Importance of three-dimensional speckle tracking in the assessment of left atrial and ventricular dysfunction in patients with myotonic dystrophy type 1 | Revista Portuguesa de Cardiologia (English edition)

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"paginaInicial" => "333" "paginaFinal" => "338" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Henrique Guedes, Nuno Moreno, Rui Pontes dos Santos, Leonor Marques, Daniel Seabra, Adriana Pereira, Aurora Andrade, Paula Pinto" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Henrique" "apellidos" => "Guedes" "email" => array:1 [ 0 => "henrique.jp.guedes@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Nuno" "apellidos" => "Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Rui Pontes" "apellidos" => "dos Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Leonor" "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => 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] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Importância da tecnologia 3D speckle tracking na avaliação da disfunção auricular e ventricular esquerda em doentes com distrofia miotónica do tipo 1" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1058 "Ancho" => 3167 "Tamanyo" => 467056 ] ] "descripcion" => array:1 [ "en" => "(1) LA LS (16 segments) obtained by means of 3D wall-motion tracking technology; during systole, the LA is stretched and LS increases, reaching a positive peak at the end of systole, corresponding to the end of atrial filling; during diastole, LS decreases to a plateau; (2) the 3D echocardiographic dataset is displayed in apical 4-chamber (A) and 2-chamber (B) views and three short-axis views in the basal (C3), mid-ventricular (C5), and superior (C7) regions, respectively. 3D LV cast (D) and GLS (E) are also presented; (3) LV GLS (16 segments) obtained by 3D wall-motion tracking technology. 3D: three-dimensional; GLS: global longitudinal strain; LA: left atrial; LS: longitudinal strain; LV: left ventricular." ] ] ] "textoCompleto" => "IntroductionMyotonic dystrophy type 1 (DM1) is a multisystem neuromuscular disease with autosomal dominant transmission that affects smooth and skeletal muscle.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> About 30% of mortality in adults with DM1 is due to cardiac involvement.<a class="elsevierStyleCrossRef" href="#bib0160">2</a> Arrhythmias, conduction system disturbances and myocardial fibrosis are the most frequent changes.<a class="elsevierStyleCrossRef" href="#bib0165">3</a> Detection of early markers may facilitate the identification of patients at risk of developing cardiac complications.Left atrial (LA) function is a complex process that includes receiving pulmonary venous return during left ventricular (LV) systole, transfer of blood passively into the left ventricle in early diastole, and active contraction in late diastole.<a class="elsevierStyleCrossRefs" href="#bib0170">4,5</a>In a comparison of volumetric real-time three-dimensional (3D) echocardiography and 3D speckle tracking echocardiography (3D-STE), the two methods were found to provide comparable and reproducible measurements, and to be interchangeable for quantification of LA dimensions and functional properties.<a class="elsevierStyleCrossRef" href="#bib0180">6</a>Echocardiographic myocardial tracking systems using 3D-STE have provided new insights into ventricular function and atrial mechanics, with many potential clinical applications.<a class="elsevierStyleCrossRefs" href="#bib0185">7,8</a> 3D formats more closely represent reality than two-dimensional (2D) formats, not only in the assessment of LV function but also in the diagnosis of valvular or myocardial disease. Determination of LV strain by 2D speckle tracking echocardiography (2D-STE) enables identification of changes in LV systolic function in patients with DM1.<a class="elsevierStyleCrossRefs" href="#bib0195">9,10</a> However, the applicability of 3D-STE in these patients is not fully established and the available data are scarce.The aim of this study was to identify early changes in LA mechanics and LV systolic function in patients with DM1 using 3D-STE.MethodsStudy populationThis was a single-center observational study. After written informed consent was obtained, all 25 patients with DM1 followed in our center and 25 healthy volunteers (control group) were consecutively selected. All DM1 patients had genetic confirmation of the diagnosis and had no known cardiovascular disease, but had signs of neuromuscular involvement (myopathic facies, myotonia or gait abnormalities).Echocardiographic protocolThe equipment used was an Artida™ scanner (Toshiba Medical Systems). The echocardiographic study began with a 2D echocardiogram following the standard protocol used in our department, measurements being made in accordance with the current guidelines of the American Society of Echocardiography,<a class="elsevierStyleCrossRef" href="#bib0205">11</a> using a PST-30SBT 1-5 MHz phased-array transducer.For 3D echocardiography a PST-25SX 1-4 MHz phased-array matrix transducer was used. Images were acquired in apical 4-chamber and 2-chamber views for both LA and LV assessment. The data set is displayed in five planes: apical 4-chamber, apical 2-chamber, and three short-axis planes: apical region, middle segments and basal portion. The software is semiautomatic: it divides the left atrium and ventricle into 16 segments automatically, and after the markers have been selected, the system performs wall motion tracking analysis, enabling analysis of the study variables. The reference values for this equipment for 3D LV strain are: global longitudinal strain (GLS), -15.9%±2.4; global circumferential strain (GCS), -30.6%±2.6; global radial strain (GRS), 35.6%±10.3; area tracking (AT), -42%±2.4.<a class="elsevierStyleCrossRef" href="#bib0210">12</a>Variables analyzedAll patients were assessed for the presence of neuromuscular manifestations (particularly myotonia, muscular weakness and modified Rankin Scale [mRS] score) and of sleep, respiratory and gastrointestinal disorders, as established in the various consultations in which the patients were followed. Regarding electrocardiographic variables, rhythm, PR interval duration and QRS duration were recorded. On 2D echocardiography, LA size and volume, LV size and diastolic function and tricuspid annular plane systolic excursion (TAPSE) were determined, while LA emptying fraction and end-systolic and end-diastolic volumes and LV ejection fraction (LVEF), end-systolic and end-diastolic volumes and mass were determined by 3D echocardiography. LA deformation was determined by measuring longitudinal strain (LS) and AT, while LV deformation was determined by measuring GLS, GCS, GRS, AT and twist by 3D-STE (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Interobserver and intraobserver variabilityData sets from the wall motion tracking results were analyzed at different times by two independent observers. The same images were also analyzed on different days by one of these observers. Blinding was ensured by analyzing the studies on different days by the same observer in a randomized order and by blinding the results between the two independent observers.Statistical analysisStatistical analysis was carried out using SPSS version 22.0. Variables were analyzed for normality of distribution using the Kolmogorov-Smirnov test. Quantitative data are expressed as mean ± SD and qualitative data as percentages. Comparisons were assessed using paired-samples t tests for quantitative data. Cox regression analysis was performed for multivariate adjustment. Correlations were assessed by simple linear regression analysis. Interobserver and intraobserver reproducibility were assessed by means of the intraclass correlation coefficient (ICC). Differences were considered statistically significant with a p-value <0.05.ResultsClinical and electrocardiographic dataMean age was 36.9±16.0 years in DM1 patients (40.3±12.4 years in controls). All patients had myotonia and 11 had muscle weakness, with a mean mRS of 1.25. Ten patients had PR interval >200 ms and seven had QRS > 120 ms. Clinical and electrocardiographic data are displayed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Echocardiographic dataTwo-dimensional echocardiography did not identify differences between the groups in left cardiac chamber size or in parameters of diastolic function (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Also, three-dimensional echocardiography did not show significant differences in LVEF (62.88%±3.27 vs. 65.64%±6.65, p=0.80), LV mass index (91.83 g/m2±21.51 vs. 85.80 g/m2±15.73, p=0.267), LV end-systolic (24.42 ml/m2±12.54 vs. 25.16 ml/m2±9.87, p=0.819) or end-diastolic volume (55.85 ml/m2±23.14 vs. 54.53 ml/m2±15.05, p=0.814), or in LA emptying fraction (42.13%±8.53 vs. 46.37%±11.21, p=0.139) or indexed end-systolic (13.12 ml/m2±4.35 vs. 13.12 ml/m2±3.50, p=0.569) and end-diastolic volumes (22.70 ml/m2±4.75 vs. 23.60 ml/m2±6.19, p=0.677).The percentage of segments analyzed with 3D-STE was 86.25%.Patients with DM1 showed significantly lower LA LS than controls (22.85%±5.06 vs. 26.82%±5.15; p=0.008), which was not the case with AT (21.77%±17.49 vs. 25.41%±12.94; p=0.412). There was a significant correlation between age and LA LS in patients with DM1 (r=-0.771; p<0.001; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>LV GLS was significantly lower in patients with DM1 than in controls (-13.55%±1.82 vs. -16.11%±1.33; p<0.001), which was not the case for GCS (-25.81%±7.57 vs. -26.11%±5.92; p=0.879), GRS (26.36%±11.61 vs. 32.43%±10.50; p=0.058), AT (-35.58%±9.02 vs. -39.27%±5.81; p=0.092) or twist (4.80±2.59 vs. 4.79±2.83, p=0.992). No correlation was found between PR interval (r=0.028; p=0.906), QRS (r=0.310; p=0.183) or 3D LV mass index (r=0.368; p=0.077) and LV GLS in DM1 patients (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).Multivariate adjustment confirmed that LA LS and LV GLS remained statistically significant (p=0.026 and p<0.001, respectively).Interobserver and intraobserver agreement for strain measurements was good. The ICCs are presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionThe assessment of myocardial deformation has been proposed as an early marker of subclinical dysfunction in DM1 patients.<a class="elsevierStyleCrossRef" href="#bib0160">2</a> The present study is, to our knowledge, the first to identify changes in both LA and LV strain measured by 3D-STE in these patients.LA mechanics is considered an important clinical variable and its importance has been demonstrated in a number of conditions.<a class="elsevierStyleCrossRefs" href="#bib0215">13–19</a> LA strain curves display the physiology of atrial function. The left atrium has four basic functions: phase 1, reservoir function (collection of pulmonary venous flow during LV systole); phase 2, conduit function (passage of blood to the left ventricle during early diastole); phase 3, active contractile pump function; and phase 4, suction force.<a class="elsevierStyleCrossRef" href="#bib0250">20</a> During the reservoir phase, the left atrium is stretched, and consequently longitudinal atrial strain increases, reaching a positive peak at the end of atrial filling. After the atrium empties, LA strain decreases to a plateau, corresponding to LA diastasis, and then continues to decrease during the LA contraction phase (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).In our study, a significant negative correlation was observed between age and LA LS in patients with DM1, which did not occur with the controls, suggesting a faster decrease in LA LS in these patients.In DM1 patients, 2D-STE is able to identify changes in LS of the right atrium, which correlate with low-voltage areas on electrophysiological study.<a class="elsevierStyleCrossRef" href="#bib0255">21</a> However, LA mechanics has been little studied and validated in these patients, so it is difficult to draw definite conclusions about these findings. We expect that with future larger studies, these changes may prove to be important for early diagnosis and therapeutic decision-making.Studies with 2D echocardiography are consistent in demonstrating decreased LV GLS in these patients,<a class="elsevierStyleCrossRefs" href="#bib0195">9,22</a> as well as changes in GCS.<a class="elsevierStyleCrossRef" href="#bib0195">9</a> In our study, we found significant differences only in GLS, which may mean that these fibers are affected early in the progression of the disease, subsequently being replaced by fibrosis, as demonstrated in previous studies<a class="elsevierStyleCrossRef" href="#bib0265">23</a> and other cardiomyopathies, such as hypertrophic cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0270">24</a> The presence of myocardial fibrosis in these patients has been documented by a cardiovascular magnetic resonance study,<a class="elsevierStyleCrossRef" href="#bib0265">23</a> in which myocardial fibrosis was found in 40% of patients and was not related to changes on electrocardiogram, Holter or echocardiogram. This suggests that assessment of myocardial fibrosis by cardiac magnetic resonance may be a useful tool in the assessment of these patients, since myocardial fibrosis may be the substrate for ventricular arrhythmias. Also, high levels of transforming growth factor beta 1, a sensitive marker of fibrosis, have been reported in patients with DM1, indicating a higher risk of arrhythmic events and sudden death.<a class="elsevierStyleCrossRef" href="#bib0275">25</a>Previous studies have shown the usefulness of subclinical detection of cardiac involvement in DM1. In one study of 36 DM1 patients, serial Holter monitoring resulted in pacemaker implantation in 11 patients,<a class="elsevierStyleCrossRef" href="#bib0280">26</a> and implantable loop recorders have been used in small studies of asymptomatic patients, leading to the detection of ventricular arrhythmias and device implantation in four out of seven patients.<a class="elsevierStyleCrossRefs" href="#bib0285">27,28</a> A recently published study demonstrated the prognostic value of LV GLS in patients with asymptomatic DM1, concluding that GLS constitutes a strong predictor of cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0295">29</a>3D wall motion tracking uses a box template to detect speckle motion in 3D. The structures are captured in a full volume and do not move out of plane like in 2D. 3D-STE has also been shown to provide a faster and more complete assessment than 2D-STE, overcoming some of the shortcomings of previous techniques by reducing the intraobserver and interobserver variability inherent in 2D measures and avoiding the angle dependence of strain and strain-rate measures obtained on Doppler tissue imaging.<a class="elsevierStyleCrossRef" href="#bib0185">7</a> Nesser et al.<a class="elsevierStyleCrossRef" href="#bib0300">30</a> assessed the accuracy of measuring LV volumes by means of 3D-STE side by side with 2D-STE using cardiac magnetic resonance as a reference. They observed that measurements by 3D-STE showed higher correlation with cardiac magnetic resonance, smaller biases and narrower limits of agreement. 3D-STE is emerging as a useful tool for a more comprehensive assessment of ventricular function and atrial mechanics and may be valuable in a general and systematic approach to these patients, bearing in mind its possible prognostic impact.This study has some limitations. One is the small number of patients (total 25), which is in line with the rarity of the disease (estimated prevalence of about 1/10000) and previous studies performed in patients with this condition. It also has the inherent limitations of an observational study and, as pointed out above, the clinical impact of LA deformation changes are still not well understood. Regarding image acquisition, a major limitation for current 3D-STE systems is their relatively low temporal resolution, with typical frame rates of 20-25 volumes/s, and sequential volume acquisition, which is vulnerable to motion artifacts if the patient is unable to cooperate. The software used continues to improve but is not fully validated for the study of the left atrium.ConclusionLA LS and LV GLS are significantly decreased in patients with DM1. These results may reflect a subclinical and early marker of myocardial dysfunction in these patients. Studies with 3D-STE can detect changes in myocardial function that may contribute to the assessment and follow-up of these patients. Future prospective studies may open new perspectives on the clinical relevance of these markers.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1031684" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec988796" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1031683" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec988797" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Echocardiographic protocol" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Variables analyzed" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Interobserver and intraobserver variability" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical and electrocardiographic data" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Echocardiographic data" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack348396" "titulo" => "Acknowledgment" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-06-25" "fechaAceptado" => "2017-10-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec988796" "palabras" => array:4 [ 0 => "Myotonic dystrophy" 1 => "Three-dimensional echocardiography" 2 => "Three-dimensional speckle tracking" 3 => "Strain" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec988797" "palabras" => array:4 [ 0 => "Distrofia miotónica" 1 => "Ecocardiografia 3D" 2 => "3D speckle tracking" 3 => "Strain" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and AimMyotonic dystrophy type 1 (DM1) is a multisystem disease in which cardiac involvement is common. The aim of this study was to identify early changes in left atrial (LA) mechanics and left ventricular (LV) systolic function in patients with myotonic dystrophy type 1 using three-dimensional (3D) speckle tracking echocardiography (3D-STE). MethodsThis observational study included 25 patients with DM1 and 25 healthy volunteers. We assessed LA and LV global strain parameters using 3D-STE. ResultsPatients with DM1 showed significantly lower longitudinal LA strain (22.85%±5.06 vs. 26.82%±5.15; p=0.008 in univariate analysis and p=0.026 in multivariate analysis) and global LV longitudinal strain (-13.55%±1.82 vs. -16.11%±1.33; p<0.001 in univariate analysis and p<0.001 in multivariate analysis), which was not observed with LA area tracking (p=0.412) or LV global circumferential strain (p=0.879), global radial strain (p=0.058), area tracking (p=0.092) or twist (p=0.992). ConclusionLA and LV global longitudinal strain is significantly decreased in patients with DM1, which may be an early marker of subclinical dysfunction in these patients." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosA distrofia miotónica do tipo 1 é uma doença multissistémica com o envolvimento cardíaco a ser comum. O objetivo deste estudo foi identificar alterações precoces no strain da aurícula esquerda e função sistólica do ventrículo esquerdo em doentes com distrofia miotónica tipo 1, com o uso da tecnologia 3D speckle tracking. MétodosEstudo observacional, que incluiu 25 doentes com distrofia miotónica do tipo 1 e 25 voluntários saudáveis. Foram avaliados os parâmetros de deformação global da aurícula esquerda e do ventrículo com o uso de 3D speckle tracking. ResultadosOs doentes com distrofia miotónica do tipo 1 apresentaram strain longitudinal da aurícula esquerda (22,85%±5,06 versus 26,82%±5,15; p=0,008 na análise univariada e p=0,026 na análise multivariada) e strain global longitudinal do ventrículo esquerdo (-13,55%±1,82 versus -16,11%±1,33, p<0,001 na análise univariada e p<0,001 na análise multivariada) significativamente menores, o que não se verificou com a area tracking da aurícula esquerda (p=0,412) ou com o strain global circunferencial (p=0,879), strain global radial (p=0,058), area tracking (p=0,092) e twist (p=0,992) do ventrículo esquerdo. ConclusãoO strain longitudinal global do ventrículo esquerdo e da aurícula esquerda encontra-se significativamente diminuído em doentes com distrofia miotónica do tipo 1, pode ser um marcador precoce de disfunção subclínica nesaes doentes." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "List of abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:12 [ 0 => array:2 [ "termino" => "DM1" "descripcion" => "myotonic dystrophy type 1" ] 1 => array:2 [ "termino" => "LA" "descripcion" => "left atrial" ] 2 => array:2 [ "termino" => "LV" "descripcion" => "left ventricular" ] 3 => array:2 [ "termino" => "3D" "descripcion" => "three-dimensional" ] 4 => array:2 [ "termino" => "STE" "descripcion" => "speckle tracking echocardiography" ] 5 => array:2 [ "termino" => "2D" "descripcion" => "two-dimensional" ] 6 => array:2 [ "termino" => "LS" "descripcion" => "longitudinal strain" ] 7 => array:2 [ "termino" => "AT" "descripcion" => "area tracking" ] 8 => array:2 [ "termino" => "GLS" "descripcion" => "global longitudinal strain" ] 9 => array:2 [ "termino" => "GCS" "descripcion" => "global circumferential strain" ] 10 => array:2 [ "termino" => "GRS" "descripcion" => "global radial strain" ] 11 => array:2 [ "termino" => "ICC" "descripcion" => "intraclass correlation coefficient" ] ] ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1058 "Ancho" => 3167 "Tamanyo" => 467056 ] ] "descripcion" => array:1 [ "en" => "(1) LA LS (16 segments) obtained by means of 3D wall-motion tracking technology; during systole, the LA is stretched and LS increases, reaching a positive peak at the end of systole, corresponding to the end of atrial filling; during diastole, LS decreases to a plateau; (2) the 3D echocardiographic dataset is displayed in apical 4-chamber (A) and 2-chamber (B) views and three short-axis views in the basal (C3), mid-ventricular (C5), and superior (C7) regions, respectively. 3D LV cast (D) and GLS (E) are also presented; (3) LV GLS (16 segments) obtained by 3D wall-motion tracking technology. 3D: three-dimensional; GLS: global longitudinal strain; LA: left atrial; LS: longitudinal strain; LV: left ventricular." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are mean ± standard deviation.DM1: myotonic dystrophy type 1; mRS: modified Rankin Scale score; N: normal; NA: not applicable." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM1 patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Controls \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.9±16.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40.3±12.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.241 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female gender (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.759 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sinus rhythm (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR interval (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">193±32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">180±24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.114 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">116±29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">106±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.346 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Myotonia (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Muscle weakness (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean mRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep disorders (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory disorders (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastrointestinal disorders (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1756432.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and electrocardiographic data." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are mean ± standard deviation.2D: two-dimensional; 3D: three-dimensional; AT: area tracking; BSA: body surface area; DM1: myotonic dystrophy type 1; dT: deceleration time; GCS: global circumferential strain; GLS: global longitudinal strain; GRS: global radial strain; IVS: intraventricular septum; LA: left atrial; LAEF: left atrial emptying fraction; LAEDV: left atrial end-diastolic volume; LAESV: left atrial end-systolic volume; LS: longitudinal strain; LV: left ventricular; LVEDV: left ventricular end-diastolic volume; LVEF: left ventricular ejection fraction; LVESV: left ventricular end-systolic volume; PW: posterior wall; TAPSE: tricuspid annular plane systolic excursion." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM1 patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Controls \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">2D echocardiography</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LA diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.10±2.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.64±3.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LAV/BSA (ml/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.68±5.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.77±6.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.070 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVEDD (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.12±4.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.53±3.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.064 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IVS (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.96±1.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.68±1.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.082 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PW (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.28±1.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.96±1.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.086 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">E/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.70±0.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.48±0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.155 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">dT (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">197.36±47.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">172.84±41.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.058 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">E/E′ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.04±2.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.40±1.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.306 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TAPSE (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.42±3.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.83±3.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.725 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">3D echocardiography</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LAEF (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.13±8.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.37±11.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.139 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LAESV/BSA (ml/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.12±4.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.12±3.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.569 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LAEDV/BSA (ml/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.70±4.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.60±6.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.677 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LA LS (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.85±5.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.82±5.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.008 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LA AT (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.77±17.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.41±12.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.412 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVEF (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.88±3.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.64±6.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV mass/BSA (g/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.83±21.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.80±15.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.267 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVESV/BSA (ml/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.42±12.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.16±9.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.819 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVEDV/BSA (ml/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.85±23.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.53±15.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.814 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GLS (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-13.55±1.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-16.11±1.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GCS (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-25.81±7.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-26.11±5.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.879 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GRS (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.36±11.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.43±10.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.058 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV AT (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-35.58±9.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-39.27±5.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.092 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV twist (°) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.80±2.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.79±2.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.992 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Multivariate adjustment</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LA LS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.026 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GLS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1756431.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Two- and three-dimensional echocardiographic data." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "GLS: global longitudinal strain; LA: left atrial; LS: longitudinal strain; LV: left ventricular; LV mass: left ventricular mass index on three-dimensional echocardiography." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">r \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR interval – LA LS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-0.304 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.192 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age – LA LS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-0.771 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR interval – LV GLS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.028 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.906 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS – LV GLS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.310 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.183 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV mass – LV GLS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.368 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.077 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1756430.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Correlations in patients with myotonic dystrophy type 1." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are means of intraclass correlation coefficient.AT: area tracking; GCS: global circumferential strain; GLS: global longitudinal strain; GRS: global radial strain; LA: left atrial; LV: left ventricular." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraobserver agreement \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interobserver agreement \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LA LS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LA AT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.83 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GLS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV AT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV twist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1756433.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Interobserver and intraobserver agreement." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myotonic dystrophy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.S. 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003700000004/v2_201805290419/S2174204918301296/v2_201805290419/en/main.assets" "Apartado" => array:4 [ "identificador" => "9917" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003700000004/v2_201805290419/S2174204918301296/v2_201805290419/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918301296?idApp=UINPBA00004E"]

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Original Article

Importance of three-dimensional speckle tracking in the assessment of left atrial and ventricular dysfunction in patients with myotonic dystrophy type 1

Importância da tecnologia 3D speckle tracking na avaliação da disfunção auricular e ventricular esquerda em doentes com distrofia miotónica do tipo 1

Henrique Guedesa,

Corresponding author

henrique.jp.guedes@gmail.com

Corresponding author.

, Nuno Morenob, Rui Pontes dos Santosa, Leonor Marquesa, Daniel Seabraa, Adriana Pereiraa, Aurora Andradea, Paula Pintoa

a Cardiology Department, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal

b Cardiology Department, Unidade Local de Saúde de Matosinhos, Hospital Pedro Hispano, Matosinhos, Portugal

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; LA LS &#40;16 segments&#41; obtained by means of 3D wall-motion tracking technology&#59; during systole&#44; the LA is stretched and LS increases&#44; reaching a positive peak at the end of systole&#44; corresponding to the end of atrial filling&#59; during diastole&#44; LS decreases to a plateau&#59; &#40;2&#41; the 3D echocardiographic dataset is displayed in apical 4-chamber &#40;A&#41; and 2-chamber &#40;B&#41; views and three short-axis views in the basal &#40;C3&#41;&#44; mid-ventricular &#40;C5&#41;&#44; and superior &#40;C7&#41; regions&#44; respectively&#46; 3D LV cast &#40;D&#41; and GLS &#40;E&#41; are also presented&#59; &#40;3&#41; LV GLS &#40;16 segments&#41; obtained by 3D wall-motion tracking technology&#46; 3D&#58; three-dimensional&#59; GLS&#58; global longitudinal strain&#59; LA&#58; left atrial&#59; LS&#58; longitudinal strain&#59; LV&#58; left ventricular&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0065" class="elsevierStylePara elsevierViewall">Myotonic dystrophy type 1 &#40;DM1&#41; is a multisystem neuromuscular disease with autosomal dominant transmission that affects smooth and skeletal muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> About 30&#37; of mortality in adults with DM1 is due to cardiac involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Arrhythmias&#44; conduction system disturbances and myocardial fibrosis are the most frequent changes&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Detection of early markers may facilitate the identification of patients at risk of developing cardiac complications&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Left atrial &#40;LA&#41; function is a complex process that includes receiving pulmonary venous return during left ventricular &#40;LV&#41; systole&#44; transfer of blood passively into the left ventricle in early diastole&#44; and active contraction in late diastole&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In a comparison of volumetric real-time three-dimensional &#40;3D&#41; echocardiography and 3D speckle tracking echocardiography &#40;3D-STE&#41;&#44; the two methods were found to provide comparable and reproducible measurements&#44; and to be interchangeable for quantification of LA dimensions and functional properties&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Echocardiographic myocardial tracking systems using 3D-STE have provided new insights into ventricular function and atrial mechanics&#44; with many potential clinical applications&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8</span></a> 3D formats more closely represent reality than two-dimensional &#40;2D&#41; formats&#44; not only in the assessment of LV function but also in the diagnosis of valvular or myocardial disease&#46; Determination of LV strain by 2D speckle tracking echocardiography &#40;2D-STE&#41; enables identification of changes in LV systolic function in patients with DM1&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; the applicability of 3D-STE in these patients is not fully established and the available data are scarce&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The aim of this study was to identify early changes in LA mechanics and LV systolic function in patients with DM1 using 3D-STE&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population</span><p id="par0090" class="elsevierStylePara elsevierViewall">This was a single-center observational study&#46; After written informed consent was obtained&#44; all 25 patients with DM1 followed in our center and 25 healthy volunteers &#40;control group&#41; were consecutively selected&#46; All DM1 patients had genetic confirmation of the diagnosis and had no known cardiovascular disease&#44; but had signs of neuromuscular involvement &#40;myopathic facies&#44; myotonia or gait abnormalities&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Echocardiographic protocol</span><p id="par0095" class="elsevierStylePara elsevierViewall">The equipment used was an Artida&#8482; scanner &#40;Toshiba Medical Systems&#41;&#46; The echocardiographic study began with a 2D echocardiogram following the standard protocol used in our department&#44; measurements being made in accordance with the current guidelines of the American Society of Echocardiography&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> using a PST-30SBT 1-5 MHz phased-array transducer&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">For 3D echocardiography a PST-25SX 1-4 MHz phased-array matrix transducer was used&#46; Images were acquired in apical 4-chamber and 2-chamber views for both LA and LV assessment&#46; The data set is displayed in five planes&#58; apical 4-chamber&#44; apical 2-chamber&#44; and three short-axis planes&#58; apical region&#44; middle segments and basal portion&#46; The software is semiautomatic&#58; it divides the left atrium and ventricle into 16 segments automatically&#44; and after the markers have been selected&#44; the system performs wall motion tracking analysis&#44; enabling analysis of the study variables&#46; The reference values for this equipment for 3D LV strain are&#58; global longitudinal strain &#40;GLS&#41;&#44; -15&#46;9&#37;&#177;2&#46;4&#59; global circumferential strain &#40;GCS&#41;&#44; -30&#46;6&#37;&#177;2&#46;6&#59; global radial strain &#40;GRS&#41;&#44; 35&#46;6&#37;&#177;10&#46;3&#59; area tracking &#40;AT&#41;&#44; -42&#37;&#177;2&#46;4&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Variables analyzed</span><p id="par0105" class="elsevierStylePara elsevierViewall">All patients were assessed for the presence of neuromuscular manifestations &#40;particularly myotonia&#44; muscular weakness and modified Rankin Scale &#91;mRS&#93; score&#41; and of sleep&#44; respiratory and gastrointestinal disorders&#44; as established in the various consultations in which the patients were followed&#46; Regarding electrocardiographic variables&#44; rhythm&#44; PR interval duration and QRS duration were recorded&#46; On 2D echocardiography&#44; LA size and volume&#44; LV size and diastolic function and tricuspid annular plane systolic excursion &#40;TAPSE&#41; were determined&#44; while LA emptying fraction and end-systolic and end-diastolic volumes and LV ejection fraction &#40;LVEF&#41;&#44; end-systolic and end-diastolic volumes and mass were determined by 3D echocardiography&#46; LA deformation was determined by measuring longitudinal strain &#40;LS&#41; and AT&#44; while LV deformation was determined by measuring GLS&#44; GCS&#44; GRS&#44; AT and twist by 3D-STE &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Interobserver and intraobserver variability</span><p id="par0110" class="elsevierStylePara elsevierViewall">Data sets from the wall motion tracking results were analyzed at different times by two independent observers&#46; The same images were also analyzed on different days by one of these observers&#46; Blinding was ensured by analyzing the studies on different days by the same observer in a randomized order and by blinding the results between the two independent observers&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0115" class="elsevierStylePara elsevierViewall">Statistical analysis was carried out using SPSS version 22&#46;0&#46; Variables were analyzed for normality of distribution using the Kolmogorov-Smirnov test&#46; Quantitative data are expressed as mean &#177; SD and qualitative data as percentages&#46; Comparisons were assessed using paired-samples t tests for quantitative data&#46; Cox regression analysis was performed for multivariate adjustment&#46; Correlations were assessed by simple linear regression analysis&#46; Interobserver and intraobserver reproducibility were assessed by means of the intraclass correlation coefficient &#40;ICC&#41;&#46; Differences were considered statistically significant with a p-value &#60;0&#46;05&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Clinical and electrocardiographic data</span><p id="par0120" class="elsevierStylePara elsevierViewall">Mean age was 36&#46;9&#177;16&#46;0 years in DM1 patients &#40;40&#46;3&#177;12&#46;4 years in controls&#41;&#46; All patients had myotonia and 11 had muscle weakness&#44; with a mean mRS of 1&#46;25&#46; Ten patients had PR interval &#62;200 ms and seven had QRS &#62; 120 ms&#46; Clinical and electrocardiographic data are displayed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Echocardiographic data</span><p id="par0125" class="elsevierStylePara elsevierViewall">Two-dimensional echocardiography did not identify differences between the groups in left cardiac chamber size or in parameters of diastolic function &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Also&#44; three-dimensional echocardiography did not show significant differences in LVEF &#40;62&#46;88&#37;&#177;3&#46;27 vs&#46; 65&#46;64&#37;&#177;6&#46;65&#44; p&#61;0&#46;80&#41;&#44; LV mass index &#40;91&#46;83 g&#47;m<span class="elsevierStyleSup">2</span>&#177;21&#46;51 vs&#46; 85&#46;80 g&#47;m<span class="elsevierStyleSup">2</span>&#177;15&#46;73&#44; p&#61;0&#46;267&#41;&#44; LV end-systolic &#40;24&#46;42 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;12&#46;54 vs&#46; 25&#46;16 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;9&#46;87&#44; p&#61;0&#46;819&#41; or end-diastolic volume &#40;55&#46;85 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;23&#46;14 vs&#46; 54&#46;53 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;15&#46;05&#44; p&#61;0&#46;814&#41;&#44; or in LA emptying fraction &#40;42&#46;13&#37;&#177;8&#46;53 vs&#46; 46&#46;37&#37;&#177;11&#46;21&#44; p&#61;0&#46;139&#41; or indexed end-systolic &#40;13&#46;12 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;4&#46;35 vs&#46; 13&#46;12 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;3&#46;50&#44; p&#61;0&#46;569&#41; and end-diastolic volumes &#40;22&#46;70 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;4&#46;75 vs&#46; 23&#46;60 ml&#47;m<span class="elsevierStyleSup">2</span>&#177;6&#46;19&#44; p&#61;0&#46;677&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The percentage of segments analyzed with 3D-STE was 86&#46;25&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Patients with DM1 showed significantly lower LA LS than controls &#40;22&#46;85&#37;&#177;5&#46;06 vs&#46; 26&#46;82&#37;&#177;5&#46;15&#59; p&#61;0&#46;008&#41;&#44; which was not the case with AT &#40;21&#46;77&#37;&#177;17&#46;49 vs&#46; 25&#46;41&#37;&#177;12&#46;94&#59; p&#61;0&#46;412&#41;&#46; There was a significant correlation between age and LA LS in patients with DM1 &#40;r&#61;-0&#46;771&#59; p&#60;0&#46;001&#59; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">LV GLS was significantly lower in patients with DM1 than in controls &#40;-13&#46;55&#37;&#177;1&#46;82 vs&#46; -16&#46;11&#37;&#177;1&#46;33&#59; p&#60;0&#46;001&#41;&#44; which was not the case for GCS &#40;-25&#46;81&#37;&#177;7&#46;57 vs&#46; -26&#46;11&#37;&#177;5&#46;92&#59; p&#61;0&#46;879&#41;&#44; GRS &#40;26&#46;36&#37;&#177;11&#46;61 vs&#46; 32&#46;43&#37;&#177;10&#46;50&#59; p&#61;0&#46;058&#41;&#44; AT &#40;-35&#46;58&#37;&#177;9&#46;02 vs&#46; -39&#46;27&#37;&#177;5&#46;81&#59; p&#61;0&#46;092&#41; or twist &#40;4&#46;80&#177;2&#46;59 vs&#46; 4&#46;79&#177;2&#46;83&#44; p&#61;0&#46;992&#41;&#46; No correlation was found between PR interval &#40;r&#61;0&#46;028&#59; p&#61;0&#46;906&#41;&#44; QRS &#40;r&#61;0&#46;310&#59; p&#61;0&#46;183&#41; or 3D LV mass index &#40;r&#61;0&#46;368&#59; p&#61;0&#46;077&#41; and LV GLS in DM1 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Multivariate adjustment confirmed that LA LS and LV GLS remained statistically significant &#40;p&#61;0&#46;026 and p&#60;0&#46;001&#44; respectively&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Interobserver and intraobserver agreement for strain measurements was good&#46; The ICCs are presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">The assessment of myocardial deformation has been proposed as an early marker of subclinical dysfunction in DM1 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> The present study is&#44; to our knowledge&#44; the first to identify changes in both LA and LV strain measured by 3D-STE in these patients&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">LA mechanics is considered an important clinical variable and its importance has been demonstrated in a number of conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#8211;19</span></a> LA strain curves display the physiology of atrial function&#46; The left atrium has four basic functions&#58; phase 1&#44; reservoir function &#40;collection of pulmonary venous flow during LV systole&#41;&#59; phase 2&#44; conduit function &#40;passage of blood to the left ventricle during early diastole&#41;&#59; phase 3&#44; active contractile pump function&#59; and phase 4&#44; suction force&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> During the reservoir phase&#44; the left atrium is stretched&#44; and consequently longitudinal atrial strain increases&#44; reaching a positive peak at the end of atrial filling&#46; After the atrium empties&#44; LA strain decreases to a plateau&#44; corresponding to LA diastasis&#44; and then continues to decrease during the LA contraction phase &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In our study&#44; a significant negative correlation was observed between age and LA LS in patients with DM1&#44; which did not occur with the controls&#44; suggesting a faster decrease in LA LS in these patients&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In DM1 patients&#44; 2D-STE is able to identify changes in LS of the right atrium&#44; which correlate with low-voltage areas on electrophysiological study&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> However&#44; LA mechanics has been little studied and validated in these patients&#44; so it is difficult to draw definite conclusions about these findings&#46; We expect that with future larger studies&#44; these changes may prove to be important for early diagnosis and therapeutic decision-making&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Studies with 2D echocardiography are consistent in demonstrating decreased LV GLS in these patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;22</span></a> as well as changes in GCS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> In our study&#44; we found significant differences only in GLS&#44; which may mean that these fibers are affected early in the progression of the disease&#44; subsequently being replaced by fibrosis&#44; as demonstrated in previous studies<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> and other cardiomyopathies&#44; such as hypertrophic cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> The presence of myocardial fibrosis in these patients has been documented by a cardiovascular magnetic resonance study&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> in which myocardial fibrosis was found in 40&#37; of patients and was not related to changes on electrocardiogram&#44; Holter or echocardiogram&#46; This suggests that assessment of myocardial fibrosis by cardiac magnetic resonance may be a useful tool in the assessment of these patients&#44; since myocardial fibrosis may be the substrate for ventricular arrhythmias&#46; Also&#44; high levels of transforming growth factor beta 1&#44; a sensitive marker of fibrosis&#44; have been reported in patients with DM1&#44; indicating a higher risk of arrhythmic events and sudden death&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Previous studies have shown the usefulness of subclinical detection of cardiac involvement in DM1&#46; In one study of 36 DM1 patients&#44; serial Holter monitoring resulted in pacemaker implantation in 11 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> and implantable loop recorders have been used in small studies of asymptomatic patients&#44; leading to the detection of ventricular arrhythmias and device implantation in four out of seven patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">27&#44;28</span></a> A recently published study demonstrated the prognostic value of LV GLS in patients with asymptomatic DM1&#44; concluding that GLS constitutes a strong predictor of cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">3D wall motion tracking uses a box template to detect speckle motion in 3D&#46; The structures are captured in a full volume and do not move out of plane like in 2D&#46; 3D-STE has also been shown to provide a faster and more complete assessment than 2D-STE&#44; overcoming some of the shortcomings of previous techniques by reducing the intraobserver and interobserver variability inherent in 2D measures and avoiding the angle dependence of strain and strain-rate measures obtained on Doppler tissue imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> Nesser et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> assessed the accuracy of measuring LV volumes by means of 3D-STE side by side with 2D-STE using cardiac magnetic resonance as a reference&#46; They observed that measurements by 3D-STE showed higher correlation with cardiac magnetic resonance&#44; smaller biases and narrower limits of agreement&#46; 3D-STE is emerging as a useful tool for a more comprehensive assessment of ventricular function and atrial mechanics and may be valuable in a general and systematic approach to these patients&#44; bearing in mind its possible prognostic impact&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; One is the small number of patients &#40;total 25&#41;&#44; which is in line with the rarity of the disease &#40;estimated prevalence of about 1&#47;10<span class="elsevierStyleHsp" style=""></span>000&#41; and previous studies performed in patients with this condition&#46; It also has the inherent limitations of an observational study and&#44; as pointed out above&#44; the clinical impact of LA deformation changes are still not well understood&#46; Regarding image acquisition&#44; a major limitation for current 3D-STE systems is their relatively low temporal resolution&#44; with typical frame rates of 20-25 volumes&#47;s&#44; and sequential volume acquisition&#44; which is vulnerable to motion artifacts if the patient is unable to cooperate&#46; The software used continues to improve but is not fully validated for the study of the left atrium&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">LA LS and LV GLS are significantly decreased in patients with DM1&#46; These results may reflect a subclinical and early marker of myocardial dysfunction in these patients&#46; Studies with 3D-STE can detect changes in myocardial function that may contribute to the assessment and follow-up of these patients&#46; Future prospective studies may open new perspectives on the clinical relevance of these markers&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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              "titulo" => "Introdu&#231;&#227;o e objetivos"
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              "titulo" => "Echocardiographic protocol"
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              "titulo" => "Variables analyzed"
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              "titulo" => "Clinical and electrocardiographic data"
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          "titulo" => "Conflicts of interest"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-06-25"
    "fechaAceptado" => "2017-10-28"
    "PalabrasClave" => array:2 [
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec988796"
          "palabras" => array:4 [
            0 => "Myotonic dystrophy"
            1 => "Three-dimensional echocardiography"
            2 => "Three-dimensional speckle tracking"
            3 => "Strain"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec988797"
          "palabras" => array:4 [
            0 => "Distrofia miot&#243;nica"
            1 => "Ecocardiografia 3D"
            2 => "3D <span class="elsevierStyleItalic">speckle tracking</span>"
            3 => "<span class="elsevierStyleItalic">Strain</span>"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Myotonic dystrophy type 1 &#40;DM1&#41; is a multisystem disease in which cardiac involvement is common&#46; The aim of this study was to identify early changes in left atrial &#40;LA&#41; mechanics and left ventricular &#40;LV&#41; systolic function in patients with myotonic dystrophy type 1 using three-dimensional &#40;3D&#41; speckle tracking echocardiography &#40;3D-STE&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This observational study included 25 patients with DM1 and 25 healthy volunteers&#46; We assessed LA and LV global strain parameters using 3D-STE&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients with DM1 showed significantly lower longitudinal LA strain &#40;22&#46;85&#37;&#177;5&#46;06 vs&#46; 26&#46;82&#37;&#177;5&#46;15&#59; p&#61;0&#46;008 in univariate analysis and p&#61;0&#46;026 in multivariate analysis&#41; and global LV longitudinal strain &#40;-13&#46;55&#37;&#177;1&#46;82 vs&#46; -16&#46;11&#37;&#177;1&#46;33&#59; p&#60;0&#46;001 in univariate analysis and p&#60;0&#46;001 in multivariate analysis&#41;&#44; which was not observed with LA area tracking &#40;p&#61;0&#46;412&#41; or LV global circumferential strain &#40;p&#61;0&#46;879&#41;&#44; global radial strain &#40;p&#61;0&#46;058&#41;&#44; area tracking &#40;p&#61;0&#46;092&#41; or twist &#40;p&#61;0&#46;992&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LA and LV global longitudinal strain is significantly decreased in patients with DM1&#44; which may be an early marker of subclinical dysfunction in these patients&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Aim"
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          1 => array:2 [
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            "titulo" => "Methods"
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A distrofia miot&#243;nica do tipo 1 &#233; uma doen&#231;a multissist&#233;mica com o envolvimento card&#237;aco a ser comum&#46; O objetivo deste estudo foi identificar altera&#231;&#245;es precoces no <span class="elsevierStyleItalic">strain</span> da aur&#237;cula esquerda e fun&#231;&#227;o sist&#243;lica do ventr&#237;culo esquerdo em doentes com distrofia miot&#243;nica tipo 1&#44; com o uso da tecnologia 3D <span class="elsevierStyleItalic">speckle tracking</span>&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo observacional&#44; que incluiu 25 doentes com distrofia miot&#243;nica do tipo 1 e 25 volunt&#225;rios saud&#225;veis&#46; Foram avaliados os par&#226;metros de deforma&#231;&#227;o global da aur&#237;cula esquerda e do ventr&#237;culo com o uso de 3D <span class="elsevierStyleItalic">speckle tracking</span>&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Os doentes com distrofia miot&#243;nica do tipo 1 apresentaram <span class="elsevierStyleItalic">strain</span> longitudinal da aur&#237;cula esquerda &#40;22&#44;85&#37;&#177;5&#44;06 <span class="elsevierStyleItalic">versus</span> 26&#44;82&#37;&#177;5&#44;15&#59; p&#61;0&#44;008 na an&#225;lise univariada e p&#61;0&#44;026 na an&#225;lise multivariada&#41; e <span class="elsevierStyleItalic">strain</span> global longitudinal do ventr&#237;culo esquerdo &#40;-13&#44;55&#37;&#177;1&#44;82 <span class="elsevierStyleItalic">versus</span> -16&#44;11&#37;&#177;1&#44;33&#44; p&#60;0&#44;001 na an&#225;lise univariada e p&#60;0&#44;001 na an&#225;lise multivariada&#41; significativamente menores&#44; o que n&#227;o se verificou com a <span class="elsevierStyleItalic">area tracking</span> da aur&#237;cula esquerda &#40;p&#61;0&#44;412&#41; ou com o <span class="elsevierStyleItalic">strain</span> global circunferencial &#40;p&#61;0&#44;879&#41;&#44; <span class="elsevierStyleItalic">strain</span> global radial &#40;p&#61;0&#44;058&#41;&#44; <span class="elsevierStyleItalic">area tracking</span> &#40;p&#61;0&#44;092&#41; e <span class="elsevierStyleItalic">twist</span> &#40;p&#61;0&#44;992&#41; do ventr&#237;culo esquerdo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">strain</span> longitudinal global do ventr&#237;culo esquerdo e da aur&#237;cula esquerda encontra-se significativamente diminu&#237;do em doentes com distrofia miot&#243;nica do tipo 1&#44; pode ser um marcador precoce de disfun&#231;&#227;o subcl&#237;nica nesaes doentes&#46;</p></span>"
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        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">List of abbreviations</span>"
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          0 => array:1 [
            "definicion" => array:12 [
              0 => array:2 [
                "termino" => "DM1"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">myotonic dystrophy type 1</p>"
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              1 => array:2 [
                "termino" => "LA"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">left atrial</p>"
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              2 => array:2 [
                "termino" => "LV"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">left ventricular</p>"
              ]
              3 => array:2 [
                "termino" => "3D"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">three-dimensional</p>"
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                "termino" => "STE"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">speckle tracking echocardiography</p>"
              ]
              5 => array:2 [
                "termino" => "2D"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">two-dimensional</p>"
              ]
              6 => array:2 [
                "termino" => "LS"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">longitudinal strain</p>"
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              7 => array:2 [
                "termino" => "AT"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">area tracking</p>"
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              8 => array:2 [
                "termino" => "GLS"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">global longitudinal strain</p>"
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              9 => array:2 [
                "termino" => "GCS"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">global circumferential strain</p>"
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                "termino" => "GRS"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">global radial strain</p>"
              ]
              11 => array:2 [
                "termino" => "ICC"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">intraclass correlation coefficient</p>"
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        "etiqueta" => "Figure 1"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; LA LS &#40;16 segments&#41; obtained by means of 3D wall-motion tracking technology&#59; during systole&#44; the LA is stretched and LS increases&#44; reaching a positive peak at the end of systole&#44; corresponding to the end of atrial filling&#59; during diastole&#44; LS decreases to a plateau&#59; &#40;2&#41; the 3D echocardiographic dataset is displayed in apical 4-chamber &#40;A&#41; and 2-chamber &#40;B&#41; views and three short-axis views in the basal &#40;C3&#41;&#44; mid-ventricular &#40;C5&#41;&#44; and superior &#40;C7&#41; regions&#44; respectively&#46; 3D LV cast &#40;D&#41; and GLS &#40;E&#41; are also presented&#59; &#40;3&#41; LV GLS &#40;16 segments&#41; obtained by 3D wall-motion tracking technology&#46; 3D&#58; three-dimensional&#59; GLS&#58; global longitudinal strain&#59; LA&#58; left atrial&#59; LS&#58; longitudinal strain&#59; LV&#58; left ventricular&#46;</p>"
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Values are mean &#177; standard deviation&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">DM1&#58; myotonic dystrophy type 1&#59; mRS&#58; modified Rankin Scale score&#59; N&#58; normal&#59; NA&#58; not applicable&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM1 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;9&#177;16&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&#46;3&#177;12&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;241&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female gender &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;759&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sinus rhythm &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR interval &#40;ms&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">193&#177;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">180&#177;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;114&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS &#40;ms&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&#177;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">106&#177;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;346&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Myotonia &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Muscle weakness &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean mRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep disorders &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory disorders &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastrointestinal disorders &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Values are mean &#177; standard deviation&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">2D&#58; two-dimensional&#59; 3D&#58; three-dimensional&#59; AT&#58; area tracking&#59; BSA&#58; body surface area&#59; DM1&#58; myotonic dystrophy type 1&#59; dT&#58; deceleration time&#59; GCS&#58; global circumferential strain&#59; GLS&#58; global longitudinal strain&#59; GRS&#58; global radial strain&#59; IVS&#58; intraventricular septum&#59; LA&#58; left atrial&#59; LAEF&#58; left atrial emptying fraction&#59; LAEDV&#58; left atrial end-diastolic volume&#59; LAESV&#58; left atrial end-systolic volume&#59; LS&#58; longitudinal strain&#59; LV&#58; left ventricular&#59; LVEDV&#58; left ventricular end-diastolic volume&#59; LVEF&#58; left ventricular ejection fraction&#59; LVESV&#58; left ventricular end-systolic volume&#59; PW&#58; posterior wall&#59; TAPSE&#58; tricuspid annular plane systolic excursion&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM1 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">2D echocardiography</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LA diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;10&#177;2&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;64&#177;3&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LAV&#47;BSA &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;68&#177;5&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;77&#177;6&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;070&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LVEDD &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;12&#177;4&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;53&#177;3&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;064&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IVS &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;96&#177;1&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;68&#177;1&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;082&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PW &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;28&#177;1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;96&#177;1&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;086&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>E&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;70&#177;0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;48&#177;0&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;155&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>dT &#40;ms&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">197&#46;36&#177;47&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172&#46;84&#177;41&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>E&#47;E&#8242;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;04&#177;2&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;40&#177;1&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;306&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TAPSE &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;42&#177;3&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;83&#177;3&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;725&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">3D echocardiography</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LAEF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;13&#177;8&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;37&#177;11&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LAESV&#47;BSA &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;12&#177;4&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;12&#177;3&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;569&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LAEDV&#47;BSA &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;70&#177;4&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;60&#177;6&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;677&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LA LS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;85&#177;5&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;82&#177;5&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LA AT &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;77&#177;17&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;41&#177;12&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;412&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LVEF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#46;88&#177;3&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;64&#177;6&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV mass&#47;BSA &#40;g&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;83&#177;21&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;80&#177;15&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;267&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LVESV&#47;BSA &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;42&#177;12&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;16&#177;9&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;819&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LVEDV&#47;BSA &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;85&#177;23&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;53&#177;15&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;814&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV GLS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-13&#46;55&#177;1&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-16&#46;11&#177;1&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV GCS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-25&#46;81&#177;7&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-26&#46;11&#177;5&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;879&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV GRS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;36&#177;11&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;43&#177;10&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV AT &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-35&#46;58&#177;9&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-39&#46;27&#177;5&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;092&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV twist &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;80&#177;2&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;79&#177;2&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;992&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Multivariate adjustment</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LA LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LV GLS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1756431.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Two- and three-dimensional echocardiographic data&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">GLS&#58; global longitudinal strain&#59; LA&#58; left atrial&#59; LS&#58; longitudinal strain&#59; LV&#58; left ventricular&#59; LV mass&#58; left ventricular mass index on three-dimensional echocardiography&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">r&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR interval &#8211; LA LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-0&#46;304&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#8211; LA LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">-0&#46;771&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR interval &#8211; LV GLS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;906&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS &#8211; LV GLS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;183&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV mass &#8211; LV GLS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;368&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;077&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Correlations in patients with myotonic dystrophy type 1&#46;</p>"
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      ]
      4 => array:8 [
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        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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            "identificador" => "at4"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Values are means of intraclass correlation coefficient&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">AT&#58; area tracking&#59; GCS&#58; global circumferential strain&#59; GLS&#58; global longitudinal strain&#59; GRS&#58; global radial strain&#59; LA&#58; left atrial&#59; LV&#58; left ventricular&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;83&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GCS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV GRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV AT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LV twist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1756433.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Interobserver and intraobserver agreement&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Myotonic dystrophy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46;S&#46; Harper"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "3rd ed&#46;"
                        "fecha" => "2001"
                        "editorial" => "Saunders"
                        "editorialLocalizacion" => "London"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Myotonic dystrophy and the heart&#58; a systematic review of evaluation and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46;K&#46; Lau"
                            1 => "R&#46;W&#46; Sy"
                            2 => "A&#46; Corbett"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijcard.2015.03.069"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Cardiol"
                        "fecha" => "2015"
                        "volumen" => "184"
                        "paginaInicial" => "600"
                        "paginaFinal" => "608"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25769007"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac manifestations of myotonic dystrophy type 1"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46; Petri"
                            1 => "J&#46; Vissing"
                            2 => "N&#46; Witting"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijcard.2011.08.037"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Cardiol"
                        "fecha" => "2012"
                        "volumen" => "160"
                        "paginaInicial" => "82"
                        "paginaFinal" => "88"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21917328"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Left atrial ejection force correlates with left atrial strain and volume-based functional properties as assessed by three-dimensional speckle tracking echocardiography &#40;from the MAGYAR-Healthy Study&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46;A&#46; Piros"
                            1 => "P&#46; Domsika"
                            2 => "A&#46; Kalapos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.repc.2015.09.017"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2016"
                        "volumen" => "35"
                        "paginaInicial" => "83"
                        "paginaFinal" => "91"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26852310"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New echocardiographic techniques for evaluation of left atrial mechanics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;C&#46; Todaro"
                            1 => "I&#46; Choudhuri"
                            2 => "M&#46; Belohlavek"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ehjci/jes174"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J Cardiovasc Imaging"
                        "fecha" => "2012"
                        "volumen" => "13"
                        "paginaInicial" => "973"
                        "paginaFinal" => "984"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22909795"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2017.10.010

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Year/Month	Html	Pdf	Total

2024 November	4	5	9
2024 October	23	29	52
2024 September	29	25	54
2024 August	40	21	61
2024 July	35	24	59
2024 June	38	29	67
2024 May	34	20	54
2024 April	36	23	59
2024 March	41	23	64
2024 February	28	19	47
2024 January	17	24	41
2023 December	23	22	45
2023 November	33	21	54
2023 October	18	15	33
2023 September	15	20	35
2023 August	19	18	37
2023 July	22	15	37
2023 June	25	11	36
2023 May	50	16	66
2023 April	27	5	32
2023 March	60	24	84
2023 February	40	22	62
2023 January	32	14	46
2022 December	55	26	81
2022 November	53	37	90
2022 October	51	29	80
2022 September	31	44	75
2022 August	28	27	55
2022 July	36	40	76
2022 June	35	28	63
2022 May	27	34	61
2022 April	38	36	74
2022 March	37	44	81
2022 February	28	37	65
2022 January	35	29	64
2021 December	34	28	62
2021 November	40	37	77
2021 October	41	42	83
2021 September	56	43	99
2021 August	61	26	87
2021 July	26	25	51
2021 June	40	22	62
2021 May	48	41	89
2021 April	47	53	100
2021 March	61	40	101
2021 February	63	23	86
2021 January	64	18	82
2020 December	49	12	61
2020 November	50	16	66
2020 October	31	17	48
2020 September	100	18	118
2020 August	18	10	28
2020 July	62	14	76
2020 June	29	9	38
2020 May	51	12	63
2020 April	34	8	42
2020 March	33	6	39
2020 February	130	58	188
2020 January	26	8	34
2019 December	44	11	55
2019 November	24	13	37
2019 October	18	5	23
2019 September	34	7	41
2019 August	26	7	33
2019 July	43	8	51
2019 June	43	17	60
2019 May	24	5	29
2019 April	26	20	46
2019 March	79	14	93
2019 February	82	9	91
2019 January	86	9	95
2018 December	52	10	62
2018 November	43	20	63
2018 October	92	19	111
2018 September	20	11	31
2018 August	31	5	36
2018 July	18	9	27
2018 June	34	7	41
2018 May	32	22	54

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