MRI regional strain analysis in patients with hypertrophic cardiomyopathy in Mediterranean cohort

MRI regional strain analysis in patients with hypertrophic cardiomyopathy in Mediterranean cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article MRI regional strain analysis in patients with hypertrophic cardiomyopathy in Mediterranean cohort Esraa Maher, Magdi Khalil, Mona Taher, Sameh Khalil This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5678626/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To evaluate the regional left ventricular myocardial strain in patient with hypertrophic cardiomyopathy (HCM) especially young apparently compensated patients by magnetic resonance imaging. Materials and Methods: 25 HCM patients representing all age groups and 25 healthy volunteers underwent 1.5 Tesla MRI examination for cardiac volumes, and mass, followed by regional strain analysis in radial, circumferential, and longitudinal directions as regard the displacement, strain, peak diastolic and systolic strain rate, peak diastolic and systolic velocity, time to peak displacement and time to peak strain. Results: In the HCM group, hypertrophic segments showing delayed gadolinium enhancement (DGE) were significantly different from non-hypertrophic apparently normal showing no enhancement concerning most of the regional radial strain parameters. In longitudinal and circumferential directions, hypertrophic segments showing DGE were significantly different from apparently normal segments with no enhancement as regard the strain, peak diastolic and systolic strain rate. Compared to normal volunteers, the hypertrophic segments with DGE were significantly different concerning most of the radial and longitudinal strain parameters, while apparently normal segments with no enhancement don’t present a similar significant difference. In circumferential analysis, hypertrophic enhancing segments were significantly different as regard the strain, peak diastolic strain rate, peak systolic velocity, and time to peak displacement, while the apparently normal non-enhancing segments present difference concerning the strain, peak systolic velocity, and time to peak displacement. Conclusion The hypertrophied segments showing DGE are more affected than the segments of apparently normal thickness non enhancing in HCM patients, especially in the radial direction, the apparently normal segments are less affected with no tendency of functional compensation. These findings are crucial in young age apparently compensated patients’ diagnosis follow up. Figures Figure 1 Background Hypertrophic cardiomyopathy is an inherited autosomal dominant disease with an estimated prevalence of 1:200 affecting approximately 0.2−0.5% of the general population (1 and 2). It is heterogenous in nature with a broad spectrum of phenotypic expression and clinical presentation caused by more than 1500 mutations in 11 or more genes encoding cardiac sarcomere proteins, including cardiac β-myosin heavy chain, cardiac myosin binding protein C, and troponin T (3 and 4). HCM presents a wide spectrum of manifestations ranging from asymptomatic with normal life expectancy to ventricular arrhythmia, sudden cardiac death, and heart failure (4). The histopathological findings in HCM include myocardial fibers disarray, hypertrophy of cardiomyocytes, myocyte disarray, interstitial and replacement fibrosis as well as abnormal intramural coronary arteries (5 and 6). Hemodynamics The left ventricle in HCM patients usually presents a diastolic dysfunction and restrictive ventricular filling with normal or reduced EDVI, a reduced ESVI, a high-normal or pseudo normal EF. It is caused by the increased interstitial fibrosis and the slowed relaxation and increased stiffness of the hypertrophied myocardial segments. Regional systolic myocardial function is also commonly impaired, as detected by pulsed and tissue Doppler imaging, 3-dimensional speckle-tracking echocardiography, and magnetic resonance imaging. Finally systolic function declines, the left ventricular wall thins with adverse remodeling, the cavity dilates, and heart failure with reduced EF develops, sometimes referred to as burnt out HCM or stage 4 of overt dysfunction (7 and 8). Measuring the regional segmental deformation and dysfunction by tissue tracking and strain analysis is more informative than simple measurement of EF in HCM patients as it can quantitatively measure segmental myocardium function in radial, circumferential, and longitudinal directions, by several parameters including displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate, peak systolic velocity, time to peak displacement and time to peak strain. The purpose of the present work was to quantify and compare the regional myocardial strain in the hypertrophied segments and segments of apparently normal thickness in comparison to normal persons. Materials and Methods Study Population Our study was approved by the ethical committee of Ain Shams University Hospitals, 25 HCM patients were included and 25 normal control persons who were included came to our institute with suspected abnormalities, yet their MRI examinations were normal. According to American heart association (AHA) guidelines (9 and 10), inclusion criteria were determined as Wall thickness equal or above 15 mm in the absence of other causes of hypertrophy. End diastolic wall thickness equal or above 13 mm with a family history of HCM. Focal asymmetric hypertrophy of the basal anterior septum, defined as septal/posterior wall thickness above 1.3 in a normotensive patient. In the pediatric population hypertrophy diagnosed at z score or myocardial thickness above 2 in correlation to sex and body surface area. The exclusion criteria included hypertension, diabetes, amyloidosis, sarcoidosis, any other pathology that contributes to myocardial hypertrophy. HCM patients 21 male and 4 female; mean age 39.4-year, range 7: 65 years. Healthy control 16 male and 9 female; mean age 33-year, range 13-56 years. With exclusion criteria of hypertension, diabetes, or any underlying disease even if controlled and non-complicated. MR Protocol Preparation before procedure: Explanation of the procedure to the patient especially the side effects of the contrast agent including coldness, warmth, or pain at the injection site, nausea, vomiting, headache, paresthesias, dizziness and itching. They should be aware of the severe life-threatening anaphylactoid or nonallergic anaphylactic and nephropathic effect. Exclusion of any hazards like functioning MRI-incompatible pacemaker. Review kidney function test to avoid nephrogenic systemic fibrosis which may happen in case of contrast administration with acute or chronic renal failure (contrast shouldn’t be given in estimated glomerular filtration rate <30 ml/min/1.73 m2). During procedure: Physiological monitoring devices and hearing protection are put in place. A high-quality electrocardiogram (ECG) signal is essential for optimum data quality in cardiac-gated sequences. The imaging coil should be chosen to maximize the signal-to-noise ratio over the body region to be examined. An appropriately equipped resuscitation cart and emergency management plan for the MR environment should be in place. Technique of imaging: Machine used is Siemens MAGNETOM Aera 1.5T MRI Scanner White blood images: They help in assessment of EF, EDV, ESV, EDVI, ESVI, SV, SVI, cardiac mass, and segmental motion pattern of both left and right ventricles. Long-axis 2 and 4 chamber views and short-axis (and or axial) Stacks, covering both ventricles from the base of the heart to the apex were acquired using a retrospective ECG-gated steady-state free precession sequence during breath hold in cooperative patients and with free breathing in uncooperative patients, the reconstructed phases per R-R interval are 30 phases, yet, some patients presented with arrhythmias need prospective gating with minimum accepted phases per R-R interval are 18 phases. Scan parameters were Repetition time (TR) 51 msec; echo time (TE) 1.4 msec; flip angle (FA) 50 degree; slice thickness 7-8 mm without slice gap; matrix is 156x256, field-of-view is rotated to avoid wrap according to the size of each patient and voxel size is modified according to the field of view. Respiratory motion artifact can be minimized by breath-holding (preferred when possible) or by acquiring 4-5 signal averages (= number of excitations) with the patient breathing. Black blood images (T2 fat suppression): They help in assessment myocardial edema in cases of acute infarction, active inflammation, and tumors. Short-axis Stacks, covering both ventricles from the base of the heart to the apex were acquired using ECG-gated fat suppression triple inversion recovery sequence during breath hold in cooperative patients and with free breathing in uncooperative patients. Scan parameters were Repetition time (TR) > 2000 msec; echo time (TE) > 60 msec; flip angle (FA) 90 degree; inversion time (TI) 120-170 msec; slice thickness 8 mm with slice gap; matrix is 208x208, field-of-view is rotated to avoid wrap according to the size of each patient and voxel size is modified according to the field of view. Respiratory motion artifact can be minimized by breath-holding (preferred when possible) or by acquiring 2–3 signal averages (= number of excitations) with the patient breathing. Phase contrast and flow assessment: Aorta and sub-aorta left ventricular outflow tract (LVOT) Q-flow phase contrast images which help determination of the peak systolic velocity and pressure gradient during rest across the narrowest point in LVOT, in blood flow volume quantification for internal validation of the SV, indirect assessment of mitral and tricuspid regurgitation if present, and cardiac output of the left ventricle. Measurements were performed with free-breathing and multiple signal averages (2) to prevent the effect of breath holding on the amount of blood passing in and out of the heart which confounds clinical interpretation. Scan parameters were Repetition time (TR) 105.2 msec; echo time (TE) 2.97 msec; flip angle (FA) 20 degree; slice thickness 8 mm; matrix is 119x192, field-of-view is rotated to avoid wrap according to the size of each patient and voxel size is modified according to the field of view. Images are acquired with retrospective ECG-gating, the reconstructed phases are 30 phases per R-R interval, velocity encoding starts from starts from 150 cm/sec in aorta. Injection of gadolinium-based contrast agent (Magnevist, Schering AG, Berlin, Germany, 0.5 mmol/kg). Delayed gadolinium enhancement (DGE): In our cases we used the available late gadolinium sequences in our centre; the free breathing single shot LGE and breath hold or free breathing with high average phase sensitive inversion recovery (PSIR) to calculate volume of replacement fibrosis. 5-10 minutes after injection of a gadolinium-based contrast agent DGE images were acquired in the same orientation as the cine images using scan parameters: Repetition time (TR) 906.4 msec; echo time (TE) 1.3 msec; flip angle (FA) 40 degree; slice thickness 8 mm; matrix is 122x192, images were acquired in diastole and triggered every 3-4 heartbeat, field-of-view is rotated to avoid wrap according the size of each patient and voxel size is modified according to the field of view. Post processing: Was done using software segments. We calculated: The functional parameters of each ventricle; end diastolic volume (EDV), end systolic volume (ESV), stroke volume (SV), end diastolic volume indexed to body surface area (EDVI), end systolic volume indexed to body surface area (ESVI), stroke volume indexed to body surface area (SVI) and ejection fraction (EF). The values were compared with the normal values of previous studies by (Kawel et al, 2015 and 2020) (13 and 14). Flow parameters for the aortic valve; peak systolic velocity, forward flow, backward flow, net flow, and regurgitation fraction. Tricuspid and mitral valve regurgitation were assessed indirectly by subtraction of the forward flow of aortic or pulmonary valves from the ventricular stroke volume then the product is subdivided by the ventricular stroke volume. MR Image Analysis MR image analyses were performed with commercially available software (cmr42, v. 5.11.4; Circle Cardiovascular Imaging, Calgary, Canada), According to 16 AHA segmentation of a bull’s-eye plot. 2-chamber and 4-chamber complementary images were used into the strain analysis, epicardial and endocardial surfaces were traced manually in end systolic and end diastolic phases, then propagated through other phases with papillary muscles exclusion only in strain assessment, they were included in volumetric and functional ventricular analysis. Regional strain parameters of the radial, circumferential, and longitudinal directions as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate, peak systolic velocity, time to peak displacement and time to peak strain were automatically computed. Cardiac function concerning the end diastolic volume absolute and indexed values (EDV and EDVI), end systolic volume absolute and indexed values (ESV and ESVI), stroke volume absolute and indexed values (SV and SVI), myocardial mass absolute and indexed values, and ejection fraction (EF) were calculated. Statistical Analysis Statistical analysis was performed with ANOVA and T-Test methods. The data are presented as mean and +/- standard deviation (SD). P value less than 0.05 was considered a statistically significant difference for all comparisons. Results Study Population HCM patients 21 male and 4 female; mean age 39.4-year, range 7: 65 years. Healthy control 16 male and 9 female; mean age 33-year, range 13–56 years. In the HCM group, there were 220 hypertrophied segments and 120 segments of an apparently normal thickness. Normal controls had 400 segments. The regional myocardium strain analysis in HCM patients in radial, circumferential, and longitudinal directions parameters are shown in Table 1 – 3 compared to healthy control table 4. Table 1 Radial strain analysis in HCM patients N Mean Standard deviation (SD) displacement(deg) HCM 220 3.7500 2.06423 Apparently normal 180 5.3017 2.45007 Total 400 4.4483 2.37259 strain (%) HCM 220 20.0977 13.09198 Apparently normal 180 27.7128 16.94304 Total 400 23.5245 15.40289 peak diastolic strain Rate(1/s) HCM 220 -1.2455 1.05589 Apparently normal 180 -1.6506 1.29574 Total 400 -1.4278 1.18569 peak diastolic Velocity(deg/s) HCM 220 -22.5109 13.05833 Apparently normal 180 -25.9861 14.34507 Total 400 -24.0748 13.74438 peak systolic strain rate(1/s) HCM 220 1.4527 1.37214 Apparently normal 180 2.0639 1.35691 Total 400 1.7278 1.39717 peak systolic velocity(deg/s) HCM 220 26.8573 16.86500 Apparently normal 180 33.6544 16.54626 Total 400 29.9160 17.04116 time to peak displacement(ms) HCM 220 354.6468 106.16875 Apparently normal 180 336.5578 85.54762 Total 400 346.5068 97.73002 time to peak strain(ms) HCM 220 339.2036 111.04739 Apparently normal 180 344.1128 93.94762 Total 400 341.4128 103.60508 Table 2 Circumferential strain analysis in HCM patients N Mean Standard deviation (SD) displacement(deg) HCM 220 1.4095 3.79885 Apparently normal 180 1.2656 4.54223 Total 400 1.3448 4.14511 strain (%) HCM 220 -11.3777 5.97949 Apparently normal 180 -14.9606 7.67467 Total 400 -12.9900 7.01667 peak diastolic strain Rate(1/s) HCM 220 0.6950 0.58686 Apparently normal 180 0.9717 0.75667 Total 400 0.8195 0.68182 peak diastolic Velocity(deg/s) HCM 220 -8.1750 30.74744 Apparently normal 180 -4.2944 35.11116 Total 400 -6.4288 32.79787 peak systolic strain rate(1/s) HCM 220 -0.9041 0.72549 Apparently normal 180 -1.2789 0.73970 Total 400 -1.0728 0.75446 peak systolic velocity(deg/s) HCM 220 7.9386 38.07865 Apparently normal 180 3.6900 43.46649 Total 400 6.0268 40.59472 time to peak displacement(ms) HCM 220 339.4059 167.06305 Apparently normal 180 323.9167 152.94768 Total 400 332.4358 160.85144 time to peak strain(ms) HCM 220 337.5836 121.95465 Apparently normal 180 347.5556 99.16645 Total 400 342.0710 112.24861 Table 3 Longitudinal strain analysis in HCM patients N Mean Standard deviation (SD) displacement(deg) HCM 216 2.8569 2.41196 Apparently normal 176 2.9801 3.04526 Total 392 2.9122 2.71169 strain (%) HCM 216 -5.9542 11.59742 Apparently normal 176 -12.2125 11.14986 Total 392 -8.7640 11.80314 peak diastolic strain Rate(1/s) HCM 216 0.4995 1.25125 Apparently normal 176 0.7847 1.27308 Total 392 0.6276 1.26746 peak diastolic Velocity(deg/s) HCM 216 -17.8653 21.10452 Apparently normal 176 -20.5591 23.45234 Total 392 -19.0747 22.20095 peak systolic strain rate(1/s) HCM 216 -0.7662 1.64343 Apparently normal 176 -1.0784 1.28969 Total 392 -0.9064 1.50125 peak systolic velocity(deg/s) HCM 216 20.4245 24.51892 Apparently normal 176 21.0784 27.04525 Total 392 20.7181 25.65249 time to peak displacement(ms) HCM 216 369.5435 144.80205 Apparently normal 176 359.6636 139.15729 Total 392 365.1077 142.19992 time to peak strain(ms) HCM 216 354.1847 163.71557 Apparently normal 176 362.4784 155.10324 Total 392 357.9084 159.75723 In the HCM group regional analysis The radial direction parameters in hypertrophic enhancing segments were significantly different from non-hypertrophic non-enhancing apparently normal segments as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate and peak systolic velocity (P < 0.05). There was no significant difference as regard the time to peak displacement (P < 0.065, approaching the significant cut off value) and time to peak strain. The longitudinal direction parameters in hypertrophic enhancing segments were significantly different from non-hypertrophic non-enhancing apparently normal as regard the strain, peak diastolic strain rate and peak systolic strain rate (P < 0.05). There was no significant difference as regard the displacement and peak systolic velocity. time to peak displacement and time to peak strain and peak diastolic velocity. The circumferential direction parameters in hypertrophic enhancing segments were significantly different from non-hypertrophic non-enhancing apparently normal as regard the strain, peak diastolic strain rate and peak systolic strain rate (P < 0.05). There was no significant difference as regard the displacement and peak systolic velocity. time to peak displacement and time to peak strain and peak diastolic velocity. In comparison, hypertrophic and normal control persons The radial regional analysis, the hypertrophic enhancing segments were significantly different from the normal as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate, peak systolic velocity, time to peak displacement and time to peak strain (P < 0.05). There was no significant difference as regard the time to peak strain, while the apparently normal non-enhancing segments in HCM patients present significant difference compared with normal persons as regard strain and peak systolic velocity only, despite absent significant difference as regard the time to peak strain, yet P < 0.085, approaching the significant cut off value. The longitudinal regional analysis, the hypertrophic enhancing segments were significantly different from the normal as regard the displacement, strain, peak diastolic strain rate, peak systolic strain rate, peak systolic velocity, and time to peak displacement (P < 0.05), while the apparently normal non-enhancing segments in HCM patients present significant difference compared with normal persons as regard the displacement, and peak systolic velocity, despite absent significant difference as regard the time to peak strain, yet P < 0.08, approaching the significant cut off value. The regional circumferential analysis, the hypertrophic enhancing segments were significantly different from the normal as regard the strain, peak diastolic strain rate, peak systolic velocity, and time to peak displacement (P < 0.05), while the apparently normal non-enhancing segments in HCM patients present significant difference compared with normal persons as regard the strain, and peak systolic velocity, despite absent significant difference as regard the time to peak strain, yet P < 0.059, approaching the significant cut off value. Discussion For HCM patients especially during stage 2 (classic phenotype), EF values are apparently normal (pseudo normal) or even higher than the normal values, while regional wall deformation and dysfunction of the hypertrophied segments and even in the segments of apparently normal thickness already occur. Radial strain parameters are more affected than circumferential and longitudinal directions as myocardial hypertrophy and wall thickness occur in the radial direction (concentric not eccentric). The non-enhancing segments with apparently normal thickness present also a significant change to a lesser degree, but they don’t have any tendency for functional compensation. Previous research demonstrated that strain analysis can have long-term predictive values in identifying the HCM patients at increased risk for adverse events in follow-up heart failure (stages of adverse remodeling and overt dysfunction) (11 and 12). Conclusion The hypertrophied segments are more affected than the segments of apparently normal thickness in HCM patients, especially in the radial direction, the apparently normal segments are also affected with no tendency of functional compensation. These findings are essential in follow up studies especially with young patients presenting preserved cardiac function. Study limitations: The population of study was limited, Declarations Funding: The authors did not receive support from any organization for the submitted work. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Data availability statement All data and studies are available for more accurate assessment. Human Ethics and Consent to Participate declarations: All participants received a detailed explanation of the MRI study, confirm their acceptance to participate and publish the results in a written form. Clinical trial number: not applicable References Minhas, A. M. K., Wyand, R. A., Ariss, R. W., Nazir, S., Shahzeb Khan, M., Jia, X., Greene, S. J., Fudim, M., Wang, A., Warraich, H. J., Kalra, A., Alam, M., & Virani, S. S. (2022). 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BioMed Central Ltd. https://doi.org/10.1186/s12968-020-00683-3 Table 4 Table 4 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table4.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5678626","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":395036663,"identity":"4fa03334-ce8e-4213-a8ac-416f95484030","order_by":0,"name":"Esraa Maher","email":"","orcid":"","institution":"Helwan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Esraa","middleName":"","lastName":"Maher","suffix":""},{"id":395036664,"identity":"7f54b952-3c1d-403f-8e48-1f22dc1a7f31","order_by":1,"name":"Magdi Khalil","email":"","orcid":"","institution":"Helwan 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17:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5678626/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5678626/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72645461,"identity":"d5fe8eee-8773-4010-aa29-3ebd649ddf29","added_by":"auto","created_at":"2024-12-30 16:44:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3176359,"visible":true,"origin":"","legend":"\u003cp\u003eillustrative case, 44-year-old male patient presents with asymmetrical hypertrophied left ventricular myocardium involving septal segments, acute myocardial break down as regard the patchy focal increased signal in T2 fat suppression WI with corresponding delayed enhancement.\u003c/p\u003e\n\u003cp\u003eSignificantly affected regional radial strain parameters in basal septal segments as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate and peak systolic velocity.\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-5678626/v1/173893fe12fe3a990889dda4.png"},{"id":74150660,"identity":"2615238b-ecb8-4449-91ea-d2ea75f621e1","added_by":"auto","created_at":"2025-01-18 18:16:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5108092,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5678626/v1/e8c750ea-98ec-4a00-944e-0708b1d0c5b3.pdf"},{"id":72646907,"identity":"825105b0-af0e-476b-a54b-acce74808149","added_by":"auto","created_at":"2024-12-30 17:00:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":126116,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-5678626/v1/ea6a732e5b6a828dfa4d074a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"MRI regional strain analysis in patients with hypertrophic cardiomyopathy in Mediterranean cohort","fulltext":[{"header":"Background","content":"\u003cp\u003eHypertrophic cardiomyopathy is an inherited autosomal dominant disease with an estimated prevalence of 1:200 affecting approximately 0.2\u0026minus;0.5% of the general population (1 and 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is heterogenous in nature with a broad spectrum of phenotypic expression and clinical presentation caused by more than 1500 mutations in 11 or more genes encoding cardiac sarcomere proteins, including cardiac \u0026beta;-myosin heavy chain, cardiac myosin binding protein C, and troponin T (3 and 4).\u003c/p\u003e\n\u003cp\u003eHCM presents a wide spectrum of manifestations ranging from asymptomatic with normal life expectancy to ventricular arrhythmia, sudden cardiac death, and heart failure (4).\u003c/p\u003e\n\u003cp\u003eThe histopathological findings in HCM include myocardial fibers disarray, hypertrophy of cardiomyocytes, myocyte disarray, interstitial and replacement fibrosis as well as abnormal intramural coronary arteries (5 and 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHemodynamics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe left ventricle in HCM patients usually presents a diastolic dysfunction and restrictive ventricular filling with normal or reduced EDVI, a reduced ESVI, a high-normal or pseudo normal EF.\u0026nbsp;It is caused by the increased interstitial fibrosis and the slowed relaxation and increased stiffness of the hypertrophied myocardial segments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegional\u0026nbsp;systolic myocardial\u0026nbsp;function\u0026nbsp;is also commonly impaired, as detected by pulsed and tissue Doppler imaging, 3-dimensional speckle-tracking echocardiography, and magnetic resonance imaging. Finally systolic\u0026nbsp;function\u0026nbsp;declines, the left ventricular wall thins with adverse remodeling, the cavity dilates, and heart failure with reduced EF develops, sometimes referred to as burnt out HCM or stage 4 of overt dysfunction (7 and 8).\u003c/p\u003e\n\u003cp\u003eMeasuring the regional segmental deformation and dysfunction by tissue tracking and strain analysis is more informative than simple measurement of EF in HCM patients as it can quantitatively measure segmental myocardium function in radial, circumferential, and longitudinal directions, by several parameters including displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate, peak systolic velocity, time to peak displacement and time to peak strain.\u003c/p\u003e\n\u003cp\u003eThe purpose of the present work was to quantify and compare the regional myocardial strain in the hypertrophied segments and segments of apparently normal thickness in comparison to normal persons.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study was approved by the ethical committee of Ain Shams University Hospitals, 25 HCM patients were included and 25 normal control persons who were included came to our institute with suspected abnormalities, yet their MRI examinations were normal.\u003c/p\u003e\n\u003cp\u003eAccording to American heart association (AHA) guidelines (9 and 10), inclusion criteria were determined as\u003c/p\u003e\n\u003col class=\"decimal_type\"\u003e\n \u003cli\u003eWall thickness equal or above 15 mm in the absence of other causes of hypertrophy.\u003c/li\u003e\n \u003cli\u003eEnd diastolic wall thickness equal or above 13 mm with a family history of HCM.\u003c/li\u003e\n \u003cli\u003eFocal asymmetric hypertrophy of the basal anterior septum, defined as septal/posterior wall thickness above 1.3 in a normotensive patient.\u003c/li\u003e\n \u003cli\u003eIn the pediatric population hypertrophy diagnosed at z score or myocardial thickness above 2 in correlation to sex and body surface area.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe exclusion criteria included hypertension, diabetes, amyloidosis, sarcoidosis, any other pathology that contributes to myocardial hypertrophy.\u003c/p\u003e\n\u003cp\u003eHCM patients 21 male and 4 female; mean age 39.4-year, range 7: 65 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealthy control 16 male and 9 female; mean age 33-year, range 13-56 years. With exclusion criteria of hypertension, diabetes, or any underlying disease even if controlled and non-complicated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMR Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003ePreparation before procedure:\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eExplanation of the procedure to the patient especially the side effects of the contrast agent including coldness, warmth, or pain at the injection site, nausea, vomiting, headache, paresthesias, dizziness and itching.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThey should be aware of the severe life-threatening anaphylactoid or nonallergic anaphylactic and nephropathic effect.\u003c/li\u003e\n \u003cli\u003eExclusion of any hazards like functioning MRI-incompatible pacemaker.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eReview kidney function test to avoid nephrogenic systemic fibrosis which may happen in case of contrast administration with acute or chronic renal failure (contrast shouldn\u0026rsquo;t be given in estimated glomerular filtration rate \u0026lt;30 ml/min/1.73 m2).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eDuring procedure:\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003ePhysiological monitoring devices and hearing protection are put in place.\u003c/li\u003e\n \u003cli\u003eA high-quality electrocardiogram (ECG) signal is essential for optimum data quality in cardiac-gated sequences.\u003c/li\u003e\n \u003cli\u003eThe imaging coil should be chosen to maximize the signal-to-noise ratio over the body region to be examined.\u003c/li\u003e\n \u003cli\u003eAn appropriately equipped resuscitation cart and emergency management plan for the MR environment should be in place.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eTechnique of imaging:\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eMachine used is Siemens MAGNETOM Aera 1.5T MRI Scanner\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eWhite blood images:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eThey help in assessment of EF, EDV, ESV, EDVI, ESVI, SV, SVI, cardiac mass, and segmental motion pattern of both left and right ventricles.\u003c/li\u003e\n \u003cli\u003eLong-axis 2 and 4 chamber views and short-axis (and or axial) Stacks, covering both ventricles from the base of the heart to the apex were acquired using a retrospective ECG-gated steady-state free precession sequence during breath hold in cooperative patients and with free breathing in uncooperative patients, the reconstructed phases per R-R interval are 30 phases, yet, some patients presented with arrhythmias need prospective gating with minimum accepted phases per R-R interval are 18 phases.\u003c/li\u003e\n \u003cli\u003eScan parameters were Repetition time (TR) 51 msec; echo time (TE) 1.4 msec; flip angle (FA) 50 degree; slice thickness 7-8 mm without slice gap; matrix is 156x256, field-of-view is rotated to avoid wrap according to the size of each patient and voxel size is modified according to the field of view.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRespiratory motion artifact can be minimized by breath-holding (preferred when possible) or by acquiring 4-5 signal averages (= number of excitations) with the patient breathing.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eBlack blood images (T2 fat suppression):\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eThey help in assessment myocardial edema in cases of acute infarction, active inflammation, and tumors.\u003c/li\u003e\n \u003cli\u003eShort-axis Stacks, covering both ventricles from the base of the heart to the apex were acquired using ECG-gated fat suppression triple inversion recovery sequence during breath hold in cooperative patients and with free breathing in uncooperative patients.\u003c/li\u003e\n \u003cli\u003eScan parameters were Repetition time (TR) \u0026gt; 2000 msec; echo time (TE) \u0026gt; 60 msec; flip angle (FA) 90 degree; inversion time (TI) 120-170 msec; slice thickness 8 mm with slice gap; matrix is 208x208, field-of-view is rotated to avoid wrap according to the size of each patient and voxel size is modified according to the field of view.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRespiratory motion artifact can be minimized by breath-holding (preferred when possible) or by acquiring 2\u0026ndash;3 signal averages (= number of excitations) with the patient breathing.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003ePhase contrast and flow assessment:\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eAorta and sub-aorta left ventricular outflow tract (LVOT) Q-flow phase contrast images which help determination of the peak systolic velocity and pressure gradient during rest across the narrowest point in LVOT, in blood flow volume quantification for internal validation of the SV, indirect assessment of mitral and tricuspid regurgitation if present, and cardiac output of the left ventricle.\u003c/li\u003e\n \u003cli\u003eMeasurements were performed with free-breathing and multiple signal averages (2) to prevent the effect of breath holding on the amount of blood passing in and out of the heart which confounds clinical interpretation.\u003c/li\u003e\n \u003cli\u003eScan parameters were Repetition time (TR) 105.2 msec; echo time (TE) 2.97 msec; flip angle (FA) 20 degree; slice thickness 8 mm; matrix is 119x192, field-of-view is rotated to avoid wrap according to the size of each patient and voxel size is modified according to the field of view.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eImages are acquired with retrospective ECG-gating, the reconstructed phases are 30 phases per R-R interval, velocity encoding starts from starts from 150 cm/sec in aorta.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;Injection of gadolinium-based contrast agent (Magnevist, Schering AG, Berlin, Germany, 0.5 mmol/kg).\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eDelayed gadolinium enhancement (DGE):\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eIn our cases we used the available late gadolinium sequences in our centre; the free breathing single shot LGE and breath hold or free breathing with high average phase sensitive inversion recovery (PSIR) to calculate volume of replacement fibrosis.\u003c/li\u003e\n \u003cli\u003e5-10 minutes after injection of a gadolinium-based contrast agent DGE images were acquired in the same orientation as the cine images using scan parameters: Repetition time (TR) 906.4 msec; echo time (TE) 1.3 msec; flip angle (FA) 40 degree; slice thickness 8 mm; matrix is 122x192, images were acquired in diastole and triggered every 3-4 heartbeat, field-of-view is rotated to avoid wrap according the size of each patient and voxel size is modified according to the field of view.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePost processing:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWas done using software segments.\u003c/p\u003e\n\u003cp\u003eWe calculated:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThe functional parameters of each ventricle; end diastolic volume (EDV), end systolic volume (ESV), stroke volume (SV), end diastolic volume indexed to body surface area (EDVI), end systolic volume indexed to body surface area (ESVI), stroke volume indexed to body surface area (SVI) and ejection fraction (EF).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe values were compared with the normal values of previous studies by (Kawel et al, 2015 and 2020) (13 and 14).\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eFlow parameters for the aortic valve; peak systolic velocity, forward flow, backward flow, net flow, and regurgitation fraction.\u003c/li\u003e\n \u003cli\u003eTricuspid and mitral valve regurgitation were assessed indirectly by subtraction of the forward flow of aortic or pulmonary valves from the ventricular stroke volume then the product is subdivided by the ventricular stroke volume.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMR Image Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMR image analyses were performed with commercially available software (cmr42, v. 5.11.4; Circle Cardiovascular Imaging, Calgary, Canada), According to 16 AHA segmentation of a bull\u0026rsquo;s-eye plot.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2-chamber and 4-chamber complementary images were used into the strain analysis, epicardial and endocardial surfaces were traced manually in end systolic and end diastolic phases, then propagated through other phases with papillary muscles exclusion only in strain assessment, they were included in volumetric and functional ventricular analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegional strain parameters of the radial, circumferential, and longitudinal directions as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate, peak systolic velocity, time to peak displacement and time to peak strain were automatically computed.\u003c/p\u003e\n\u003cp\u003eCardiac function concerning the end diastolic volume absolute and indexed values (EDV and EDVI), end systolic volume absolute and indexed values (ESV and ESVI), stroke volume absolute and indexed values (SV and SVI), myocardial mass absolute and indexed values, and ejection fraction (EF) were calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed with ANOVA and T-Test methods. The data are presented as mean and +/- standard deviation (SD). P value less than 0.05 was considered a statistically significant difference for all comparisons.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eHCM patients 21 male and 4 female; mean age 39.4-year, range 7: 65 years.\u003c/p\u003e \u003cp\u003eHealthy control 16 male and 9 female; mean age 33-year, range 13\u0026ndash;56 years.\u003c/p\u003e \u003cp\u003eIn the HCM group, there were 220 hypertrophied segments and 120 segments of an apparently normal thickness.\u003c/p\u003e \u003cp\u003eNormal controls had 400 segments.\u003c/p\u003e \u003cp\u003eThe regional myocardium strain analysis in HCM patients in radial, circumferential, and longitudinal directions parameters are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e compared to healthy control table 4.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadial strain analysis in HCM patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003edisplacement(deg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.7500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.06423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.3017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.45007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.4483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.37259\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003estrain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.0977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.09198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.7128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.94304\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.5245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.40289\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak diastolic strain Rate(1/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.2455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.05589\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.6506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.29574\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.4278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.18569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak diastolic Velocity(deg/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-22.5109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.05833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-25.9861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.34507\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-24.0748\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.74438\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak systolic strain rate(1/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.4527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.37214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0639\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.35691\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.39717\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak systolic velocity(deg/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.8573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.86500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.6544\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.54626\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.9160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.04116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etime to peak displacement(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e354.6468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e106.16875\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e336.5578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e85.54762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e346.5068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e97.73002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etime to peak strain(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e339.2036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e111.04739\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e344.1128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e93.94762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e341.4128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e103.60508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCircumferential strain analysis in HCM patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003edisplacement(deg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.4095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.79885\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2656\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.54223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.3448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.14511\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003estrain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-11.3777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.97949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-14.9606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.67467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-12.9900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.01667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak diastolic strain Rate(1/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6950\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.58686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9717\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.75667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.8195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.68182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak diastolic Velocity(deg/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-8.1750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30.74744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.2944\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35.11116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-6.4288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32.79787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak systolic strain rate(1/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.9041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.72549\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.2789\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.73970\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.0728\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.75446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak systolic velocity(deg/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.9386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.07865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43.46649\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.0268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.59472\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etime to peak displacement(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e339.4059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e167.06305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e323.9167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e152.94768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e332.4358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e160.85144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etime to peak strain(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e337.5836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121.95465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e347.5556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e99.16645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e342.0710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e112.24861\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLongitudinal strain analysis in HCM patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003edisplacement(deg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.41196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.9801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.04526\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.9122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.71169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003estrain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.9542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.59742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-12.2125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.14986\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-8.7640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.80314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak diastolic strain Rate(1/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.25125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.27308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.26746\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak diastolic Velocity(deg/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-17.8653\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.10452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-20.5591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.45234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-19.0747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.20095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak systolic strain rate(1/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.7662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.64343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.0784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.28969\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.9064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.50125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003epeak systolic velocity(deg/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.4245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.51892\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.0784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.04525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.7181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.65249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etime to peak displacement(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e369.5435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e144.80205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e359.6636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139.15729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e365.1077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e142.19992\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etime to peak strain(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e354.1847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e163.71557\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApparently normal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e362.4784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e155.10324\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e357.9084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e159.75723\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eIn the HCM group regional analysis\u003c/h2\u003e \u003cp\u003eThe \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eradial direction\u003c/span\u003e parameters in hypertrophic enhancing segments were significantly different from non-hypertrophic non-enhancing apparently normal segments as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate and peak systolic velocity (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference as regard the time to peak displacement (P\u0026thinsp;\u0026lt;\u0026thinsp;0.065, approaching the significant cut off value) and time to peak strain.\u003c/p\u003e \u003cp\u003eThe \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003elongitudinal direction\u003c/span\u003e parameters in hypertrophic enhancing segments were significantly different from non-hypertrophic non-enhancing apparently normal as regard the strain, peak diastolic strain rate and peak systolic strain rate (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference as regard the displacement and peak systolic velocity. time to peak displacement and time to peak strain and peak diastolic velocity.\u003c/p\u003e \u003cp\u003eThe \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ecircumferential direction\u003c/span\u003e parameters in hypertrophic enhancing segments were significantly different from non-hypertrophic non-enhancing apparently normal as regard the strain, peak diastolic strain rate and peak systolic strain rate (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference as regard the displacement and peak systolic velocity. time to peak displacement and time to peak strain and peak diastolic velocity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eIn comparison, hypertrophic and normal control persons\u003c/h2\u003e \u003cp\u003eThe radial regional analysis, the hypertrophic enhancing segments were significantly different from the normal as regard the displacement, strain, peak diastolic strain rate, peak diastolic velocity, peak systolic strain rate, peak systolic velocity, time to peak displacement and time to peak strain (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference as regard the time to peak strain, while the apparently normal non-enhancing segments in HCM patients present significant difference compared with normal persons as regard strain and peak systolic velocity only, despite absent significant difference as regard the time to peak strain, yet P\u0026thinsp;\u0026lt;\u0026thinsp;0.085, approaching the significant cut off value.\u003c/p\u003e \u003cp\u003eThe longitudinal regional analysis, the hypertrophic enhancing segments were significantly different from the normal as regard the displacement, strain, peak diastolic strain rate, peak systolic strain rate, peak systolic velocity, and time to peak displacement (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while the apparently normal non-enhancing segments in HCM patients present significant difference compared with normal persons as regard the displacement, and peak systolic velocity, despite absent significant difference as regard the time to peak strain, yet P\u0026thinsp;\u0026lt;\u0026thinsp;0.08, approaching the significant cut off value.\u003c/p\u003e \u003cp\u003eThe regional circumferential analysis, the hypertrophic enhancing segments were significantly different from the normal as regard the strain, peak diastolic strain rate, peak systolic velocity, and time to peak displacement (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while the apparently normal non-enhancing segments in HCM patients present significant difference compared with normal persons as regard the strain, and peak systolic velocity, despite absent significant difference as regard the time to peak strain, yet P\u0026thinsp;\u0026lt;\u0026thinsp;0.059, approaching the significant cut off value.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor HCM patients especially during stage 2 (classic phenotype), EF values are apparently normal (pseudo normal) or even higher than the normal values, while regional wall deformation and dysfunction of the hypertrophied segments and even in the segments of apparently normal thickness already occur.\u003c/p\u003e \u003cp\u003eRadial strain parameters are more affected than circumferential and longitudinal directions as myocardial hypertrophy and wall thickness occur in the radial direction (concentric not eccentric).\u003c/p\u003e \u003cp\u003eThe non-enhancing segments with apparently normal thickness present also a significant change to a lesser degree, but they don\u0026rsquo;t have any tendency for functional compensation.\u003c/p\u003e \u003cp\u003ePrevious research demonstrated that strain analysis can have long-term predictive values in identifying the HCM patients at increased risk for adverse events in follow-up heart failure (stages of adverse remodeling and overt dysfunction) (11 and 12).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe hypertrophied segments are more affected than the segments of apparently normal thickness in HCM patients, especially in the radial direction, the apparently normal segments are also affected with no tendency of functional compensation.\u003c/p\u003e \u003cp\u003eThese findings are essential in follow up studies especially with young patients presenting preserved cardiac function.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy limitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe population of study was limited,\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFunding: The authors did not receive support from any organization for the submitted work.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eData availability statement\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll data and studies are available for more accurate assessment.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eHuman Ethics and Consent to Participate declarations:\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAll participants received a detailed explanation of the MRI study, confirm their acceptance to participate and publish the results in a written form.\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e\u003cu\u003eClinical trial number: not applicable\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMinhas, A. M. K., Wyand, R. A., Ariss, R. W., Nazir, S., Shahzeb Khan, M., Jia, X., Greene, S. J., Fudim, M., Wang, A., Warraich, H. J., Kalra, A., Alam, M., \u0026amp; Virani, S. S. (2022). Demographic and Regional Trends of Hypertrophic Cardiomyopathy-Related Mortality in the United States, 1999 to 2019. Circulation: Heart Failure, 15(9), E009292. https://doi.org/10.1161/CIRCHEARTFAILURE.121.009292.\u003c/li\u003e\n \u003cli\u003eSemsarian C, Ingles J, Maron MS, Maron BJ. New perspectives on the prevalence of hypertrophic cardiomyopathy. J Am Coll Cardiol 2015; 65:1249\u0026ndash;1254.\u003c/li\u003e\n \u003cli\u003eBaxi AJ, Restrepo CS, Vargas D, et al. Hypertrophic cardiomyopathy from A to Z: Genetics, pathophysiology, imaging, and management. Radiographics 2016;36:335\u0026ndash;354. 2016 Mar-Apr;36(2):335-54. doi: 10.1148/rg.2016150137.\u003c/li\u003e\n \u003cli\u003eAmano, Y., Kitamura, M., Takano, H., Yanagisawa, F., Tachi, M., Suzuki, Y., Kumita, S., \u0026amp; Takayama, M. (2018). Cardiac MR imaging of hypertrophic cardiomyopathy: Techniques, findings, and clinical relevance. In Magnetic Resonance in Medical Sciences (Vol. 17, Issue 2, pp. 120\u0026ndash;131). Japanese Society for Magnetic Resonance in Medicine. https://doi.org/10.2463/mrms.rev.2017-0145\u003c/li\u003e\n \u003cli\u003eCui, H., Schaff, H. v., Lentz Carvalho, J., Nishimura, R. A., Geske, J. B., Dearani, J. A., Lahr, B. D., Lee, A. T., Bos, J. M., Ackerman, M. J., Ommen, S. R., \u0026amp; Maleszewski, J. J. (2021). Myocardial Histopathology in Patients With Obstructive Hypertrophic Cardiomyopathy. Journal of the American College of Cardiology, 77(17), 2159\u0026ndash;2170. https://doi.org/10.1016/j.jacc.2021.03.008\u003c/li\u003e\n \u003cli\u003eAlmaas, V., and Amlie, P. Histopathological Changes and Clinical Implications in Patients with Hypertrophic Cardiomyopathy, European Cardiology 2010;6(2):88\u0026ndash;90 https://doi.org/10.15420/ecr.2010.6.2.88\u003c/li\u003e\n \u003cli\u003eMarian, A. J., \u0026amp; Braunwald, E. (2017). Hypertrophic cardiomyopathy: Genetics, pathogenesis, clinical manifestations, diagnosis, and therapy. Circulation Research, 121(7), 749\u0026ndash;770. https://doi.org/10.1161/CIRCRESAHA.117.311059\u003c/li\u003e\n \u003cli\u003eOlivotto, I., Cecchi, F., Poggesi, C., \u0026amp; Yacoub, M. H. (2012). Patterns of disease progression in hypertrophic cardiomyopathy an individualized approach to clinical staging. Circulation: Heart Failure, 5(4), 535\u0026ndash;546. https://doi.org/10.1161/CIRCHEARTFAILURE.112.967026\u003c/li\u003e\n \u003cli\u003eOmmen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, et al. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2020;162:e23-106. \u003c/li\u003e\n \u003cli\u003eLopez L, Colan S, Stylianou M, Granger S, Trachtenberg F, Frommelt P, et al. Relationship of Echocardiographic Z Scores Adjusted for Body Surface Area to Age, Sex, Race, and Ethnicity: The Pediatric Heart Network Normal Echocardiogram Database. Circ Cardiovasc Imaging 2017;10: e006979.\u003c/li\u003e\n \u003cli\u003eReant P, Reynaud A, Pillois X, et al. Comparison of resting and exercise echocardiographic as indicators of outcomes in hypertrophic. J Am Soc Echocardiogr 2015;28:194\u0026ndash;203.\u003c/li\u003e\n \u003cli\u003eReant P, Mirabel M, Lloyd G, et al. Global longitudinal strain is associated with heart failure outcomes in hypertrophic cardiomyopathy. Heart 2016;102:741\u0026ndash;747.\u003c/li\u003e\n \u003cli\u003eKawel-Boehm, N., Maceira, A., Valsangiacomo-Buechel, E. R., Vogel-Claussen, J., Turkbey, E. B., Williams, R., Plein, S., Tee, M., Eng, J., \u0026amp; Bluemke, D. A. (2015). Normal values for cardiovascular magnetic resonance in adults and children. In \u003cem\u003eJournal of Cardiovascular Magnetic Resonance\u003c/em\u003e (Vol. 17, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12968-015-0111-7\u003c/li\u003e\n \u003cli\u003eKawel-Boehm, N., Hetzel, S. J., Ambale-Venkatesh, B., Captur, G., Francois, C. J., Jerosch-Herold, M., Salerno, M., Teague, S. D., Valsangiacomo-Buechel, E., van der Geest, R. J., \u0026amp; Bluemke, D. A. (2020). Reference ranges (\u0026ldquo;normal values\u0026rdquo;) for cardiovascular magnetic resonance (CMR) in adults and children: 2020 update. In \u003cem\u003eJournal of Cardiovascular Magnetic Resonance\u003c/em\u003e (Vol. 22, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12968-020-00683-3\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 4","content":"\u003cp\u003eTable 4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5678626/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5678626/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To evaluate the regional left ventricular myocardial strain in patient with hypertrophic cardiomyopathy (HCM) especially young apparently compensated patients by magnetic resonance imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e 25 HCM patients representing all age groups and 25 healthy volunteers underwent 1.5 Tesla MRI examination for cardiac volumes, and mass, followed by regional strain analysis in radial, circumferential, and longitudinal directions as regard the displacement, strain, peak diastolic and systolic strain rate, peak diastolic and systolic velocity, time to peak displacement and time to peak strain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In the HCM group, hypertrophic segments showing delayed gadolinium enhancement (DGE) were significantly different from non-hypertrophic apparently normal showing no enhancement concerning most of the regional radial strain parameters.\u003c/p\u003e\n\u003cp\u003eIn longitudinal and circumferential directions, hypertrophic segments showing DGE were significantly different from apparently normal segments with no enhancement as regard the strain, peak diastolic and systolic strain rate.\u003c/p\u003e\n\u003cp\u003eCompared to normal volunteers, the hypertrophic segments with DGE were significantly different concerning most of the radial and longitudinal strain parameters, while apparently normal segments with no enhancement don’t present a similar significant difference.\u003c/p\u003e\n\u003cp\u003eIn circumferential analysis, hypertrophic enhancing segments were significantly different as regard the strain, peak diastolic strain rate, peak systolic velocity, and time to peak displacement, while the apparently normal non-enhancing segments present difference concerning the strain, peak systolic velocity, and time to peak displacement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe hypertrophied segments showing DGE are more affected than the segments of apparently normal thickness non enhancing in HCM patients, especially in the radial direction, the apparently normal segments are less affected with no tendency of functional compensation.\u003c/p\u003e\n\u003cp\u003eThese findings are crucial in young age apparently compensated patients’ diagnosis follow up.\u003c/p\u003e","manuscriptTitle":"MRI regional strain analysis in patients with hypertrophic cardiomyopathy in Mediterranean 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