladaptive myocardial remodeling in hypertension. Circ Cardiovasc Imaging 10

  22. Gaudron PD, Liu D, Scholz F, Hu K, Florescu C, Herrmann S, Bijnens B, Ertl G, Stork S, Weidemann F (2016) The septal bulge–an early echocardiographic sign in hypertensive heart disease. J Am Soc Hypertens 10:70–80

    Article  Google Scholar 

  23. Sahiti F, Morbach C, Cejka V, Albert J, Eichner FA, Gelbrich G, Heuschmann PU, Stork S (2021) Left ventricular remodeling and myocardial work: results from the population-based STAAB Cohort Study. Front Cardiovasc Med 8:669335

  24. Huang J, Yang C, Yan ZN, Fan L, Ni CF (2021) Global myocardial work: a new way to detect subclinical myocardial dysfunction with normal left ventricle ejection fraction in essential hypertension patients: compared with myocardial layer-specific strain analysis. Echocardiography 38:850–860

    Article  Google Scholar 

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Acknowledgements

J. Van den Eynde was supported by the Belgian American Educational Foundation.

Author information

Author notes

  1. Junzhen Zhan and Jef Van den Eynde are both first authors and contributed equally to this study.

Authors and Affiliations

  1. Department of Pediatrics, The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins School of Medicine, Johns Hopkins University, 1800 Orleans St, Baltimore, MD, M231521287, USA

    Junzhen Zhan, Jef Van den Eynde, Ege Ozdemir, Rita Long, Allison Hays, David A. Danford, Benjamin Barnes & Shelby Kutty

  2. Department of Cardiovascular Sciences, KU Leuven & Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium

    Jef Van den Eynde

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  1. Junzhen Zhan
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Contributions

Mr. Zhan, Ms. Long and Mr. Van den Eynde conceptualized and designed the study, collected data, carried out the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript. Drs. Ozdemir, Hays, Danford, Barnes, and Kutty conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Shelby Kutty.

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Ethics approval

This study conforms to the ethical guidelines of the 1964 Declaration of Helsinki as reflected by a priory approval by our institution’s Human Research and Ethic Committee.

Consent to participate

Individual informed consent was waived by the Committee given the retrospective nature of this study.

Consent for publication

Individual informed consent was waived by the Committee given the retrospective nature of this study.

Conflict of interests

S. Kutty is consultant for GE Healthcare. All other authors declare that they have no competing interests. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Communicated by Peter de Winter

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Zhan, J., Van den Eynde, J., Ozdemir, E. et al. Left ventricular myocardial work indices in pediatric hypertension: correlations with conventional echocardiographic assessment and subphenotyping. Eur J Pediatr 181, 2643–2654 (2022). https://doi.org/10.1007/s00431-022-04447-2

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  • DOI: https://doi.org/10.1007/s00431-022-04447-2

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