Abstract
Objective
This study aimed to investigate the effects of gender, age and other physiologic parameters on left ventricular (LV) myocardial work (MW) in healthy subjects and to explore the potential correlation between the MW and the ventricular myocardial band (VMB).
Methods
According to the inclusion criteria 479 subjects aged ≥20 years old who visited our hospital from September 2019 to August 2022 were enrolled and were divided into three groups by 15 years as the age interval. Among them, 187 were 20-39 years old {(39.04%), including 87 men (46.52%) and 100 women (53.47%)}; 153 were 40-54 years old {(31.94%), including 63 men (41.18%) and 90 women (58.82%)}; 139 were aged ≥55 years {(29.02%), including 75 men (53.96%) and 64 women (46.04%)}. All subjects underwent echocardiography and apical views were analyzed. Blood pressure (BP) was measured after the examination.
Results
MW exhibited distinct gender- and age-specific characteristics. Within the same age group, females demonstrated higher MW values than males. Furthermore, a significant age-related decline in MW was observed in females, particularly after 55 years of age. Additionally, the distribution patterns of MW, especially active work, suggested a potential correlation with the VMB.
Conclusion
1. MW evaluating by using echocardiography may be a good method for the assessment of real time, quantitative global and regional MW and the MW has obvious gender and age characteristics.2. There is a certain potential correlation between the MW and the VMB.
Keywords: Echocardiography, Myocardial work, Ventricular myocardial band, Left ventricular funtion
1. Introduction
Clinically, left ventricular (LV) systolic function is commonly assessed using indices of myocardial fiber shortening, such as left ventricular ejection fraction (LVEF) for global function, and wall thickening, myocardial velocity, and strain for regional function. However, these parameters do not directly reflect myocardial work (MW) or oxygen demand. In 2012, Russell et al. [1]. introduced a non-invasive method to assess myocardial work (MW) by combining speckle tracking imaging (STI)-derived myocardial strain and LV) afterload. This approach has been validated against invasive methods and positron emission tomography (PET) in animal studies, and is now widely used in clinical practice. MW encompasses both global (GMW) and segmental (SMW) measures, reflecting overall and regional systolic function, respectively.
For the assessment of regional function, the ventricle is divided into segments. According to the recommendation [2,3] (Fig. 1-Supplemental Material), there are three models (16-segments、17-segments and 18-segments). In this study, we used 18-segment model according to the analysis software provided by the merchant.
The macroscopic structure of the heart has been debated for centuries [4]. A significant contribution was made by Francisco Torrent-Guasp [5], who proposed the model of the ventricular myocardial band (VMB)(Fig. 1). This model describes the myocardium as a continuous helical band that forms the base and apex of the heart, the base segment of the LV free wall is formed by basal loop(BL) and the apex contains descending segment (DS) and ascending segment (AS). This distribution of the fibers forms the heart's special pattern in systolic and diastolic activity. The contraction of the LV follows a specific sequence: the LV free wall basal segment, then the DS (subendocardial myocardium) and gradually travels to the apex of the heart, and the spiral structure of the apical myocardium causes the contraction of the myocardium causing the heart to rotate and twist, counterclockwise at the base of the heart, and clockwise at the apex, just as the Lower described in 1669, heart contractions are like wringing out a cloth to squeeze out water [6].Subsequent contraction of the DS makes the ventricular base twist, rotate, and pulls it downward, thereby shortening the long axis of the ventricular cavity, reducing its volume and allowing ventricular ejection.
Fig. 1.
Unfolded VMB. A.VMB of the pig heart that cardiac surgery expert in our hospital delaminated and striped according to Torrents-Guasp. B. VMB with different color to mark segment corresponding to A. Blue: right segment; red: left segment; yellow: descending segment; green: ascending segment. C. The correlated echocardiographic short-axis slices seen from the apex to the top according to Omar's study [7]. (a. pulmonary artery root; b. Posterior interventricular groove; c. The boundary point between the basal segment and the apex segment, which is also the position where the basal segment folds back to form the descending segment; d. Demarcation between descending segment and ascending segment; e. aortic root. VMB, ventricular myocardial band.). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
VMB gives us a new impression of the distribution of myocardium in terms of spatial structure. Is there a certain correlation between the orderly contraction derived from VMB and the contribution (work) made by each segment of myocardium in the process of contraction? In the existing literature reports, the author has not found such a relevant report.
To our knowledge, this is the first study to establish normal reference value for SMW across all 18-segments to investigate the possible potential correlation between MW and VMB. It is hoped that the results of this study can be used on a clinical basis in different cardiac pathologies, especially the ischemic heart disease (IHD) and may be used for clinical determination of cardiac function to achieve better clinical therapeutic effect.
2. Materials and methods
2.1. Study population
2.1.1. Inclusion and exclusion criteria
2.1.1.1. Inclusion criteria
1. ≥20 years old 2. sinus rhythm 3. no clinical evidence supported hypertension, diabetes, kidney related disease, severe valvular disease, congenital heart disease, cardiomyopathy, coronary heart disease 0.4、high-quality image.
2.1.1.2. Exclusion criteria
1. <20 years old. 2.arrhythmology. 3.with clinical evidence supported hypertension, diabetes, kidney related disease, severe valvular disease, congenital heart disease, cardiomyopathy and coronary heart disease. 4.poor-quality image 5. people who refused to participate in the study. 6.people who can't sign an informed consent form.
2.1.2. Study population
According to the inclusion criteria, 479 subjects aged ≥20 years who visited our hospital between September 2019 to August 2022 were enrolled. They were divided into three groups based on 15-year age intervals. Among them, 187 subjects were 20-39 years old {(39.04%), including 87 men (46.52%) and 100 women (53.47%)}; 153 subjects were 40-54 years old {(31.94%), including 63 men (41.18%) and 90 women (58.82%)}; 139 subjects were aged ≥55 years {(29.02%), including 75 men (53.96%) and 64 women (46.04%)}.
2.2. 2D echocardiography
Transthoracic echocardiography (TTE) was performed with the subject lying at rest in the left lateral decubitus position by experienced sonographers. Ultrasound data were acquired and analyzed using commercially available system (S5-1 probe, Vivid E95, GE Medical Systems, Oslo, Norway) and analysis software EchoPAC version 203.The basic information of the subjects were first recorded, the electrocardiogram device is connected. Frame rates was adjusted at 50-90s−1. Routine grayscale two-dimensional (2D) cine loops from 3 consecutive beats were obtained at end-expiratory apnea from standard 3 apical views (four-chamber, two-chamber, and long-axis)(Fig. 2). Each view should include the complete LV (the endocardial and epicardium were clearly displayed).
Fig. 2.
A. show the bull's-eye graph of normal MW; B. Standard 3 apical views(a-c) for analysis the MW and the form of bull's eye map(d). a: apical four-chamber (A4C),b: apical two-chamber (A2C), c: apical long-axis (ALX) views. MW, myocardial work. C shows the strain curves from all three apical views: a) apical four-chamber (A4C), b) apical two-chamber (A2C), and c) apical long-axis (ALX). Symbols respectively represent base, mid, and apical segments.(“ ” and “ ” stand for base segment; “ ” and “ ”stand for mid sgement; “ ”and “ ” stand for apex segment.)
2.3. BP measurement
After image acquisition, BP was measured for each subject in a supine position with the left upper arm fully exposed. The measurement was carried out in full accordance with the 2020 recommendations of the International Society of Hypertension on blood pressure measurement [8]. Blood pressure ≥ 140/90 mmHg was defined as hypertension.
2.4. Analysis of MW
The analysis of MW is completed in two steps. The first is the myocardial strain, the second is the MW. We selected a long axis dynamic image with high quality that met the requirements (including the intact LV, intact myocardium, and clear display of the endocardium and epicardium; at the same time can clearly observe the aortic valve (AV) and mitral valve (MV) opening and closing situation), select automated myocardial functional imaging (AFI), the instrument system will automatically match the other two apical sections for analysis according to the heart rate.
After the analysis of all three apical views is completed, the system will then calculate the corresponding strain, and combine it with the event time[mitral valve closure (MVC), aortic valve opening (AVO), aortic valve closing (AVC) and mitral valve opening (MVO)] and the patient's BP, then the data of MW can be obtained and showed it in the form of bull's-eye map(Fig. 2).
(The definitions of various parameters related to MW are provided in the supplementary materials.)
2.5. Measurement variability
Using the methods described above, the 2D images of 20 samples of different age groups of different genders were randomly selected for analysis by two observers and by one observer with a minimum time interval of 2 weeks for the measurement of GMW. The measurements were performed on the same cardiac cycle of the same image. All readers were blinded to previous measurements.
3. Statistical analysis
In order to obtain more accurate and convincing data results, we conducted horizontal and vertical comparisons of all the data obtained, that is, between different genders in the same age group and between different ages in the same gender; comparison between different walls of the same segment and different segments of the same wall. Statistical analysis was performed using the SPSS version 26.0(SPSS Inc., Chicago, IL, USA). Continuous data were expressed as mean ± standard deviation (SD) and categorical data were expressed as numbers percentages and frequencies. Differences between the two types of continuous data consistent with a normal distribution were compared by t-test and differences between more than two types of continuous data with a normal distribution were compared by one-way analysis of variance (ANOVA). We conducted the Kolmogorov-Smirnov test on the original data or the transformed data to check for normality. If the data passes the normality test, use ANOVA; if it fails the normality test, use Kruskal-Wallis H. We performed pairwise multiple comparisons using the Bonferroni method to correct the p-values. Intra-observer and inter-observer variability was assessed in 20 randomly selected subjects using the Bland–Altman analyses. All reported P-values were two-sided and a value of P < 0.05 was considered statistically significant.
4. Results
4.1. Basic characteristics of the subjects(Table 1)
Table 1.
Above Comparison of characteristics in the same gender between different age groups. Below Comparison of characteristics in the same age group between different genders. ANOVA, one-way analysis of variance; BSA, body surface area; BMI, body mass index; DBP, diastolic blood pressure; SBP, systolic blood pressure.
As shown in Table 1,there were statistically significant differences (P < 0.05) in height, body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP) in femals between different age groups, the results of BMI, SBP and DBP showed lower in 20-39 years old group.There were no statistically significant differences(P > 0.05) in age, BMI and BP between men and women in ≥55 age group, while there were statistically significant differences in other indicators (P < 0.05).
4.2. Comparison of GMW and SMW parameters
4.2.1. The normal values of GWM (Table 2)
Table 2.
Above Comparison of GMW in the same age group with different gender. Below Comparison of GMW in the same gender with different ages. ANOVA: one-way analysis of variance; GCW, global constructive work; GLS, global longitudinal strain; GMW, global myocardial work. GWE, global work efficiency; GWI, global work index; GWW, global work waste.
| Age (y) |
Gendel | GLS |
GWI |
GCW |
GWW |
GWE |
|||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean ± SD (mm) | P-value | Mean ± SD (mmHg%) | P-value | Mean ± SD (mmHg%) | P-value | Mean ± SD (mmHg%) | P-value | Mean ± SD(%) | P-value | ||
| 20-39 | Male | −19.60 ± 1.93 | 0.000 | 2029.4 ± 240.78 | 0.506 | 2184.32 ± 230.05 | 0.419 | 92.64 ± 45.46 | 0.232 | 95.27 ± 1.92 | 0.892 |
| Femal | −21.42 ± 1.94 | 2004.11 ± 272.74 | 2153.31 ± 283.23 | 85.14 ± 39.93 | 95.32 ± 3.14 | ||||||
| 40-54 | Male | −19.48 ± 1.86 | 0.000 | 1969.32 ± 275.02 | 0.000 | 2145.34 ± 282.16 | 0.000 | 97.08 ± 59.24 | 0.837 | 95.10 ± 2.22 | 0.450 |
| Femal | −21.40 ± 1.91 | 2158.43 ± 294.55 | 2312.88 ± 282.31 | 95.13 ± 55.74 | 95.39 ± 2.42 | ||||||
| ≥55 | Male | −19.27 ± 1.93 | 0.001 | 1990.64 ± 270.99 | 0.019 | 2179.12 ± 362.81 | 0.045 | 124.31 ± 65.13 | 0.720 | 92.76 ± 8.12 | 0.123 |
| Femal | −20.47 ± 2.15 | 2108.00 ± 292.78 | 2296.80 ± 291.93 | 129.78 ± 108.57 | 94.47 ± 2.80 | ||||||
| Gender | Age(y) | GLS |
GWI |
GCW |
GWW |
GWE |
||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean ± SD (mm) |
ANOVA |
Mean ± SD (mmHg%) |
ANOVA |
Mean ± SD (mmHg%) |
ANOVA |
Mean ± SD (mmHg%) |
ANOVA |
Mean ± SD(%) | ANOVA |
|||||||||||||||||
| P Value | 20-39 | 40-54 | ≥55 | P Value | 20-39 | 40-54 | ≥55 | P Value | 20-39 | 40-54 | ≥55 | P Value | 20-39 | 40-54 | ≥55 | P Value | 20-39 | 40-54 | ≥55 | |||||||
| Female | 20-39 | −21.42 ± 1.94 | 0.007 | 0.004 | 2004.11 ± 272.74 | 0.001 | 0.000 | 0.027 | 2153.31 ± 283.23 | 0.000 | 0.000 | 0.002 | 85.14 ± 39.93 | 0.657 | 95.32 ± 3.14 | 0.112 | ||||||||||
| 40-54 | −21.40 ± 1.91 | 0.006 | 2158.43 ± 294.55 | 0.000 | 2312.88 ± 282.31 | 0.000 | 95.13 ± 55.74 | 95.39 ± 2.42 | ||||||||||||||||||
| ≥55 | −20.47 ± 2.15 | 0.004 | 0.006 | 2108.00 ± 292.78 | 0.027 | 2296.8 ± 291.93 | 0.002 | 129.78 ± 108.57 | 94.47 ± 2.80 | |||||||||||||||||
| Male | 20-39 | −19.60 ± 1.93 | 0.551 | 2029.40 ± 240.78 | 0.364 | 2184.32 ± 230.05 | 0.705 | 92.64 ± 45.46 | 0.001 | 0.001 | 95.27 ± 1.92 | 0.003 | 0.002 | |||||||||||||
| 40-54 | −19.48 ± 1.86 | 1969.32 ± 275.02 | 2145.34 ± 282.16 | 97.08 ± 59.24 | 0.006 | 95.10 ± 2.22 | 0.007 | |||||||||||||||||||
| ≥55 | −19.27 ± 1.93 | 1990.64 ± 270.99 | 2179.12 ± 362.81 | 124.31 ± 65.13 | 0.001 | 0.006 | 92.76 ± 8.12 | 0.002 | 0.007 | |||||||||||||||||
Table 2 showed a better GLS and higher GWI and GCW in females than in males(P < 0.05). At the same time,the lower GLS and higher GWI/GCW/GWW/GWE in ≥55 years old group (P < 0.05).
4.2.2. Normal values of SMW's parameters in different genders of different ages
(Table 3-Supplemental Material)
Table 3.
Comparison of SMW's parameters in different segment between different genders of the same age. ANOVA: one-way analysis of variance; ConsW: constructive work; MW: myocardial work index; MWE: myocardial work efficiency; PSS: peak systolic strain; SMW, segmental myocardial work. SysconsW: systolic construct work; SyswastedW: systolic wasted work.
| Parameters | Age(y) | Gender | 20-39 | 40-54 | ≥55 | ||||||
| Male | Female | P Value | Male | Female | P Value | Male | Female | P Value | |||
| MW | Segments | BasalInferior | 2166.10 ± 431.54 | 2228.14 ± 457.11 | 0.343 | 2147.39 ± 445.33 | 2238.00 ± 506.29 | 0.255 | 2052.88 ± 539.32 | 2153.5 ± 513.86 | 0.265 |
| BasalPosterior | 1992.03 ± 494.39 | 2078.43 ± 487.61 | 0.231 | 2014.58 ± 443.40 | 2241.93 ± 617.04 | 0.013 | 2019.18 ± 554.92 | 2114.84 ± 598.80 | 0.330 | ||
| BasalLateral | 1876.58 ± 413.91 | 1913.1 ± 427.00 | 0.555 | 1821.31 ± 404.52 | 2101.36 ± 464.17 | 0.000 | 1754.88 ± 552.47 | 2131.15 ± 547.54 | 0.000 | ||
| BasalAnterior | 1681.55 ± 350.41 | 1716.51 ± 412.05 | 0.536 | 1551.66 ± 386.72 | 1834.65 ± 424.49 | 0.000 | 1625.64 ± 442.77 | 1880.46 ± 496.56 | 0.002 | ||
| BasalAnteroseptal | 1458.81 ± 409.47 | 1545.22 ± 396.61 | 0.145 | 1474.61 ± 385.24 | 1632.96 ± 446.78 | 0.024 | 1453.65 ± 430.01 | 1559.06 ± 369.72 | 0.127 | ||
| BasalSeptal | 1844.18 ± 325.83 | 1894.66 ± 333.17 | 0.298 | 1773.06 ± 364.54 | 1963.31 ± 375.15 | 0.002 | 1710.64 ± 404.82 | 1757.67 ± 478.04 | 0.531 | ||
| MidInferior | 1998.81 ± 347.35 | 2066.66 ± 364.48 | 0.196 | 2016.15 ± 370.08 | 2177.28 ± 427.43 | 0.017 | 1998.86 ± 383.35 | 2119.07 ± 488.48 | 0.114 | ||
| MidPosterior | 1800.02 ± 351.40 | 1916.06 ± 336.74 | 0.022 | 1736.90 ± 356.65 | 1943.86 ± 450.45 | 0.003 | 1773.26 ± 400.54 | 1949.07 ± 523.13 | 0.030 | ||
| MidLateral | 1789.56 ± 352.29 | 1848.91 ± 375.61 | 0.269 | 1691.03 ± 383.28 | 1956.97 ± 417.31 | 0.000 | 1706.22 ± 386.97 | 1922.6 ± 421.69 | 0.002 | ||
| MidAnterior | 1723.59 ± 361.51 | 1677.61 ± 398.75 | 0.412 | 1774.87 ± 399.04 | 1873.03 ± 433.90 | 0.157 | 1774.36 ± 400.36 | 1891.92 ± 408.12 | 0.089 | ||
| MidAnteroseptal | 1989.66 ± 374.00 | 1928.19 ± 404.63 | 0.285 | 2010.42 ± 390.69 | 2137.75 ± 466.03 | 0.078 | 2100.32 ± 423.94 | 2117.90 ± 411.87 | 0.805 | ||
| MidSeptal | 1978.35 ± 298.61 | 2028.08 ± 341.16 | 0.294 | 2027.55 ± 302.58 | 2158.74 ± 397.06 | 0.029 | 2008.10 ± 356.31 | 2117.87 ± 406.65 | 0.096 | ||
| ApicalInferior | 2570.68 ± 506.64 | 2504.24 ± 490.51 | 0.364 | 2466.20 ± 490.35 | 2770.03 ± 521.94 | 0.000 | 2458.42 ± 471.35 | 2572.52 ± 600.74 | 0.221 | ||
| ApicalPosterior | 2256.72 ± 428.93 | 2174.32 ± 392.60 | 0.172 | 2047.90 ± 529.29 | 2236.84 ± 540.33 | 0.033 | 2093.35 ± 447.36 | 2181.45 ± 544.73 | 0.297 | ||
| ApicalLateral | 2097.59 ± 523.81 | 2037.4 ± 423.80 | 0.386 | 2056.80 ± 558.74 | 2261.21 ± 477.22 | 0.016 | 2106.87 ± 519.61 | 2182.55 ± 456.05 | 0.367 | ||
| ApicalAnterior | 2078.86 ± 399.48 | 2004.53 ± 428.92 | 0.224 | 2032.34 ± 485.17 | 2243.91 ± 492.47 | 0.009 | 2111.89 ± 498.82 | 2129.52 ± 528.13 | 0.840 | ||
| ApicalAnteroseptal | 2372.02 ± 476.43 | 2076.94 ± 463.54 | 0.000 | 2218.01 ± 477.12 | 2339.05 ± 593.74 | 0.181 | 2336.43 ± 507.82 | 2408.91 ± 475.44 | 0.389 | ||
| ApicalSeptal | 2671.21 ± 449.45 | 2458.35 ± 505.76 | 0.003 | 2531.26 ± 435.46 | 2664.82 ± 497.90 | 0.088 | 2569.33 ± 484.56 | 2638.97 ± 466.13 | 0.392 | ||
| MWE | Segments | BasalInferior | 95.43 ± 4.00 | 95.67 ± 2.97 | 0.649 | 96.46 ± 2.69 | 95.65 ± 3.75 | 0.125 | 94.17 ± 6.27 | 94.01 ± 5.75 | 0.878 |
| BasalPosterior | 91.74 ± 7.01 | 92.15 ± 6.46 | 0.683 | 93.49 ± 4.49 | 92.58 ± 6.52 | 0.343 | 91.973 ± 6.43 | 92.68 ± 5.11 | 0.467 | ||
| BasalLateral | 94.29 ± 5.10 | 94.58 ± 3.88 | 0.670 | 94.41 ± 4.05 | 94.64 ± 5.37 | 0.773 | 91.45 ± 9.17 | 94.93 ± 4.11 | 0.004 | ||
| BasalAnterior | 95.52 ± 3.45 | 94.65 ± 5.15 | 0.168 | 94.46 ± 4.62 | 94.62 ± 5.64 | 0.851 | 92.42 ± 5.44 | 93.87 ± 6.17 | 0.144 | ||
| BasalAnteroseptal | 90.34 ± 6.35 | 91.84 ± 5.52 | 0.087 | 89.69 ± 6.58 | 90.74 ± 8.13 | 0.399 | 88.74 ± 8.27 | 90.68 ± 6.07 | 0.123 | ||
| BasalSeptal | 94.75 ± 3.91 | 94.87 ± 3.47 | 0.837 | 94.07 ± 4.47 | 94.34 ± 3.60 | 0.686 | 92.84 ± 5.96 | 92.14 ± 7.35 | 0.537 | ||
| MidInferior | 94.31 ± 4.03 | 95.67 ± 3.39 | 0.013 | 95.031 ± 3.72 | 95.72 ± 3.65 | 0.256 | 93.25 ± 6.23 | 94.60 ± 5.11 | 0.168 | ||
| MidPosterior | 94.87 ± 3.70 | 96.18 ± 3.35 | 0.012 | 95 ± 3.71 | 94.76 ± 4.77 | 0.746 | 93.56 ± 5.34 | 93.70 ± 5.89 | 0.881 | ||
| MidLateral | 95.98 ± 4.54 | 95.69 ± 3.97 | 0.633 | 96.15 ± 3.64 | 95.77 ± 3.99 | 0.549 | 94.54 ± 4.91 | 95.12 ± 4.46 | 0.472 | ||
| MidAnterior | 94.95 ± 4.75 | 94.83 ± 4.67 | 0.858 | 95.76 ± 4.21 | 95.74 ± 4.41 | 0.980 | 95.29 ± 5.82 | 95.12 ± 4.87 | 0.855 | ||
| MidAnteroseptal | 95.42 ± 3.67 | 95.89 ± 3.17 | 0.355 | 94.82 ± 4.57 | 96.16 ± 3.80 | 0.050 | 94.68 ± 4.64 | 95.68 ± 3.92 | 0.174 | ||
| MidSeptal | 94.28 ± 4.02 | 96.2 ± 2.91 | 0.000 | 94.69 ± 3.88 | 95.64 ± 3.62 | 0.125 | 93.02 ± 5.79 | 95.12 ± 4.49 | 0.020 | ||
| ApicalInferior | 97.33 ± 2.98 | 97.13 ± 2.89 | 0.638 | 95.87 ± 3.83 | 97.28 ± 2.54 | 0.012 | 95.17 ± 4.57 | 94.79 ± 5.01 | 0.644 | ||
| ApicalPosterior | 96.85 ± 2.72 | 96.51 ± 2.85 | 0.406 | 95.92 ± 3.49 | 95.86 ± 4.03 | 0.932 | 95.09 ± 4.11 | 95.21 ± 4.29 | 0.861 | ||
| ApicalLateral | 96.28 ± 4.68 | 96.45 ± 3.28 | 0.782 | 96.15 ± 4.30 | 96.57 ± 3.37 | 0.501 | 96.13 ± 3.97 | 96.21 ± 3.53 | 0.895 | ||
| ApicalAnterior | 96.98 ± 3.66 | 96.4 ± 2.97 | 0.227 | 96.31 ± 3.61 | 97.01 ± 2.99 | 0.198 | 94.92 ± 4.98 | 94.73 ± 5.48 | 0.835 | ||
| ApicalAnteroseptal | 97.21 ± 2.28 | 96.25 ± 3.37 | 0.021 | 96.33 ± 3.19 | 96.4 ± 4.07 | 0.914 | 95.18 ± 5.06 | 96.26 ± 3.10 | 0.141 | ||
| ApicalSeptal | 97.77 ± 2.04 | 97.04 ± 2.79 | 0.046 | 96.30 ± 4.54 | 96.98 ± 3.29 | 0.280 | 96.18 ± 3.80 | 96.23 ± 3.42 | 0.939 | ||
| ConsW | Segments | BasalInferior | 2294.3 ± 404.561 | 2330.63 ± 455.43 | 0.567 | 2258.54 ± 459.30 | 2314.72 ± 473.42 | 0.466 | 2210.95 ± 478.50 | 2251.8 ± 496.19 | 0.623 |
| BasalPosterior | 2194.56 ± 453.89 | 2236.66 ± 457.14 | 0.529 | 2185.05 ± 444.8 | 2399.16 ± 592.45 | 0.016 | 2254.6 ± 539.12 | 2296.33 ± 582.58 | 0.662 | ||
| BasalLateral | 2023.83 ± 377.06 | 2073.17 ± 417.85 | 0.401 | 1931.05 ± 416.02 | 2195.92 ± 443.80 | 0.000 | 1913.87 ± 494.27 | 2233.48 ± 524.32 | 0.000 | ||
| BasalAnterior | 1758.67 ± 364.30 | 1829.9 ± 404.83 | 0.210 | 1604.06 ± 377.66 | 1917.7 ± 403.56 | 0.000 | 1711.85 ± 441.32 | 1963.03 ± 503.4 | 0.002 | ||
| BasalAnteroseptal | 1700.6 ± 363.34 | 1794.56 ± 369.33 | 0.082 | 1695.67 ± 338.33 | 1868.07 ± 380.31 | 0.004 | 1693.23 ± 449.97 | 1789.73 ± 436.09 | 0.203 | ||
| BasalSeptal | 1949.55 ± 320.57 | 1985.7 ± 348.79 | 0.464 | 1860.65 ± 383.63 | 2036.38 ± 363.97 | 0.005 | 1810.05 ± 382.64 | 1836.28 ± 449.85 | 0.711 | ||
| MidInferior | 2269.01 ± 354.95 | 2279.19 ± 403.07 | 0.856 | 2273.49 ± 391.25 | 2390.18 ± 447.85 | 0.097 | 2303.04 ± 381.26 | 2332.75 ± 550.18 | 0.717 | ||
| MidPosterior | 1996.95 ± 364.50 | 2063.59 ± 336.3 | 0.195 | 1924.48 ± 373.9 | 2131.67 ± 456.47 | 0.003 | 2007.28 ± 436.74 | 2165.16 ± 513.76 | 0.052 | ||
| MidLateral | 1936.56 ± 351.79 | 1997.15 ± 382.48 | 0.264 | 1809.43 ± 363.03 | 2074.37 ± 404.42 | 0.000 | 1849.91 ± 387.17 | 2066.66 ± 436.00 | 0.002 | ||
| MidAnterior | 1908.38 ± 352.89 | 1855.78 ± 404.33 | 0.348 | 1910.67 ± 407.11 | 2022.12 ± 413.08 | 0.101 | 1912.31 ± 403.22 | 2040.36 ± 454.30 | 0.081 | ||
| MidAnteroseptal | 2202.97 ± 375.71 | 2100.58 ± 397.83 | 0.073 | 2240.22 ± 416.85 | 2315.38 ± 448.47 | 0.295 | 2376.59 ± 422.05 | 2320.34 ± 469.09 | 0.458 | ||
| MidSeptal | 2215.80 ± 296.41 | 2181.14 ± 334.85 | 0.457 | 2263.78 ± 317.83 | 2351.23 ± 402.65 | 0.136 | 2339.48 ± 372.27 | 2335.91 ± 396.66 | 0.956 | ||
| ApicalInferior | 2732.16 ± 505.25 | 2658.18 ± 510.55 | 0.322 | 2699.98 ± 528.35 | 2935.18 ± 520.73 | 0.007 | 2795.08 ± 499.80 | 2836.02 ± 621.99 | 0.668 | ||
| ApicalPosterior | 2401.39 ± 428.29 | 2348.17 ± 408.71 | 0.386 | 2233.52 ± 515.46 | 2423.72 ± 540.96 | 0.031 | 2343.00 ± 456.03 | 2445.34 ± 561.96 | 0.246 | ||
| ApicalLateral | 2203.60 ± 504.13 | 2163.9 ± 439.53 | 0.566 | 2232.25 ± 547.80 | 2416.14 ± 499.09 | 0.033 | 2344.51 ± 526.84 | 2391.25 ± 512.75 | 0.598 | ||
| ApicalAnterior | 2216.53 ± 398.39 | 2134.02 ± 455.53 | 0.192 | 2227.46 ± 554.02 | 2384.07 ± 489.98 | 0.067 | 2417.08 ± 494.80 | 2379.89 ± 556.52 | 0.677 | ||
| ApicalAnteroseptal | 2475.72 ± 476.17 | 2219.89 ± 491.01 | 0.000 | 2431.49 ± 518.81 | 2528.5 ± 592.43 | 0.296 | 2623.59 ± 524.40 | 2659.28 ± 549.06 | 0.696 | ||
| ApicalSeptal | 2764.87 ± 429.33 | 2566.54 ± 468.60 | 0.003 | 2738.00 ± 453.53 | 2835.37 ± 494.91 | 0.217 | 2845.56 ± 497.92 | 2888.86 ± 505.55 | 0.613 | ||
| WastedW | Segments | BasalInferior | 94.02 ± 95.94 | 88.88 ± 72.24 | 0.677 | 66.46 ± 60.3 | 88.03 ± 82.9 | 0.064 | 128.55 ± 171.35 | 125.83 ± 123.92 | 0.916 |
| BasalPosterior | 184.31 ± 172.09 | 170.7 ± 167.02 | 0.584 | 139.7 ± 116.26 | 170.29 ± 153.86 | 0.184 | 179.13 ± 161.09 | 161.84 ± 118.84 | 0.469 | ||
| BasalLateral | 110.05 ± 117.82 | 100.85 ± 80.2 | 0.529 | 101.76 ± 91.5 | 102.79 ± 103.34 | 0.950 | 159.72 ± 186.41 | 100.38 ± 74.74 | 0.013 | ||
| BasalAnterior | 71.3 ± 62.42 | 87.09 ± 90.61 | 0.163 | 82.03 ± 80.58 | 95.49 ± 105.4 | 0.395 | 122.28 ± 88.53 | 110.41 ± 122.62 | 0.510 | ||
| BasalAnteroseptal | 163.68 ± 110.99 | 141.34 ± 100.13 | 0.150 | 184.03 ± 130.52 | 179.69 ± 157.61 | 0.858 | 199.72 ± 160.64 | 172.13 ± 128.12 | 0.271 | ||
| BasalSeptal | 96.67 ± 78.97 | 94.03 ± 70.13 | 0.809 | 105.1 ± 98.87 | 108.28 ± 71.87 | 0.818 | 133.36 ± 140.69 | 138.38 ± 131.27 | 0.829 | ||
| MidInferior | 125.25 ± 103.61 | 91.9 ± 95.08 | 0.023 | 110.56 ± 109.24 | 92.82 ± 91.84 | 0.279 | 159.81 ± 185.77 | 115.44 ± 119.9 | 0.103 | ||
| MidPosterior | 96.61 ± 77.65 | 68.6 ± 68.94 | 0.010 | 93.25 ± 84.73 | 102.8 ± 104.41 | 0.549 | 130.72 ± 127.05 | 124.28 ± 118.75 | 0.759 | ||
| MidLateral | 72.6 ± 100.89 | 76.68 ± 85.66 | 0.765 | 58.57 ± 65.05 | 78.16 ± 84.64 | 0.125 | 95.31 ± 95.78 | 89.2 ± 86.37 | 0.696 | ||
| MidAnterior | 87.06 ± 87.83 | 87.07 ± 86.75 | 0.999 | 69.6 ± 75.15 | 76.46 ± 90.78 | 0.623 | 78.89 ± 97.51 | 87.8 ± 81.29 | 0.564 | ||
| MidAnteroseptal | 93.77 ± 88.23 | 73.81 ± 65.94 | 0.085 | 109.46 ± 108.52 | 81.1 ± 93.33 | 0.086 | 122.57 ± 123.51 | 93.66 ± 96.95 | 0.132 | ||
| MidSeptal | 122.18 ± 97.32 | 73.99 ± 75.84 | 0.000 | 116.78 ± 101.59 | 97.3 ± 97.97 | 0.235 | 168.73 ± 168.77 | 105.2 ± 111.66 | 0.009 | ||
| ApicalInferior | 60.7 ± 84 | 67.16 ± 93.03 | 0.621 | 107.49 ± 132.77 | 66.41 ± 78.78 | 0.030 | 134.16 ± 159.46 | 141.2 ± 155.05 | 0.793 | ||
| ApicalPosterior | 64.87 ± 66.11 | 73.2 ± 73.4 | 0.419 | 80.63 ± 76.72 | 86.47 ± 83.52 | 0.661 | 107.68 ± 112.13 | 110.08 ± 115.12 | 0.901 | ||
| ApicalLateral | 71.55 ± 107.71 | 68.56 ± 76.93 | 0.826 | 82.6 ± 122.53 | 74.69 ± 83.36 | 0.635 | 78.41 ± 94.47 | 85.22 ± 104.59 | 0.688 | ||
| ApicalAnterior | 58.85 ± 99.16 | 68.35 ± 73.37 | 0.454 | 79.33 ± 103.55 | 62.98 ± 78.9 | 0.270 | 122.35 ± 148.86 | 128.06 ± 166.73 | 0.831 | ||
| ApicalAnteroseptal | 57.06 ± 57.01 | 74.76 ± 82.45 | 0.086 | 77.86 ± 87.92 | 77.43 ± 99.46 | 0.978 | 118.52 ± 140.78 | 90.56 ± 99.2 | 0.185 | ||
| ApicalSeptal | 49.66 ± 60.02 | 66.11 ± 76.86 | 0.108 | 98.1 ± 157.01 | 73.92 ± 102.33 | 0.286 | 98.99 ± 127.32 | 97.33 ± 107.09 | 0.935 | ||
| PositiveW | Segments | BasalInferior | 2281.84 ± 401.86 | 2330.62 ± 460.17 | 0.444 | 2243.00 ± 453.71 | 2326.83 ± 480.52 | 0.279 | 2207.48 ± 489.94 | 2272.61 ± 491.64 | 0.437 |
| BasalPosterior | 2193.75 ± 449.99 | 2251.98 ± 459.81 | 0.384 | 2182.41 ± 448.87 | 2419.18 ± 586.55 | 0.008 | 2242.07 ± 537.85 | 2302.86 ± 596.46 | 0.529 | ||
| BasalLateral | 2010.76 ± 381.56 | 2051.6 ± 412.65 | 0.485 | 1929.78 ± 409.65 | 2208.43 ± 436.91 | 0.000 | 1922.99 ± 489.09 | 2242.72 ± 530.08 | 0.000 | ||
| BasalAnterior | 1749.36 ± 353.57 | 1809.48 ± 395.59 | 0.278 | 1614.51 ± 378.75 | 1919.8 ± 391.82 | 0.000 | 1727.53 ± 427.37 | 1980.14 ± 495.82 | 0.002 | ||
| BasalAnteroseptal | 1656.91 ± 367.3 | 1738.79 ± 373.06 | 0.133 | 1679.03 ± 341.36 | 1837.29 ± 377.69 | 0.009 | 1674.11 ± 431.91 | 1766.05 ± 398.85 | 0.197 | ||
| BasalSeptal | 1947.26 ± 312.29 | 1991.68 ± 340.99 | 0.357 | 1871.49 ± 368.63 | 2058.97 ± 362.3 | 0.002 | 1837.47 ± 388.84 | 1874.83 ± 450.24 | 0.600 | ||
| MidInferior | 2193.76 ± 342.88 | 2220.4 ± 389.24 | 0.622 | 2197.84 ± 380.85 | 2330.92 ± 435.06 | 0.052 | 2231.03 ± 360.04 | 2286.78 ± 505.16 | 0.462 | ||
| MidPosterior | 1946.93 ± 355.33 | 2027.24 ± 331.79 | 0.112 | 1876.68 ± 366.37 | 2092.32 ± 441.96 | 0.002 | 1956.03 ± 417.43 | 2122.61 ± 499.14 | 0.034 | ||
| MidLateral | 1892.83 ± 343.97 | 1960.49 ± 369.83 | 0.199 | 1772.21 ± 359.40 | 2052 ± 404.17 | 0.000 | 1822.37 ± 376.06 | 2040.13 ± 412.78 | 0.001 | ||
| MidAnterior | 1846.63 ± 342.45 | 1799.26 ± 394.39 | 0.385 | 1867.00 ± 393.07 | 1975.88 ± 408.09 | 0.101 | 1874.23 ± 381.43 | 2006.56 ± 421.11 | 0.054 | ||
| MidAnteroseptal | 2136.9 ± 369.96 | 2047.82 ± 394.52 | 0.115 | 2177.10 ± 387.81 | 2260.37 ± 443.9 | 0.231 | 2299.8 ± 408.06 | 2269 ± 435.84 | 0.668 | ||
| MidSeptal | 2154.55 ± 283.61 | 2141.03 ± 336.91 | 0.769 | 2200.00 ± 305.63 | 2301.8 ± 391.94 | 0.073 | 2256.21 ± 349.72 | 2280.41 ± 386.04 | 0.699 | ||
| ApicalInferior | 2682.14 ± 499.7 | 2609.51 ± 493.32 | 0.320 | 2634.24 ± 510.61 | 2884.3 ± 512.953 | 0.003 | 2691.08 ± 475.33 | 2777.52 ± 597.44 | 0.344 | ||
| ApicalPosterior | 2360.91 ± 420.04 | 2295.85 ± 395.02 | 0.277 | 2178.73 ± 517.22 | 2371.02 ± 533.9 | 0.028 | 2269.77 ± 436.72 | 2368 ± 545.13 | 0.240 | ||
| ApicalLateral | 2175.37 ± 495.26 | 2125.65 ± 417.67 | 0.457 | 2178.48 ± 556.30 | 2363.31 ± 481.17 | 0.030 | 2259.85 ± 499.67 | 2326.16 ± 475.28 | 0.427 | ||
| ApicalAnterior | 2170.29 ± 392.56 | 2092.46 ± 434.99 | 0.203 | 2161.52 ± 532.24 | 2337.3 ± 487.117 | 0.036 | 2314.11 ± 483.73 | 2313.7 ± 537.5 | 0.996 | ||
| ApicalAnteroseptal | 2448.14 ± 470.9 | 2181.09 ± 466.69 | 0.000 | 2361.60 ± 488.93 | 2471.18 ± 577.99 | 0.221 | 2535.28 ± 500.78 | 2580.58 ± 506.02 | 0.598 | ||
| ApicalSeptal | 2739.72 ± 437.73 | 2540.6 ± 475.27 | 0.003 | 2677.67 ± 437.79 | 2780.36 ± 479.95 | 0.179 | 2751.15 ± 480.94 | 2809.72 ± 463.71 | 0.468 | ||
| MW | Segments | BasalInferior | 2166.10 ± 431.54 | 2228.14 ± 457.11 | 0.343 | 2147.39 ± 445.33 | 2238.00 ± 506.29 | 0.255 | 2052.88 ± 539.32 | 2153.5 ± 513.86 | 0.265 |
| BasalPosterior | 1992.03 ± 494.39 | 2078.43 ± 487.61 | 0.231 | 2014.58 ± 443.40 | 2241.93 ± 617.04 | 0.013 | 2019.18 ± 554.92 | 2114.84 ± 598.80 | 0.330 | ||
| BasalLateral | 1876.58 ± 413.91 | 1913.1 ± 427.00 | 0.555 | 1821.31 ± 404.52 | 2101.36 ± 464.17 | 0.000 | 1754.88 ± 552.47 | 2131.15 ± 547.54 | 0.000 | ||
| BasalAnterior | 1681.55 ± 350.41 | 1716.51 ± 412.05 | 0.536 | 1551.66 ± 386.72 | 1834.65 ± 424.49 | 0.000 | 1625.64 ± 442.77 | 1880.46 ± 496.56 | 0.002 | ||
| BasalAnteroseptal | 1458.81 ± 409.47 | 1545.22 ± 396.61 | 0.145 | 1474.61 ± 385.24 | 1632.96 ± 446.78 | 0.024 | 1453.65 ± 430.01 | 1559.06 ± 369.72 | 0.127 | ||
| BasalSeptal | 1844.18 ± 325.83 | 1894.66 ± 333.17 | 0.298 | 1773.06 ± 364.54 | 1963.31 ± 375.15 | 0.002 | 1710.64 ± 404.82 | 1757.67 ± 478.04 | 0.531 | ||
| MidInferior | 1998.81 ± 347.35 | 2066.66 ± 364.48 | 0.196 | 2016.15 ± 370.08 | 2177.28 ± 427.43 | 0.017 | 1998.86 ± 383.35 | 2119.07 ± 488.48 | 0.114 | ||
| MidPosterior | 1800.02 ± 351.40 | 1916.06 ± 336.74 | 0.022 | 1736.90 ± 356.65 | 1943.86 ± 450.45 | 0.003 | 1773.26 ± 400.54 | 1949.07 ± 523.13 | 0.030 | ||
| MidLateral | 1789.56 ± 352.29 | 1848.91 ± 375.61 | 0.269 | 1691.03 ± 383.28 | 1956.97 ± 417.31 | 0.000 | 1706.22 ± 386.97 | 1922.6 ± 421.69 | 0.002 | ||
| MidAnterior | 1723.59 ± 361.51 | 1677.61 ± 398.75 | 0.412 | 1774.87 ± 399.04 | 1873.03 ± 433.90 | 0.157 | 1774.36 ± 400.36 | 1891.92 ± 408.12 | 0.089 | ||
| MidAnteroseptal | 1989.66 ± 374.00 | 1928.19 ± 404.63 | 0.285 | 2010.42 ± 390.69 | 2137.75 ± 466.03 | 0.078 | 2100.32 ± 423.94 | 2117.90 ± 411.87 | 0.805 | ||
| MidSeptal | 1978.35 ± 298.61 | 2028.08 ± 341.16 | 0.294 | 2027.55 ± 302.58 | 2158.74 ± 397.06 | 0.029 | 2008.10 ± 356.31 | 2117.87 ± 406.65 | 0.096 | ||
| ApicalInferior | 2570.68 ± 506.64 | 2504.24 ± 490.51 | 0.364 | 2466.20 ± 490.35 | 2770.03 ± 521.94 | 0.000 | 2458.42 ± 471.35 | 2572.52 ± 600.74 | 0.221 | ||
| ApicalPosterior | 2256.72 ± 428.93 | 2174.32 ± 392.60 | 0.172 | 2047.90 ± 529.29 | 2236.84 ± 540.33 | 0.033 | 2093.35 ± 447.36 | 2181.45 ± 544.73 | 0.297 | ||
| ApicalLateral | 2097.59 ± 523.81 | 2037.4 ± 423.80 | 0.386 | 2056.80 ± 558.74 | 2261.21 ± 477.22 | 0.016 | 2106.87 ± 519.61 | 2182.55 ± 456.05 | 0.367 | ||
| ApicalAnterior | 2078.86 ± 399.48 | 2004.53 ± 428.92 | 0.224 | 2032.34 ± 485.17 | 2243.91 ± 492.47 | 0.009 | 2111.89 ± 498.82 | 2129.52 ± 528.13 | 0.840 | ||
| ApicalAnteroseptal | 2372.02 ± 476.43 | 2076.94 ± 463.54 | 0.000 | 2218.01 ± 477.12 | 2339.05 ± 593.74 | 0.181 | 2336.43 ± 507.82 | 2408.91 ± 475.44 | 0.389 | ||
| ApicalSeptal | 2671.21 ± 449.45 | 2458.35 ± 505.76 | 0.003 | 2531.26 ± 435.46 | 2664.82 ± 497.90 | 0.088 | 2569.33 ± 484.56 | 2638.97 ± 466.13 | 0.392 | ||
| MWE | Segments | BasalInferior | 95.43 ± 4.00 | 95.67 ± 2.97 | 0.649 | 96.46 ± 2.69 | 95.65 ± 3.75 | 0.125 | 94.17 ± 6.27 | 94.01 ± 5.75 | 0.878 |
| BasalPosterior | 91.74 ± 7.01 | 92.15 ± 6.46 | 0.683 | 93.49 ± 4.49 | 92.58 ± 6.52 | 0.343 | 91.973 ± 6.43 | 92.68 ± 5.11 | 0.467 | ||
| BasalLateral | 94.29 ± 5.10 | 94.58 ± 3.88 | 0.670 | 94.41 ± 4.05 | 94.64 ± 5.37 | 0.773 | 91.45 ± 9.17 | 94.93 ± 4.11 | 0.004 | ||
| BasalAnterior | 95.52 ± 3.45 | 94.65 ± 5.15 | 0.168 | 94.46 ± 4.62 | 94.62 ± 5.64 | 0.851 | 92.42 ± 5.44 | 93.87 ± 6.17 | 0.144 | ||
| BasalAnteroseptal | 90.34 ± 6.35 | 91.84 ± 5.52 | 0.087 | 89.69 ± 6.58 | 90.74 ± 8.13 | 0.399 | 88.74 ± 8.27 | 90.68 ± 6.07 | 0.123 | ||
| BasalSeptal | 94.75 ± 3.91 | 94.87 ± 3.47 | 0.837 | 94.07 ± 4.47 | 94.34 ± 3.60 | 0.686 | 92.84 ± 5.96 | 92.14 ± 7.35 | 0.537 | ||
| MidInferior | 94.31 ± 4.03 | 95.67 ± 3.39 | 0.013 | 95.031 ± 3.72 | 95.72 ± 3.65 | 0.256 | 93.25 ± 6.23 | 94.60 ± 5.11 | 0.168 | ||
| MidPosterior | 94.87 ± 3.70 | 96.18 ± 3.35 | 0.012 | 95 ± 3.71 | 94.76 ± 4.77 | 0.746 | 93.56 ± 5.34 | 93.70 ± 5.89 | 0.881 | ||
| MidLateral | 95.98 ± 4.54 | 95.69 ± 3.97 | 0.633 | 96.15 ± 3.64 | 95.77 ± 3.99 | 0.549 | 94.54 ± 4.91 | 95.12 ± 4.46 | 0.472 | ||
| MidAnterior | 94.95 ± 4.75 | 94.83 ± 4.67 | 0.858 | 95.76 ± 4.21 | 95.74 ± 4.41 | 0.980 | 95.29 ± 5.82 | 95.12 ± 4.87 | 0.855 | ||
| MidAnteroseptal | 95.42 ± 3.67 | 95.89 ± 3.17 | 0.355 | 94.82 ± 4.57 | 96.16 ± 3.80 | 0.050 | 94.68 ± 4.64 | 95.68 ± 3.92 | 0.174 | ||
| MidSeptal | 94.28 ± 4.02 | 96.2 ± 2.91 | 0.000 | 94.69 ± 3.88 | 95.64 ± 3.62 | 0.125 | 93.02 ± 5.79 | 95.12 ± 4.49 | 0.020 | ||
| ApicalInferior | 97.33 ± 2.98 | 97.13 ± 2.89 | 0.638 | 95.87 ± 3.83 | 97.28 ± 2.54 | 0.012 | 95.17 ± 4.57 | 94.79 ± 5.01 | 0.644 | ||
| ApicalPosterior | 96.85 ± 2.72 | 96.51 ± 2.85 | 0.406 | 95.92 ± 3.49 | 95.86 ± 4.03 | 0.932 | 95.09 ± 4.11 | 95.21 ± 4.29 | 0.861 | ||
| ApicalLateral | 96.28 ± 4.68 | 96.45 ± 3.28 | 0.782 | 96.15 ± 4.30 | 96.57 ± 3.37 | 0.501 | 96.13 ± 3.97 | 96.21 ± 3.53 | 0.895 | ||
| ApicalAnterior | 96.98 ± 3.66 | 96.4 ± 2.97 | 0.227 | 96.31 ± 3.61 | 97.01 ± 2.99 | 0.198 | 94.92 ± 4.98 | 94.73 ± 5.48 | 0.835 | ||
| ApicalAnteroseptal | 97.21 ± 2.28 | 96.25 ± 3.37 | 0.021 | 96.33 ± 3.19 | 96.4 ± 4.07 | 0.914 | 95.18 ± 5.06 | 96.26 ± 3.10 | 0.141 | ||
| ApicalSeptal | 97.77 ± 2.04 | 97.04 ± 2.79 | 0.046 | 96.30 ± 4.54 | 96.98 ± 3.29 | 0.280 | 96.18 ± 3.80 | 96.23 ± 3.42 | 0.939 | ||
| ConsW | Segments | BasalInferior | 2294.3 ± 404.561 | 2330.63 ± 455.43 | 0.567 | 2258.54 ± 459.30 | 2314.72 ± 473.42 | 0.466 | 2210.95 ± 478.50 | 2251.8 ± 496.19 | 0.623 |
| BasalPosterior | 2194.56 ± 453.89 | 2236.66 ± 457.14 | 0.529 | 2185.05 ± 444.8 | 2399.16 ± 592.45 | 0.016 | 2254.6 ± 539.12 | 2296.33 ± 582.58 | 0.662 | ||
| BasalLateral | 2023.83 ± 377.06 | 2073.17 ± 417.85 | 0.401 | 1931.05 ± 416.02 | 2195.92 ± 443.80 | 0.000 | 1913.87 ± 494.27 | 2233.48 ± 524.32 | 0.000 | ||
| BasalAnterior | 1758.67 ± 364.30 | 1829.9 ± 404.83 | 0.210 | 1604.06 ± 377.66 | 1917.7 ± 403.56 | 0.000 | 1711.85 ± 441.32 | 1963.03 ± 503.4 | 0.002 | ||
| BasalAnteroseptal | 1700.6 ± 363.34 | 1794.56 ± 369.33 | 0.082 | 1695.67 ± 338.33 | 1868.07 ± 380.31 | 0.004 | 1693.23 ± 449.97 | 1789.73 ± 436.09 | 0.203 | ||
| BasalSeptal | 1949.55 ± 320.57 | 1985.7 ± 348.79 | 0.464 | 1860.65 ± 383.63 | 2036.38 ± 363.97 | 0.005 | 1810.05 ± 382.64 | 1836.28 ± 449.85 | 0.711 | ||
| MidInferior | 2269.01 ± 354.95 | 2279.19 ± 403.07 | 0.856 | 2273.49 ± 391.25 | 2390.18 ± 447.85 | 0.097 | 2303.04 ± 381.26 | 2332.75 ± 550.18 | 0.717 | ||
| MidPosterior | 1996.95 ± 364.50 | 2063.59 ± 336.3 | 0.195 | 1924.48 ± 373.9 | 2131.67 ± 456.47 | 0.003 | 2007.28 ± 436.74 | 2165.16 ± 513.76 | 0.052 | ||
| MidLateral | 1936.56 ± 351.79 | 1997.15 ± 382.48 | 0.264 | 1809.43 ± 363.03 | 2074.37 ± 404.42 | 0.000 | 1849.91 ± 387.17 | 2066.66 ± 436.00 | 0.002 | ||
| MidAnterior | 1908.38 ± 352.89 | 1855.78 ± 404.33 | 0.348 | 1910.67 ± 407.11 | 2022.12 ± 413.08 | 0.101 | 1912.31 ± 403.22 | 2040.36 ± 454.30 | 0.081 | ||
| MidAnteroseptal | 2202.97 ± 375.71 | 2100.58 ± 397.83 | 0.073 | 2240.22 ± 416.85 | 2315.38 ± 448.47 | 0.295 | 2376.59 ± 422.05 | 2320.34 ± 469.09 | 0.458 | ||
| MidSeptal | 2215.80 ± 296.41 | 2181.14 ± 334.85 | 0.457 | 2263.78 ± 317.83 | 2351.23 ± 402.65 | 0.136 | 2339.48 ± 372.27 | 2335.91 ± 396.66 | 0.956 | ||
| ApicalInferior | 2732.16 ± 505.25 | 2658.18 ± 510.55 | 0.322 | 2699.98 ± 528.35 | 2935.18 ± 520.73 | 0.007 | 2795.08 ± 499.80 | 2836.02 ± 621.99 | 0.668 | ||
| ApicalPosterior | 2401.39 ± 428.29 | 2348.17 ± 408.71 | 0.386 | 2233.52 ± 515.46 | 2423.72 ± 540.96 | 0.031 | 2343.00 ± 456.03 | 2445.34 ± 561.96 | 0.246 | ||
| ApicalLateral | 2203.60 ± 504.13 | 2163.9 ± 439.53 | 0.566 | 2232.25 ± 547.80 | 2416.14 ± 499.09 | 0.033 | 2344.51 ± 526.84 | 2391.25 ± 512.75 | 0.598 | ||
| ApicalAnterior | 2216.53 ± 398.39 | 2134.02 ± 455.53 | 0.192 | 2227.46 ± 554.02 | 2384.07 ± 489.98 | 0.067 | 2417.08 ± 494.80 | 2379.89 ± 556.52 | 0.677 | ||
| ApicalAnteroseptal | 2475.72 ± 476.17 | 2219.89 ± 491.01 | 0.000 | 2431.49 ± 518.81 | 2528.5 ± 592.43 | 0.296 | 2623.59 ± 524.40 | 2659.28 ± 549.06 | 0.696 | ||
| ApicalSeptal | 2764.87 ± 429.33 | 2566.54 ± 468.60 | 0.003 | 2738.00 ± 453.53 | 2835.37 ± 494.91 | 0.217 | 2845.56 ± 497.92 | 2888.86 ± 505.55 | 0.613 | ||
| WastedW | Segments | BasalInferior | 94.02 ± 95.94 | 88.88 ± 72.24 | 0.677 | 66.46 ± 60.3 | 88.03 ± 82.9 | 0.064 | 128.55 ± 171.35 | 125.83 ± 123.92 | 0.916 |
| BasalPosterior | 184.31 ± 172.09 | 170.7 ± 167.02 | 0.584 | 139.7 ± 116.26 | 170.29 ± 153.86 | 0.184 | 179.13 ± 161.09 | 161.84 ± 118.84 | 0.469 | ||
| BasalLateral | 110.05 ± 117.82 | 100.85 ± 80.2 | 0.529 | 101.76 ± 91.5 | 102.79 ± 103.34 | 0.950 | 159.72 ± 186.41 | 100.38 ± 74.74 | 0.013 | ||
| BasalAnterior | 71.3 ± 62.42 | 87.09 ± 90.61 | 0.163 | 82.03 ± 80.58 | 95.49 ± 105.4 | 0.395 | 122.28 ± 88.53 | 110.41 ± 122.62 | 0.510 | ||
| BasalAnteroseptal | 163.68 ± 110.99 | 141.34 ± 100.13 | 0.150 | 184.03 ± 130.52 | 179.69 ± 157.61 | 0.858 | 199.72 ± 160.64 | 172.13 ± 128.12 | 0.271 | ||
| BasalSeptal | 96.67 ± 78.97 | 94.03 ± 70.13 | 0.809 | 105.1 ± 98.87 | 108.28 ± 71.87 | 0.818 | 133.36 ± 140.69 | 138.38 ± 131.27 | 0.829 | ||
| MidInferior | 125.25 ± 103.61 | 91.9 ± 95.08 | 0.023 | 110.56 ± 109.24 | 92.82 ± 91.84 | 0.279 | 159.81 ± 185.77 | 115.44 ± 119.9 | 0.103 | ||
| MidPosterior | 96.61 ± 77.65 | 68.6 ± 68.94 | 0.010 | 93.25 ± 84.73 | 102.8 ± 104.41 | 0.549 | 130.72 ± 127.05 | 124.28 ± 118.75 | 0.759 | ||
| MidLateral | 72.6 ± 100.89 | 76.68 ± 85.66 | 0.765 | 58.57 ± 65.05 | 78.16 ± 84.64 | 0.125 | 95.31 ± 95.78 | 89.2 ± 86.37 | 0.696 | ||
| MidAnterior | 87.06 ± 87.83 | 87.07 ± 86.75 | 0.999 | 69.6 ± 75.15 | 76.46 ± 90.78 | 0.623 | 78.89 ± 97.51 | 87.8 ± 81.29 | 0.564 | ||
| MidAnteroseptal | 93.77 ± 88.23 | 73.81 ± 65.94 | 0.085 | 109.46 ± 108.52 | 81.1 ± 93.33 | 0.086 | 122.57 ± 123.51 | 93.66 ± 96.95 | 0.132 | ||
| MidSeptal | 122.18 ± 97.32 | 73.99 ± 75.84 | 0.000 | 116.78 ± 101.59 | 97.3 ± 97.97 | 0.235 | 168.73 ± 168.77 | 105.2 ± 111.66 | 0.009 | ||
| ApicalInferior | 60.7 ± 84 | 67.16 ± 93.03 | 0.621 | 107.49 ± 132.77 | 66.41 ± 78.78 | 0.030 | 134.16 ± 159.46 | 141.2 ± 155.05 | 0.793 | ||
| ApicalPosterior | 64.87 ± 66.11 | 73.2 ± 73.4 | 0.419 | 80.63 ± 76.72 | 86.47 ± 83.52 | 0.661 | 107.68 ± 112.13 | 110.08 ± 115.12 | 0.901 | ||
| ApicalLateral | 71.55 ± 107.71 | 68.56 ± 76.93 | 0.826 | 82.6 ± 122.53 | 74.69 ± 83.36 | 0.635 | 78.41 ± 94.47 | 85.22 ± 104.59 | 0.688 | ||
| ApicalAnterior | 58.85 ± 99.16 | 68.35 ± 73.37 | 0.454 | 79.33 ± 103.55 | 62.98 ± 78.9 | 0.270 | 122.35 ± 148.86 | 128.06 ± 166.73 | 0.831 | ||
| ApicalAnteroseptal | 57.06 ± 57.01 | 74.76 ± 82.45 | 0.086 | 77.86 ± 87.92 | 77.43 ± 99.46 | 0.978 | 118.52 ± 140.78 | 90.56 ± 99.2 | 0.185 | ||
| ApicalSeptal | 49.66 ± 60.02 | 66.11 ± 76.86 | 0.108 | 98.1 ± 157.01 | 73.92 ± 102.33 | 0.286 | 98.99 ± 127.32 | 97.33 ± 107.09 | 0.935 | ||
| PositiveW | Segments | BasalInferior | 2281.84 ± 401.86 | 2330.62 ± 460.17 | 0.444 | 2243.00 ± 453.71 | 2326.83 ± 480.52 | 0.279 | 2207.48 ± 489.94 | 2272.61 ± 491.64 | 0.437 |
| BasalPosterior | 2193.75 ± 449.99 | 2251.98 ± 459.81 | 0.384 | 2182.41 ± 448.87 | 2419.18 ± 586.55 | 0.008 | 2242.07 ± 537.85 | 2302.86 ± 596.46 | 0.529 | ||
| BasalLateral | 2010.76 ± 381.56 | 2051.6 ± 412.65 | 0.485 | 1929.78 ± 409.65 | 2208.43 ± 436.91 | 0.000 | 1922.99 ± 489.09 | 2242.72 ± 530.08 | 0.000 | ||
| BasalAnterior | 1749.36 ± 353.57 | 1809.48 ± 395.59 | 0.278 | 1614.51 ± 378.75 | 1919.8 ± 391.82 | 0.000 | 1727.53 ± 427.37 | 1980.14 ± 495.82 | 0.002 | ||
| BasalAnteroseptal | 1656.91 ± 367.3 | 1738.79 ± 373.06 | 0.133 | 1679.03 ± 341.36 | 1837.29 ± 377.69 | 0.009 | 1674.11 ± 431.91 | 1766.05 ± 398.85 | 0.197 | ||
| BasalSeptal | 1947.26 ± 312.29 | 1991.68 ± 340.99 | 0.357 | 1871.49 ± 368.63 | 2058.97 ± 362.3 | 0.002 | 1837.47 ± 388.84 | 1874.83 ± 450.24 | 0.600 | ||
| MidInferior | 2193.76 ± 342.88 | 2220.4 ± 389.24 | 0.622 | 2197.84 ± 380.85 | 2330.92 ± 435.06 | 0.052 | 2231.03 ± 360.04 | 2286.78 ± 505.16 | 0.462 | ||
| MidPosterior | 1946.93 ± 355.33 | 2027.24 ± 331.79 | 0.112 | 1876.68 ± 366.37 | 2092.32 ± 441.96 | 0.002 | 1956.03 ± 417.43 | 2122.61 ± 499.14 | 0.034 | ||
| MidLateral | 1892.83 ± 343.97 | 1960.49 ± 369.83 | 0.199 | 1772.21 ± 359.40 | 2052 ± 404.17 | 0.000 | 1822.37 ± 376.06 | 2040.13 ± 412.78 | 0.001 | ||
| MidAnterior | 1846.63 ± 342.45 | 1799.26 ± 394.39 | 0.385 | 1867.00 ± 393.07 | 1975.88 ± 408.09 | 0.101 | 1874.23 ± 381.43 | 2006.56 ± 421.11 | 0.054 | ||
| MidAnteroseptal | 2136.9 ± 369.96 | 2047.82 ± 394.52 | 0.115 | 2177.10 ± 387.81 | 2260.37 ± 443.9 | 0.231 | 2299.8 ± 408.06 | 2269 ± 435.84 | 0.668 | ||
| MidSeptal | 2154.55 ± 283.61 | 2141.03 ± 336.91 | 0.769 | 2200.00 ± 305.63 | 2301.8 ± 391.94 | 0.073 | 2256.21 ± 349.72 | 2280.41 ± 386.04 | 0.699 | ||
| ApicalInferior | 2682.14 ± 499.7 | 2609.51 ± 493.32 | 0.320 | 2634.24 ± 510.61 | 2884.3 ± 512.953 | 0.003 | 2691.08 ± 475.33 | 2777.52 ± 597.44 | 0.344 | ||
| ApicalPosterior | 2360.91 ± 420.04 | 2295.85 ± 395.02 | 0.277 | 2178.73 ± 517.22 | 2371.02 ± 533.9 | 0.028 | 2269.77 ± 436.72 | 2368 ± 545.13 | 0.240 | ||
| ApicalLateral | 2175.37 ± 495.26 | 2125.65 ± 417.67 | 0.457 | 2178.48 ± 556.30 | 2363.31 ± 481.17 | 0.030 | 2259.85 ± 499.67 | 2326.16 ± 475.28 | 0.427 | ||
| ApicalAnterior | 2170.29 ± 392.56 | 2092.46 ± 434.99 | 0.203 | 2161.52 ± 532.24 | 2337.3 ± 487.117 | 0.036 | 2314.11 ± 483.73 | 2313.7 ± 537.5 | 0.996 | ||
| ApicalAnteroseptal | 2448.14 ± 470.9 | 2181.09 ± 466.69 | 0.000 | 2361.60 ± 488.93 | 2471.18 ± 577.99 | 0.221 | 2535.28 ± 500.78 | 2580.58 ± 506.02 | 0.598 | ||
| ApicalSeptal | 2739.72 ± 437.73 | 2540.6 ± 475.27 | 0.003 | 2677.67 ± 437.79 | 2780.36 ± 479.95 | 0.179 | 2751.15 ± 480.94 | 2809.72 ± 463.71 | 0.468 | ||
From Table 3, we can find that all the parameters represent the active works (the work helps the heart bump blood, including MW/ConsW/PositiveW/SysconsW showed obviously aged characteristics. The number of segments in 40-54 years old with significant statistical difference was significantly more than the other two age groups.
4.2.3. Comparison of SMW's parameters between different walls in the same segment in males and females (Table 4, Figure 4 and Figure 5-Supplemental Material)
According to the results, all the parameters showed a certain degree of age-relatedness. In addition, the average diagram of each useful work, which is conducive to the heart's pumping blood, show a trend of symmetrical distribution of "V" or "U" shape in the middle and the apex segment. The average work curve of the base segment shows a completely different pattern from that of the middle segment and the apex segment, but presents a "fishhook" type.
4.2.4. Comparison of the SMW's parameters in the same wall between different ages in males and females (Table 5-Supplemental Material)
From the table we can find there are obviously difference in females from that in males. Whatever which parameter, there existed more segments having statistically significant difference between each group, especially the useful work.
4.2.5. Comparison of SMW's parameters in the same segment between different age groups in males and females (Table 6 and Fig. 6-Supplemental Material)
The myocardial work parameters of the same segment show certain age-related characteristics in the same-sex population, especially MWE, NegativeW, and SyswastedW and this characteristic is observed in all gender groups.
Repeatability and reproducibility (Table 4 and Fig. 8 -Supplemental Material)
Table 4.
Repeatability and reproducibility of GMW evaluated by echocardiography. GMW, global myocardial work. GCW, global constructive work; GWE, global work efficiency; GWI, global work index; GWW, global work waste; LOA, lower limits of agreement.
| Gender | Age(y) | Variables | Mean | Mean | Bias | P-value | 95%LOA | Age(y) | Mean | Mean | Bias | P-value | 95%LOA | Age(y) | Mean | Mean | Bias | P-value | 95%LOA |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Female | 20-39 | Inter-observer | 40-54 | Inter-observer | ≥55 | Inter-observer | |||||||||||||
| GWI(mmHg%) | 2005.250 | 1987.900 | 17.350 | 0.869 | -891.268 ∼ 925.968 | 2132.300 | 2099.550 | 32.750 | 0.729 | -784.643 ∼ 850.143 | 2099.700 | 2065.050 | 34.650 | 0.657 | -638.801 ∼ 708.101 | ||||
| GCW(mmHg%) | 2158.750 | 2130.050 | 453.806 | 0.780 | -860.744 ∼ 918.144 | 2278.150 | 2247.100 | 31.000 | 0.757 | -834.722 ∼ 896.722 | 2318.350 | 2229.600 | 88.750 | 0.250 | -567.424 ∼ 744.924 | ||||
| GWW(mmHg%) | 91.850 | 78.500 | 50.908 | 0.255 | -86.428 ∼ 113.128 | 88.000 | 102.400 | -14.400 | 0.314 | -136.310 ∼ 107.510 | 114.850 | 111.650 | 3.200 | 0.768 | -90.425 ∼ 96.825 | ||||
| GWE(%) | 95.200 | 95.850 | 2.540 | 0.267 | -5.628 ∼ 4.328 | 95.600 | 95.000 | 0.600 | 0.254 | -3.869 ∼ 5.069 | 94.550 | 94.500 | 0.050 | 0.917 | -4.094 ∼ 4.194 | ||||
| Intra-observer | Intra-observer | Intra-observer | |||||||||||||||||
| GWI(mmHg%) | 2055.650 | 2036.600 | 19.050 | 0.832 | -756.826 ∼ 794.926 | 2150.750 | 2073.500 | 77.250 | 0.446 | -792.434 ∼ 946.934 | 2072.850 | 2057.850 | 15.000 | 0.878 | -833.343 ∼ 863.343 | ||||
| GCW(mmHg%) | 2188.100 | 2167.100 | 21.000 | 0.821 | -782.483 ∼ 824.483 | 2264.150 | 2244.350 | 19.800 | 0.823 | -744.142 ∼ 783.742 | 2273.700 | 2245.050 | 28.650 | 0.751 | -751.146 ∼ 808.446 | ||||
| GWW(mmHg%) | 85.650 | 80.450 | 5.200 | 0.654 | -94.898 ∼ 105.298 | 83.900 | 91.650 | -7.750 | 0.545 | -118.044 ∼ 102.544 | 123.263 | 106.895 | 16.368 | 0.395 | -143.983 ∼ 176.720 | ||||
| GWE(%) | 95.700 | 94.300 | 1.400 | 0.330 | -10.871 ∼ 13.671 | 95.850 | 95.300 | 0.550 | 0.304 | -4.012 ∼ 5.112 | 93.950 | 95.050 | -1.100 | 0.259 | -9.389 ∼ 7.189 | ||||
| Male | 20-39 | Inter-observer | 40-54 | Inter-observer | ≥55 | Inter-observer | |||||||||||||
| GWI(mmHg%) | 1977.300 | 2001.850 | -24.550 | 0.634 | -469.391 ∼ 420.291 | 2014.650 | 1986.800 | 27.850 | 0.803 | -935.950 ∼ 991.650 | 2059.300 | 1926.550 | 132.750 | 0.143 | -629.056 ∼ 894.556 | ||||
| GCW(mmHg%) | 2162.450 | 2165.900 | -3.450 | 0.946 | -442.330 ∼ 435.430 | 2206.300 | 2199.700 | 6.600 | 0.954 | -974.021 ∼ 987.221 | 2324.800 | 2159.750 | 165.050 | 0.073 | -597.993 ∼ 928.093 | ||||
| GWW(mmHg%) | 101.850 | 104.600 | -2.750 | 0.791 | -92.262 ∼ 86.762 | 107.550 | 110.150 | -2.600 | 0.907 | -195.436 ∼ 190.236 | 152.450 | 121.200 | 31.250 | 0.211 | -180.397 ∼ 242.897 | ||||
| GWE(%) | 94.850 | 94.700 | 0.150 | 0.745 | -3.835 ∼ 4.135 | 94.750 | 94.850 | -0.100 | 0.901 | -7.063 ∼ 6.863 | 93.200 | 94.200 | -1.000 | 0.270 | -8.710 ∼ 6.710 | ||||
| Intra-observer | Intra-observer | Intra-observer | |||||||||||||||||
| GWI(mmHg%) | 2011.950 | 1967.200 | 44.750 | 0.456 | -470.773 ∼ 560.273 | 1959.750 | 2021.800 | -62.050 | 0.342 | -619.960 ∼ 495.860 | 2022.200 | 1930.950 | 91.250 | 0.283 | -632.296 ∼ 814.796 | ||||
| GCW(mmHg%) | 2178.550 | 2149.800 | 28.750 | 0.653 | -523.357 ∼ 580.857 | 2128.900 | 2176.350 | -47.450 | 0.523 | -687.234 ∼ 592.334 | 2257.800 | 2128.250 | 129.550 | 0.095 | -516.848 ∼ 775.948 | ||||
| GWW(mmHg%) | 109.900 | 96.550 | 13.350 | 0.116 | -57.709 ∼ 84.409 | 104.800 | 87.350 | 17.450 | 0.264 | -115.538 ∼ 150.438 | 116.950 | 109.450 | 7.500 | 0.718 | -171.784 ∼ 186.784 | ||||
| GWE(%) | 94.450 | 95.100 | -0.650 | 0.126 | -4.206 ∼ 2.906 | 94.700 | 95.700 | -1.000 | 0.094 | -5.967 ∼ 3.967 | 94.250 | 91.550 | 2.700 | 0.405 | -25.106 ∼ 30.506 | ||||
Inter-observer and intra-observer variability for MW indices are summarized in Table 4. Inter-observer and intra-observer analyses showed good repeatability and reproducibility in MW indices(Fig. 8).
5. Discussion
5.1. The normal value of MW
As an important indicator to evaluate cardiac systolic function, LVEF traditionally is still widely used because it can quickly give the result. However, there still exist using the same normal values to judge cardiac systolic function regardless of gender and age and this result is unlikely to represent the global systolic function. MW evaluating by echocardiography can not only reliably evaluate the global but also the regional systolic function.
From the results of our study, we find that the MW is not only gender differences, but also age differences, and this difference is especially prominent in the females. This may be related to the presence of high estrogen levels in the females. A large number of literatures [[9], [10], [11], [12], [13], [14], [15], [16]] have proved that female estrogen is closely related to cardiovascular diseases, including hypertension, coronary heart disease (CHD), heart failure (HF), etc. Some research teams [17,18] have applied exogenous estrogen to the treatment of cardiovascular diseases in postmenopausal populations based on this characteristic of estrogen. However, there is currently some controversy regarding the effectiveness of this treatment, and the latest scientific statement from the American Heart Association further confirms the current consensus: menopausal hormone therapy (MHT) initiated before the age of 60 or within 10 years after menopause has greater benefits than risks for cardiovascular health, while it is not recommended for cardiovascular disease prevention in women over 60 years old [19]. The mechanism underlying the time-dependent benefits has been elaborated in relevant reviews: in the early postmenopausal period, estrogen can protect the healthy vascular endothelium, regulate blood lipids, inhibit inflammation, and exert a vascular protective effect; in the late postmenopausal period, the blood vessels have developed atherosclerosis, and estrogen may activate plaques and promote thrombosis, thereby increasing the risk of cardiovascular events [20].
In summary, combined with our research results, the characteristics of MW in women are the same as those of other cardiovascular diseases, and there is a big difference between men and women, and the differences between women at different ages also show obvious age characteristics. 55 years old is a watershed, after 55 years old, GWI and GCW are lower than before. This may be related to the fact that most women have gone through menopause by this age. According to population-based studies and clinical guidelines in China, the average age at natural menopause among Chinese women is approximately 49.5 years, with most women experiencing menopause between 48 and 52 years [21,22], there are also studies that showed the average age of menopause is about 54 if women live in their 80s [23], but not in the men, and the above performance may also be related to the estrogen and its level. In addition, since the BSA of women is smaller than that of men in the same age group at any age, based on Paivi E. Korhonen et al. 's study on the correlation between BSA and BP shows that the blood pressure load per body surface area of women is significantly higher than that of men [24], the GWI and GCW of women in the same age group are both higher than that of men. SMW, just like GMW, ConsW,etc.,which are beneficial to pumping blood also showed gender and age characteristics.
Therefore, we believe that age and gender should be taken into account when evaluating heart systolic function, whether the global or regional function, so as to reflect the systolic function of the heart more objectively and provide better guidance for clinical treatment.
5.2. The possible potential correlation between VMB and MW
5.2.1. VMB and clinical applications
When the normal spiral-shaped cardiac muscle fibers shorten by 15%, it can result in approximately 60% of the ejection fraction [25,26]. Clinically, diseases such as ischemic heart disease and dilated cardiomyopathy that cause the heart to enlarge cause the heart to expand in a spherical shape, with the apex becoming rounded and losing the normal "V"-shaped structure. The oblique cardiac muscle fibers also become more parallel. This change in the fiber alignment reduces the ability of the heart to spiral, twist and shorten, affecting the contraction and relaxation functions of the myocardium, and leading to heart failure(Fig. 3).To improve the contraction function of the heart, Batista first proposed the concept of "restoring the apex anchoring point", which can be achieved through two methods. One is the "direct remodeling method" proposed by Jatene [27], and the other is the "circular suspension suture method" proposed by Fontan [28]. These surgical methods aim to restore the normal anatomical structure related to the macroscopic morphology of the heart apex, forming a vortex to enhance the ejection and suction (shortening and lengthening) patterns. Therefore, the ventricular function of the postoperative dilated heart that undergoes surgical ventricular repair will rapidly improve [27,29]. When the neuroendocrine responses (such as cytokines, epinephrine/norepinephrine, renin-angiotensin system) and the remodeling adaptability to congestive heart failure change, the contraction function will gradually improve in the later stage [30].The above clinical evidence once again demonstrates that the direction of myocardial fibers at the apex of the heart determines the overall contraction activity of the heart.
Fig. 3.
A Systolic dynamics of the cardiac apex. The upper panel illustrates the elliptical shape of the heart during normal ejection and suction. The lower panel shows a dilated heart with a spherical structure and absent apex. The shaded regions indicate the extent of shortening and elongation observed via magnetic resonance imaging. Compared to the normal elliptical shape, both shortening (descending segment) and elongation (ascending segment) are reduced.B The shape of the ventricle and the trajectories of the fibers in the apical ring and the basal ring are shown by the solid-line arrows. (Left) The basal ring becomes wider, but no change occurs, while (right) the apical ring becomes flatter, being closer to the basal ring compared to the normal oblique fiber arrangement.
5.2.2. VMB and cardiac segments
According to our study, each segment has its own different contribution in the process of contraction. The basal segment does the least work, the apical segment does the most work. At the same time, the work done by the walls of each segment has its own distribution characteristics, in the basal segment showed irregular distribution among the walls, while in the mid and apical segments showed relatively regular distribution, in the shape of "U" or "V". This is a curious phenomenon, regardless of gender and age, the performance of the mid and apical segment was always similar. This reminded us of the concept of VMB.
In order to better understand the relevance of our findings to the VMB, we first fused the segmentations of the VMB with those of echocardiography. The VMB is divided into BL and AL by the posterior group of papillary muscle. Echocardiographic method to divide segments of the heart from both the longitudinal and transverse directions. The longitudinal segment (i.e., the long axis of the heart): from the bottom to the apex can be divided into base segment (from bottom to the mitral valve level), mid segment (between mitral valve level and papillary muscle level) and apical segment (from the papillary muscle level to the apex), horizontal division: that is, the six walls of each segment mentioned before. In 1997, Torrent-Guasp [31] also made a related segmental study on the VMB(Fig. 10-Supplemental Material). In 2018, Omar et al. [7] studied the VMB through echocardiography and described the anatomically correlation between the band with echocardiographic views (Fig. 3).
With the basis of this segment composition, we made a correlation analysis of the segmental distribution characteristics of MW and VMB: from our research, the apex of the heart is always the most, followed by the mid segment, and the lowest is the base segment.
5.2.3. MW of the base segment
The basal segment myocardium of LV did the least work among the three longitudinal segments, a phenomenon also found in Buckberg et al. 's study [32]: the more extensive shortening in the apical than the basal position (basal contraction averaged 35 ± 5% less than apical contraction, and this general trend was consistent for both the endocardial and the epicardial muscles).
The characteristics in the graph of the average work were that the inferior wall is at the highest point, that is, the most work is done. This may be related to the fact that the inferior wall is mainly constituted by the DS (the subendocardial myocardium, which moves at an angle of nearly 45° from the central axis, and the angle will change to be parallel to the central axis when it contracts, causing the heart to twist and rotate. At this time, the longitudinal contractile force is the largest. The strain value is naturally the largest) and the AS (subepicardial myocardium, obviously, the AS has a greater angle with the central axis because of the angle with DS, but it is still larger than the longitudinal strain of the circle myocardium). This was also confirmed by Buckberg et al. [32], in contrast to the anterior wall of the left ventricle, endocardial and epicardial sides of the posterior wall presented near similar amount of contraction.
5.2.4. MW of mid and apical segments
As mentioned above, the work distribution of the mid segment and the apical segment is very similar, and it is very likely that the AS of the VMB should be the same concept at the anatomical level, so we will discuss these two segments together.
As mentioned above, the apical segment of left ventricle is mainly composed of DS and AS, both of which trend almost parallel to the central axis, especially the DS. With the rotation and torsion in the process of cardiac contraction, the myocardium becomes more and more parallel to the central axis. This nearly complete longitudinal running generates the maximum strain value and forms a huge pulling force to move the base of the heart to the apex in the process of longitudinal shortening. The contraction of the DS plays an important role in the process of contraction: (1) the shortening of the major axis of the ventricle; (2) The counterclockwise twist at the bottom of the ventricle and the clockwise twist at the apex of the heart (viewed from the apex of the heart) rotate simultaneously, like "wringing out a cloth" [33]; (3) Changes in the size and shape of atrioventricular valve opening [12,34]. In addition to the huge contraction force of the DS, the DS accounted for the largest proportion of the weight composition of the ventricular wall, and the continuous contraction time of the DS was significantly longer than that of the AS during systole.
5.3. Limitations
This was a single-center study. The sample sizes of different gender and age groups were unequal, raising the possibility that gender and aging effect may have been amplified or not adequately detected. However, the enrollment according to the strict criteria applied in this study and with adequate acoustic window is rather challenging, particularly in the elderly subgroup and the obese people. In older subjects, undiagnosed conditions that could influence cardiovascular function may have been present, potentially affecting our results. In addition, this was a single-ethnicity study, the representation of this result is not comprehensive.
The relationship between MV and VMB, we only made some inferences on the possibility, and did not conduct in-depth analysis, which will continue to be explored in our future research, hoping to obtain supporting data to support it.
6. Conclusions
-
1.
This study established normal reference ranges of GMW and SMW across different genders with age groups. Echocardiography assessment of MW is a valuable method for evaluating LV systolic function, both globally and regionally. However, for accurate clinical interpretation, both gender and age must be considered, as a single reference range is not applicable to all populations.
-
2.
There may be some correlation between MW and VMB.Correctly understanding the direction of the myocardium provides a solid basis for clinical treatment of patients with heart failure caused by cardiac enlargement, significantly improving cardiac function and increasing the survival rate of patients.
CRediT authorship contribution statement
Limin Luo: Writing – original draft, Data curation, Conceptualization. Qiang Liu: Formal analysis, Data curation. Qiaoyan Wu: Methodology, Investigation. Huiping Hou: Methodology, Formal analysis. Zehan Xie: Software, Data curation. Yongshi Wang: Software, Methodology, Formal analysis. Xianhong Shu: Writing – review & editing.
Ethical approval
The study protocol was approved by the Hospital Ethics Committee (B-2021-027).
Availability of data and materials
The authors confirm that the data supporting the findings of this study are available within the article.
Funding
This project was supported by a fund from Xiamen Medical and Health Guiding Project(NO.3502Z20224ZD091). The funder has played no role in the writing of this article.
Declaration of competing interest
The authors declare that they have no competing interests.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijcrp.2026.200637.
Contributor Information
Yongshi Wang, Email: wang.yongshi@zs-hospital.sh.cn.
Xianhong Shu, Email: shu.xianhong@zs-hospital.sh.cn.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article.