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Updated: Jun 19, 2026
Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation
Published on: October 20, 2016
Association of LVOT Gradient and LA Strain with Cardiac Events in Pediatric HCM
Addison Gearhart1,2,3, Sonia F Epstein4, Kimberlee Gauvreau1,2
1Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
Insights
In young patients with hypertrophic cardiomyopathy (HCM), exercise-induced left ventricular outflow tract (LVOT) obstruction and reduced left atrial (LA) strain are linked to cardiac events. LA strain offers greater predictive value than traditional measures for assessing cardiac risk.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Echocardiography
Background:
- Left ventricular outflow tract (LVOT) obstruction and reduced left atrial (LA) strain are known risk factors for cardiac events in adults with hypertrophic cardiomyopathy (HCM).
- Limited data exist on the prognostic value of these parameters in pediatric HCM populations.
Purpose of the Study:
- To evaluate the association between exercise-induced LVOT obstruction, LA strain, and cardiac events in young patients with HCM.
- To compare the predictive value of LA strain with traditional diastolic indices for cardiac events in pediatric HCM.
Main Methods:
- Retrospective analysis of 114 pediatric HCM patients undergoing exercise stress echocardiography (ESE) from 2014-2022.
- Patients stratified into groups based on resting and exercise LVOT gradients.
- Analysis of LA reservoir strain (LASr), conduit strain (LAScd), and LA stiffness using TOMTEC AutoStrain LA software.
Main Results:
- Patients with higher exercise LVOT gradients (Group 3) had a significantly greater hazard of composite cardiac events compared to those with moderate gradients (Group 2).
- Reduced LASr and LAScd, and increased LA stiffness were independently associated with composite cardiac events.
- LA strain and stiffness models demonstrated higher predictive accuracy (c-index 0.81-0.82) compared to models using traditional diastolic indices (c-index 0.76).
Conclusions:
- In pediatric HCM, exercise-induced LVOT obstruction is associated with increased cardiac event risk.
- Reduced left atrial strain provides incremental prognostic value beyond LVOT gradient and traditional diastolic indices for identifying young patients at risk of cardiac events.
Abstract:
In adults with hypertrophic cardiomyopathy (HCM), left ventricular outflow tract (LVOT) obstruction on exercise stress echocardiography (ESE) and reduced left atrial (LA) strain increase heart failure and cardiac outcome risk. However, limited pediatric data exist. We evaluated the association of exercise-induced LVOT obstruction and LA strain with cardiac events in young HCM patients. Patients who underwent ESE (n = 114, 32%F, median = 17 yrs) from 2014-2022 at a single center were stratified by LVOT gradients: Group 1 (n = 44, rest/exercise gradients < 30mmHg); Group 2 (n = 41, rest < 30mmHg; exercise ≥ 30mmHg); Group 3 (n = 29, rest/exercise ≥ 30mmHg). LA reservoir (LASr), conduit (LAScd), and contractile strain were analyzed with TOMTEC AutoStrain LA. Composite cardiac event included: heart failure, non-sustained/sustained ventricular tachycardia, cardiac syncope, heart transplantation, and HCM-related death. At follow-up (median = 2.0 years), there was a greater hazard of the composite event in Group 3 vs. 2 (hazard-ratio [HR] = 4.97, p = 0.013). Severe events were rare and largely observed in Group 3. Increased HR was seen in Group 2 vs. 1 but the difference was not significant. Adjusting for LVOT gradient (Group 3), lower LASr or LAScd or increased LA stiffness (E/e' to LASr ratio) were associated with composite event (HR LASr = 1.57; LAScd = 1.70; LA stiffness = 1.31; all p < 0.01). Concordance indices were similar for these three strain/stiffness models (0.81-0.82) and higher than in models including LVOT group with traditional diastolic indices (LA volume index or E/e'; c-index = 0.76). In one of the largest pediatric HCM cohorts undergoing ESE, reduced LA strain demonstrated greater incremental value to LVOT gradient than traditional diastolic indices when evaluating association with cardiac events.
