Comment on “Left Ventricular Twist and Untwist in Patients Undergoing Elective Percutaneous Coronary Intervention”

Dear Editor, I am writing to express my heartfelt appreciation for the authors and the esteemed editorial team of the Journal of Cardiovascular Echography for their invaluable contribution to the field of echocardiography through the publication of the article titled “Left Ventricular (LV) Twist and Untwist in Patients undergoing elective percutaneous coronary intervention (PCI)” by Ali A. Elzieny, Said S. Montaser, Ahmed M. Emara, and Mahmoud K. Ahmed, which was published in July–September 2021 issue.[1] This study delves deeply into the dynamic intricacies of LV twists and untwist mechanics in patients undergoing elective PCI. It sheds significant light on a pivotal aspect of cardiac systolic and diastolic function, specifically how PCI influences LV function in patients with stable angina pectoris. A notable finding of the study is the discernible improvement in LV diastolic and systolic parameters following elective PCI, as evidenced by significant changes in E/A ratios, E/e' ratios, and global longitudinal strain.[2] The correlation established between recoil and peak untwist with speckle tracking echocardiography (STE) echocardiography data enhances the clinical implications of these findings, as observed in prior studies. Moreover, the clinical significance of the findings presented in this study cannot be overstated, as they provide crucial insights into the effectiveness of PCI in patients with stable angina pectoris.[3] Furthermore, the documentation of enhanced twist and untwist parameters using two-dimensional speckle tracking echocardiography (2D STE) before conventional echocardiographic parameters is of paramount importance. These insights could significantly contribute to improved patient care and treatment decisions in the context of coronary artery disease. The implications of this data may extend to patients with heart failure with preserved ejection fraction.[4] In addition, the dynamics of LV twist and untwist, as elucidated through STE strain echo, serve as pivotal mechanisms in maintaining myocardial function. During ejection, a sophisticated interplay of counterclockwise LV rotation near the apex and clockwise rotation near the LV base orchestrates uniform distribution of fiber stress and shortening across the myocardial wall. This twisting motion, coupled with the shearing of subendocardial fibers, stores potential energy essential for subsequent diastolic uncoiling and untwisting, culminating in diastolic suction. Notably, alterations in twist/untwist parameters exhibit robust correlations with conventional 2D-Echocardiographic metrics and plasma levels of NT‐proBNP, offering valuable insights into LV function, particularly in heart failure with preserved ejection fraction (HFpEF) patients. Moreover, echocardiographic assessment of apical untwisting emerges as a prognostic tool in asymptomatic individuals with HF risk factors. The untwisting motion generates a diastolic intraventricular pressure gradient (DIVPG), fostering blood suction from the left atrium into the LV, a process quantitatively associated with peak untwisting rate. Consequently, DIVPG serves as a reliable flow-based index of early LV diastolic function. However, to harness the full potential of LV twist/untwist parameters, standardization of data acquisition and analysis is imperative, as current practices heavily rely on operator proficiency and lack uniformity.[4,5] This journal serves as an indispensable resource for medical professionals and researchers, fostering the exchange of knowledge, and promoting advancements in cardiovascular medicine. I extend my gratitude for your attention to this letter and kindly request that you convey my appreciation to the authors for their invaluable contributions to cardiology research. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.