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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
AFRICA
231
Left ventricular twist before and after haemodialysis: an
analysis using speckle-tracking echocardiography
Anthony Yip, Saraladevi Naicker, Ferande Peters, Elena Libhaber, Nirvathi Maharaj, Mduduzi
Mashabane, Mohammed Rafique Essop
Abstract
Background:
The most commonly used parameter of cardiac
function in the chronic kidney disease (CKD) patient is ejec-
tion fraction (EF), using transthoracic echocardiography
(TTE). EF is a highly load-dependent measurement, which
varies considerably in CKD patients undergoing haemodi-
alysis. The aim of this pilot study was to evaluate a novel
measure of myocardial function, left ventricular twist, which
is defined as the ‘wringing action of the heart’, using speckle-
tracking echocardiography in CKD patients before and after
haemodialysis.
Methods:
Twenty-six patients were recruited from the
Chris Hani Baragwanath Hospital haemodialysis unit.
TTE was performed according to a detailed standardised
protocol before and after a single haemodialysis session.
Echocardiography was also performed on 26 age- and gender-
matched healthy subjects.
Results:
The mean age of the control versus CKD group was
44
±
11.4 and 43.4
±
12.2 years, respectively; 46% were male.
Apical rotation was diminished in CKD patients comparedto
controls (4.83
±
2.3 vs 6.31
±
1.6 °;
p
=
0.01) despite no differ-
ence in EF (61.7
±
6.2 vs 58.8
±
13;
p
=
0.68). There were no
differences in the components of twist: apical rotation, basal
rotation and net twist before and after dialysis, despite an
increase in EF (58.8
±
13.7 vs 61.2
±
13.6;
p
=
0.02) following
dialysis.
Conclusion:
Unlike EF, the components of twist are relatively
independent of changes in haemodynamic load seen during
dialysis. The decrease in apical rotation may represent an
early marker of cardiac pathology in the late-stage CKD
patient.
Keywords:
left ventricular twist, speckle-tracking echocardiogra-
phy, chronic kidney disease, dialysis
Submitted 5/12/17, accepted 11/3/18
Published online 20/4/18
Cardiovasc J Afr
2018;
29
: 231–236
www.cvja.co.zaDOI: 10.5830/CVJA-2018-019
Cardiovascular pathology accounts for half of the deaths in
chronic kidney disease (CKD) patients.
1,2
Causes of increased
mortality rates include sudden death from arrhythmias,
heart failure and ischaemic heart disease.
1,3-6
Transthoracic
echocardiography (TTE) is the most commonly used imaging
modality to assess cardiac function in patients with CKD.
However, the most widely used echocardiographic measurement
is ejection fraction (EF), which is load dependent and varies
considerably with the volume shifts experienced during
haemodialysis.
7
Cardio-renal specialists have explored other measures to
evaluate cardiac function in CKD, using myocardial deformation
or strain, which more accurately describes ventricular movement
during systolic and diastolic function. It consists of longitudinal,
radial and circumferential strain, and ventricular twist.
8
Tissue
Doppler imaging was previously used to measure strain but
required correct alignment of the Doppler signal to the angle
of the myocardial fibres.
8
In recent years, speckle-tracking
echocardiography (STE) has emerged as a potentially more
accurate technique to measure myocardial deformation.
9
STE is an echocardiographic modality based on the accurate
tracking of groups of pixels called ‘speckles’ throughout the
cardiac cycle.
9
Using this technique, parameters reflecting
myocardial deformation, such as global longitudinal strain,
radial and circumferential strain, and left ventricular twist can
be assessed. The initial studies conducted in chronic kidney
disease patients using speckle tracking to evaluate myocardial
function demonstrated a reduction in longitudinal strain but
not in circumferential or radial strain and did not evaluate left
ventricular twist.
10-12
Left ventricular (LV) twist is described as a ‘wringing’
action of the heart. It represents a clockwise rotation of the
base and a counter-clockwise rotation of the apex during
systole.
13
Using STE, LV twist
14
has been validated against
Division of Cardiology, Chris Hani Baragwanath Hospital,
Johannesburg, South Africa
Anthony Yip, MB BCh, MSc, FCP (SA), MRCP (UK), Cert
Cardiology (SA)
Ferande Peters, MB BCh, FCP, FACC, FESC
Elena Libhaber, PhD
Nirvathi Maharaj, MB BCh, FCP, PhD
Mohammed Rafique Essop, MB BCh, FCP, FRCP, FACC
Department of Internal Medicine, Charlotte Maxeke
Johannesburg Academic Hospital, South Africa
Saraladevi Naicker, MB BCh PhD, FRCP
Division of Nephrology, Chris Hani Baragwanath Hospital,
Johannesburg, South Africa
Mduduzi Mashabane, MB BCh, FCP
Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, South Africa
Anthony Yip, MB BCh, MSc, FCP (SA), MRCP (UK), Cert
Cardiology (SA),
dranthonyyip@gmail.comSaraladevi Naicker, MB BCh, PhD, FRCP
Ferande Peters, MB BCh, FCP, FACC, FESC
Elena Libhaber, PhD
Nirvathi Maharaj, MB BCh, FCP, PhD
Mduduzi Mashabane, MB BCh, FCP
Mohammed Rafique Essop, MB BCh, FCP, FRCP, FACC