Abstracts of medical phd thesis: research on myocardial defprmation by speckle tracking echocardiography in patients with chronic kidney disease

Chronic kidney disease with and without dialysis, of particular significance in patients with normal left ventricular ejection fraction.. From the above reasons, we carried out the proje

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCE

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NGUYEN DINH CHUC

RESEARCH ON MYOCARDIAL DEFPRMATION

BY SPECKLE TRACKING ECHOCARDIOGRAPHY IN PATIENTS

WITH CHRONIC KIDNEY DISEASE

Spe ciality: C ardiology Code : 62.72.01.41

ABSTRAC TS O F MEDICAL PHD THESIS

HA NO I - 2021

This Thesis was done in

108 Institute of Clinical Me dical and Pharmaceutical Sciences

Supe rvisor:

1 Ass Prof PhD Pham T hai Giang

2 Ass Prof PhD Pham Nguyen Son

The thesis can be found at:

1 Nat ional Library of Viet nam

2 Library of Institute of Clinical Medical and Pharmaceutical Sciences

3 Central Institute for Medical Sciences Information and T echnology

INTRO DUC TIO N

Chronic kidney disease (CKD) is a disease with many complications involving many different organ systems, depending on the stage of chronic kidney disease, the complications encountered can vary in number as well as level severity of the disease Anemia, bone and mineral metabolism disorders, peripheral vascular disease, neurological disease, mental disorders, especially cardiovascular complications are common complicat ions in patients with CKD In the world, there are many authors using speckle tracking echocardiography to assess heart function in patients with hypertension, diabetes and other diseases and are used in pat ients Chronic kidney disease with and without dialysis, of particular significance in patients with normal left ventricular ejection fraction

In Viet nam, there are no works using speckle tracking echocardiography in patients with chronic kidney disease From the

above reasons, we carried out the project "Research on Myocardial

de formation by spe ckle tracking e chocardiography in patients

wi th chronic kidne y disease" with two objects:

1- Survey on the clinical, subclinical and m yocardial deform ation in chronic kidney patients with a norm al left ventricular ejection fraction

2- Investigate the relationship between the param eters of speckle tracking echocardiographic with som e clinical and subclinical features in patients with chronic kidney disease with a norm al left ventricular ejection fraction

TH E N EW CONTRIBU TIO NS O F TH E TH ESIS

This is the first study in Viet nam with a large number of study subject s, using speckle t racking echocardiography to evaluate in detail left ventricular function along the longitudinal, radial and circumference direction as well as left ventricular rotation, twist, and untwist in chronic kidney disease with normal left ventricular ejection fraction

Myocardial deformation: GLS decreased 37.9%, MSP decreased: 16.3%, GLSRe decreased: 13.7%, MDP decreased: 11.1% The rotation and twist of left ventricular increased more than the control group without any difference The systolic and diastolic parameters decrease with the grade of disease, positively correlated with the GFR CKD with increased blood pressure, diabetes with decreased deformation index, the rate of impaired systolic function, diastolic increased more in the group of chronic kidney disease without diabetes, increased blood pressure CKD with left ventricular hypertrophy: Myocardial deformation index decreases, the rate of systolic and diastolic dysfunct ion increases Multivariable analysise: Hypertension is an independent predictor of decreased systolic and diastolic function in the stages of CKD

Research results show that in chronic kidney patients with a normal left ventricular ejection fraction, there is a decrease in both systolic and diastolic function Although the rate of reduct ion is not high, it is an early change This is the meaningful contribution of the

topic to the major

TH E LAYO UT O F TH E TH ESIS

The thesis with 136 pages including: Introduct ion (2 pages), literature review (34 pages), material and methods (27 pages), results (36 pages), discussion (34 pages), conclusion (2 pages), request (1

page) T he thesis has 41 tables, 8 charts, 12 pictures, 3 diagrams Using 174 references including 20 documents in Viet namese, 154 documents in English

Chapte r 1 LITERA TUR E R EVIEW 1.1 Chronic kidney disease

1.1.1 Conce pts and te rminology

Chronic Kidne y Disease (C KD): In 2002, the American

Nat ional Nephrology Association and the Kidney Disease Consequence Assessment Council (NKF / KDOQI) released the first practical guidance on chronic kidney disease By 2012, the International Nephrology Associat ion (ISN) issued guidance from the Global Ki dney Disease Consequence Improvement Group (KDIGO) that complements the 2002 Renal Disease Practice Guidelines is defined as having one of the following 2 standards:

(1) Renal damage lasting for ≥ 3 months leads to changes in kidney structure and function These disorders may or may not reduce glomerular filtration rate (GFR), manifest in histopathological lesions, changes in blood chemist ry, urine or renal morphology through diagnostic imaging

(2) Glomerular Filtration Rate (GFR) decreased by <60 ml / min / 1.73 m2 cont inuously for more than 3 months, with or without accompanying renal structural damage

Chronic Renal Failure (C RF): A condition of chronic

irreversible impairment of kidney function, over a period of months and years, due to irreversible damage to the number and function of

nephrons Chronic renal failure is defined as GFR <60 ml / min lasting

3 months or more

End Stage Ren al Disease (ESRD): is defined as an irreversible

impairment of kidney function, severe enough to cause death in the absence of dialysis or a kidney t ransplant End-stage chronic kidney disease corresponding to stage 5 chronic kidney disease as classified

by NKF / KDOQI 2002, patients with glomerular filtration rate <15

ml / min / 1.73m2, or people in need of kidney replacement therapy regardless of glomerular filtration rate

1.1.2 Stages of chronic kidney díease

Table 1.1 Stages of chronic kidne y disease (According to

NFK-KDOQI 2002)

1 Kidney damage with normal or GFR ≥ 90

2 Kidney damage with mild GFR 60 - 90

1.2 Spe ckle tracking echocardiography

Strain: Strain represents a measure that evaluates the degree of

deformation of the analyzed segment in relation to its initial dimensions It is expressed as a percentage The st rain equat ion (ε) is

as follows: ε = (L - L0)/L0, where L is the length of t he object after deformation, and L0 is the basal length of t he object By convention, depending on the direction, a lengthening or thickening deformation is given a positive value, whereas a shortening or thinning deformation

is given a negat ive one

Strain Rate : The strain rate (ε’) represents the myocardial

deformation rate It is expressed as s-1; in other words, if the same strain value is reached in half the time, the strain rate value will be doubled Experimental studies have shown t hat the strain rate is less dependent on LV load variations than strain However, because the strain rate signal is noisier and less reproducible, most clinical st udies still use st rain measurements

Longitudinal Strain: represents myocardial deformat ion

directed from the base to the apex During systole, ventricular myocardial fibers shorten with a translational movement from the base

to the apex; the consequent reduct ion of the distance between single kernels is represented by negative t rend curves Through longitudinal strain analyses in 4-chamber, 2-chamber, and apical long-axis views, both regional and global strain values (global longitudinal strain) can

be obtained Global longitudinal strain recently has been validated as a quantitative index for global LV funct ion

deformation, ie, toward the center of the LV cavity, and thus indicat es the LV thickening and thinning motion during the cardiac cycle Consequent ly, during systole, given the progressive radial propulsion

of single kernels, radial strain values are represented by positive curves Radial strain values are obtained by speckle-tracking echocardiographic analysis of both basal and apical LV short-axis views

Ci rcumferen tial Strain: represents LV myocardial fiber

shortening along the circular perimeter observed on a short-axis view Consequent ly, during systole, for circumferential speckle-to-speckle distance reduct ion, circumferential strain measurements are

represented by negative curves As for longitudinal strain, it is possible to obtain a global circumferential strain value

Twisting and Torsion: Until recently, the evaluation of LV

twisting has been possible only through MRI, but currently, tracking echocardiography has emerged as a new promising tool for

speckle-LV twisting analysis Left ventricular twisting is a component of the normal LV systolic contraction that arises from the reciprocal rotation

of the LV apex and base during systole and constitutes an important aspect of cardiac biomechanics Intrinsic to its physiologic characteristics, the quantification of LV twisting by speckle-tracking echocardiography is made possible by analyzing the reciprocal rotation of the LV apex and base during systole Left ventricular twisting is then calculated as the net difference in mean rotation between the apical and basal levels Left ventricular torsion is defined

as LV t wisting normalized with the base-to-apex distance

Untwisting: Growing att ention has been also recently given to

the role of untwisting in diastolic LV filling mechanics Untwisting velocity is thought to be a critical initial manifestation of active relaxation, which makes this measurement relevant for investigat ing diastole and, mainly, isovolumic relaxation because it seems to be less

dependent on load compared to other diastolic parameters

Charte r 2 MATERIAL AND M ETHO DS 2.1 Study population

Study on 300 subject s, divided into 2 groups:

- C KD group: Including 190 patients diagnosed with chronic

kidney disease from stage 1 to stage 5, without dialysis

- C ontrol group: Including 110 normal people

2.1.1 The inclusion crite ria

- Patient was first diagnosed or diagnosed with CKD

- A left ventricular ejection fraction EF ≥ 50%

- Agree to participate in research

* C ontrol group

- People who come for medical examination at the Hospital

- Including both men and women

- Age from 18 and over and age equivalent to the group of diseases

- No history of cardiovascular disease

- History and current no kidney disease

- Conventional Echocardiography, normal electrocardiogram

- Subject s to cooperate, voluntarily participate in research

2.1.2 The exclusion crite ria

* C KD group

- Patients with cardiovascular disease before kidney disease

- Suffering from acute diseases such as pneumonia, viral infection

during the study period Severe chronic kidney disease requires emergency treatment

- Suspect ed of having a surgical condition at the time of research

- Patients with malignancies accompanied by kidney disease

- Have a cognitive or psychiatric disorder

- No research cooperation

- T he quality of conventional echocardiography is not guaranteed

* C ontrol group

- Have had treatment for cardiovascular disease

- Have kidney disease, cardiovascular disease, diabetes mellitus, hypertension, pulmonary disease

- People who are pregnant or have had a baby within the previous 6 months

- Have a cognitive or psychiatric disorder

- Refuse to participate in the study

- T he quality of conventional echocardiography is not guaranteed

2.2 Methods

2.2.1.Me thod: Descriptive cross-sectional study, comparing

disease-control groups with analysis

2.2.2 Sample size: n = 138

2.2.3 Time and place:

- T ime: From January 2015 to November 2018

- Location: At Phu Tho Provincial General Hospital

2.2.4 Ste ps to study

2.2.2.1 The control

* Ask medical history: history of kidney disease, urinary disease, hypertension, gastroduodenal disease History of blood loss, trauma, surgery History of blood donation, blood transfusion

* Clinical examination: Whole body: edema, skin and mucosa, measuring blood pressure, heart rate, height, weight, determine BMI

of the subject See the specialists

* The laboratory tests

2.2.2.2 CKD group

* Questioning: Exploiting a history of some diseases such as urinary kidney disease, blood disease and other chronic diseases (chronic hepatitis, tuberculosis, chronic heart disease .) History of alcohol, tobacco, and drug addict ion History of chronic kidney disease conservation therapy, anemia treatment, iron supplementation

* Examination: Subject s are comprehensively examined by doctors including: Perception, height, weight determine the patient's BMI Symptoms: edema, anemia, Pay special attention to some manifestations such as: acute infections, skin diseases, digestive organs, cardiovascular system, respiratory system, t hyroid, peripheral lymph nodes , spleen Signs or symptoms of acute blood loss such as black stools, vomiting blood, coughing up blood, nosebleeds, bleeding, hematuria Blood pressure measurement, status determination patient's blood pressure

* Do subclinical t ests

2.2.5 Echocardiography

* Timing of echocardiography: The patients are done in t he first 2

days of hospital admission The control group received ultrasound after being selected for the study

* Ech ocardiography e quipment: GE's Vivid E9 ultrasound system

(General Electric), manufactured in 2013, with probe M4S (frequency: 1,5 - 4, 0 MHz) Software EchoPAC version 113 of GE

* Spe ckle tracking echocardiography

 Image Acquisition

Images are obtained and recorded by using conventional dimensional gray scale echocardiography during breat h holding with stable electrocardiographic t racing Care must be taken to obtain t rue apical and short-axis images using standard anatomic landmarks in each view and to avoid foreshortening of the analyzed myocardial structure, thus allowing a more reliable delineation of the endocardial border T he optimal frame rate for the 2-dimensional image acquisition is set between 40 - 90 frames per second It is recommended to begin with speckle-tracking echocardiographic analysis of an apical long-axis chamber view to select the frame corresponding to the aortic valve closure, which is a useful reference for the subsequent analysis Apical 4- and 2- chamber view acquisitions are necessary for longitudinal strain Short-axis recordings, useful for radial strain, circumferential strain, and rotation analysis, T o standardize acquisitions, the basal plane is identified as the plane including the tips of the mitral leaflets, whereas t he apical plane is identified distally to the papillary muscles as the plane just proximal to the level at which LV cavity end-systolic obliteration occurs Particular attention should be paid to making the LV cross section as circular as possible

2- Calculate deformation parameters

Dat a are extracted to Excel 2010 to calculate:

 Longitudinal strain and strain rate : Global left ventricular

systolic longitudinal strain (GLS) is the mean value of the longitudinal

strain of 17 segments in all 3 views from the apex (3 chambers, 4 chambers, 2 chambers), are calculated automatically according to the bull's eye map and have negative values, the unit of measure is (%) The Global left ventricular longitudinal early diastolic strain rate (GLSRe), the Global left ventricular longitudinal late diastolic strain rate (GLSRa) is t he mean value of the corresponding strain rate of the myocardial segment (18 segments) in all 3 views from the tip (3 chambers, 4 chambers, 2 chambers) GLSRe, GLSRa are positive, the unit of measure is (s-1)

 Circumference strain and strain rate : The Global Left

ventricular systolic circumferencial strain (GCS), the Global left ventricular early diastolic circumferencial strain rate (GCSRe), the Global left ventricular late diastolic circumferencial strain (GCSRa) is the mean value of strain and strain rate of the 6 myocardial segments

at the short axis cross sect ion in the papillary muscle The GCS index

is negative, the unit of measure is (%), the GCSRe, GCSRa index is positive, and the unit of measure is (s-1)

 Radial strain and strain rate : The Global left ventricular systolic

radial strain (GRS), the Global left ventricular early diastolic radial strain rate (GRSRe), the Global left ventricular late diastolic radial strain rate (GRSRa) is t he mean value of the st rain and the strain rate

of the 6 myocardial segments in the short axis views in the papillary muscle T he GRS index is positive, the unit of measure is (%), the GRSRe, GRSRa is negative, and the unit of measure is (s-1)

 Myocardial function pe rformance:

- Myocardial systolic performance (MSP): MSP = GRS - ( GLR + GCS) / 3, positive value, calculation unit is (%)

- Myocardial systolic performance (MDP): MDP = (GLSRe + GCSRe) - GRSRe / 3, positive values, unit (s-1)