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\begin{document}

\title{Evaluation of Left Ventricular Function by Three-Dimensional
Speckle-Tracking Echocardiography in Patients with Chronic Kidney
Failure}



\author[1]{Yubo  Wang}%
\author[1]{Hui Huang}%
\author[1]{Shan Lin}%
\author[1]{Meijia Hao}%
\author[1]{Lujiao He}%
\author[1]{Jun Wen}%
\author[1]{Yahui Weng}%
\author[1]{Jiangyi Wang}%
\author[1]{Kun Liu}%
\author[1]{Xiaojun Bi}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective To establish a quantitative evaluation of the left ventricle's
systolic function in patients with chronic kidney failure (CKF) by
three-dimensional speckle-tracking echocardiography(3D-STE). Methods
Two-dimensional transthoracic echocardiography and three-dimensional
transthoracic echocardiography were performed on 30 patients with CKF.
The ejection fraction (EF), mass and global peak longitudinal strain
(GL), global circumferential strain (GC), global area strain (GA), and
global radial strain (GR) of the left ventricle were calculated. Results
(1) EF, GL, GC, GA, and GR in the CKF group were significantly lower
than in the control group. Meanwhile, GL, GC, GA, and GR were well
correlated with EF. (2) For patients with normal EF in the CKF group,
GL, GC, GA, and GR were lower than in the control group, while the left
ventricular mass was significantly higher than in the control group. (3)
For patients with hypertension in the CKF group, EF, GL, GC, GA, and GR
calculated using three-dimensional echocardiography were significantly
lower than in patients with normal blood pressure; however, the
myocardial mass was higher. Conclusions Parameters calculated using
three-dimensional speckle-tracking software were lower in the CKF group.
Simultaneously, the left ventricular mass was higher than in the control
group, showing that the myocardial contraction function was impaired and
that myocardial reconstruction occurred.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Severe cardiovascular complications often occur in patients with chronic
kidney failure (CKF). About half of end-stage renal patients with the
disease die of cardiovascular disease. The mortality of dialysis
patients is 10--20 times higher than that of healthy people, and the
critical factors are ischemic cardiomyopathy and myocardial hypertrophy.
It is crucial to find the cardiac function changes of patients affected
with chronic renal failure.

Traditional echocardiography, such as two-dimensional speckle-tracking
echocardiography can assess the changes in the heart's structure and
function in renal failure patients. It can perform semi-quantitative
measurements of the heart's deformation \textsuperscript{{[}1{]}}.
However, two-dimensional methods have caveats; notably, they cannot
display the three-dimensional motion of the heart itself. Although the
left ventricular ejection fraction (EF) is normal in CKF patients,
traditional ultrasound examination cannot detect abnormal cardiac
function sensitively.

Three-dimensional speckle-tracking echocardiography can accurately
calculate the deformation and motion of the heart in renal failure
patients and evaluate the integral and local left ventricular features
by the sequence tracing movement route of myocardial echo spots at
different interframes in three-dimensional space.

This study assessed the cardiac motion of CKF patients in
three-dimensional space using three-dimensional speckle-tracking
technology to accurately detect abnormal cardiac function in renal
failure patients.

\textbf{Research objects}

Thirty patients with CKF were selected in our hospital from May 2012 to
July 2012. Among the selected cases, 25 were male, ten were female, and
the mean age was 44 \selectlanguage{ngerman}± 13 years. In the normal control group, 12 cases
were male, seven were female, and the mean age was 44 ± 14 years.

\textbf{Instruments and methods}

\textbf{1. Instruments}

Informed consent was obtained from patients before they were enrolled in
the study. Vivid E9 ultrasonic echocardiography was supplied by GE using
4 V and M5S probe, frequency from 1.7 to 3.4 MHz, mechanical index of
1.1. Imaging acquisition: The subjects were told to breathe calmly and
to relax. Blood pressure was measured three times before checking.
Creatinine, urea, and uric acid levels were recorded. Upon connecting
the ECG, patients were told to adopt a left lateral position and breathe
quietly. Images were stored by an M5S probe placed near the left side of
the sternum for the shaft section and apex four-chamber. The full volume
4v mode was selected, and the depth and full volume fan Angle were
adjusted. A sound beam covered the left ventricle. Frame frequency
stayed above 25 frames per second. After telling patients to breathe
calmly, images of the cardiac cycle were selected and stored on the hard
disk for offline analysis.

\textbf{2. Image analysis}

Images of the left ventricle were taken. The left interior and
interventricular diameters were measured beside the parasternal left
ventricle at a long axis section. EF was measured from the apical
four-chamber view. After entering the Echopac workstation and enabling 4
v analysis, the apical four-chamber, apical two-chamber, and left apical
ventricle at a long axis section were displayed according to the order
on the screen. Three short-axis images of the mitral valve, papillary
muscle, and apex level were taken. The Angle of each section was
adjusted to display two-dimensional structures of the left ventricular
heart. From the endocardial and epicardial views, a point was selected
so that the system drew images automatically at the heart valve ring and
apex when diastolic and systolic readings ended. Each section had to be
adjusted to fit the endocardial and epicardial surfaces. The computer
automatically calculated the heart EF, left ventricular weight, global
longitudinal strain, global circumferential strain (GC), global area
strain (GA), and global radial strain (GR). The first manipulator
measured above parameters twice repeatedly, and then another manipulator
measured the parameters a third time, resulting in the final average.

\textbf{3. Statistical analysis}

SPSS 20.0 software was used. All measurement data were presented as mean
± standard deviation (SD). P \textless{} 0.05 was considered
statistically significant. The unpaired t-test was used to compare the
group of CKF patients with the control group. The Pearson correlation
test was used to compare the left ventricular EF, GL, GC, GR, GA, and
left ventricular weight between groups. To assess intraobserver and
interobserver variability, 30 random subjects (15 from each group) were
analyzed on two separate occasions by the same operator and two
different operators, respectively. Intraclass correlation coefficients
(ICC) were assessed using a two-way mixed-effects model for
intraobserver variability and a two-way random-effects model for
interobserver variability. ICCs \textgreater{}0.80 were considered
excellent and 0.60 to 0.80 good.

\textbf{Results}

A decreased EF was observed in CKF patients by three-dimensional
speckle-tracking software. The GL, GC, GA, GR levels were also decreased
compared to healthy controls (figures 1 and 2). The difference was
considered statistically significant (table 1). EF by three-dimensional
speckle-tracking software is correlated with GL, GC, GA, GR, and the
correlation coefficients are 0.741, 0.925, 0.874, and 0.882,
respectively. The measured values of the left ventricular EF, GL, GC,
GR, GA, and left ventricular weight were highly consistent.

(1) Parameters calculated in the CKF group using three-dimensional
speckle-tracking software compared with healthy controls.

(2) GL, GC, GA, and GR levels decreased compared to the healthy
controls, the measurement of EF is normal in CKF patients, and the left
ventricular mass was significantly higher in controls compared to the
controls (Table 2).

(3) For CKF patients with hypertension, EF, GL, GC, GA, and GR,
calculated using three-dimensional echocardiography, were significantly
lower than those with normal blood pressure, and myocardial mass was
lower too (table 3).

(4) Intra- and Interobserver Variability

For intraobserver variability, ICCs were considered excellent for the
vast majority of deformation parameters. For interobserver variability,
ICCs were considered excellent or good (Table 4).

\textbf{Discussion}

Many CKF patients have suffered cardiovascular disease, hypertension,
and diabetes before hemodialysis. Such risk factors can accelerate
vascular diseases and are linked to higher ventricular hypertrophy,
myocardial fibrosis, valvular disease, arrhythmia, and sudden
death\textsuperscript{{[}2{]}}. Meanwhile, CKF patients exhibit
increased risk factors related to the disease itself, including
metabolic waste in the heart's deposition, enhanced oxidative stress,
inflammation, blood volume, and overload pressure
\textsuperscript{{[}3{]}}. In CKF patients undergoing hemodialysis,
coronary artery stenosis, coronary reserve, destruction of
microcirculation, and an overload of pressure and capacity causes
cardiac remodeling and function change, which damages the myocardial
structure. Long-term overload of the left ventricle leads to myocardial
cell death and fibrosis, destruction of ventricular diastolic, the
discordance of ventricular electrical conduction, heart cavity
expansion, and compensatory hypertrophy \textsuperscript{{[}4, 5{]}}.
Thus, despite hemodialysis, all CKF patients display abnormalities in
cardiac function, and a good assessment would guide clinical decisions.

Speckle-tracking is an echocardiographic method based on tracking
characteristic speckle patterns created by interfering with ultrasound
beams in the myocardium, which provides a good method for the study of
myocardial mechanics \textsuperscript{{[}6{]}}. Studies have used
two-dimensional speckle-tracking technology to evaluate cardiac function
in CKD patients. They found that risk factors such as GC, GR, and
reduction of radial strain were associated with coronary artery disease
closely. Using logistic regression analysis, they found that segments of
radial strain lower than six or more are strongly associated with
coronary artery disease \textsuperscript{{[}7{]}}. Longitudinal strain
can detect abnormal cardiac contraction under normal
EF\textsuperscript{{[}8{]}}. Although many studies have shown that
two-dimensional speckle-tracking technology could detect changes in
myocardial contraction with ischemic cardiomyopathy
early\textsuperscript{{[}9{]}}, these studies were limited to a single
plane. Therefore, the cardiac motion would remove the plane of
speckle-tracking, and motion tracking in that plane was lost.
Three-dimensional speckle-tracking technology overcame this issue
\textsuperscript{{[}10, 11{]}}. Thus, it can evaluate the myocardial
motion more effectively and become more popular among clinicians
\textsuperscript{{[}12-14{]}}.

In this study, we found that the EF of left ventricular function, GL,
GC, GA, and GR showed decreased levels compared to patients in the
normal control group. Thus, the cardiac function of CKF patients with
risk factors was impaired. Cardiac function was accurately evaluated
using three-dimensional speckle-tracking technology, and EF of left
ventricular had a good correlation and repeatability, in which the GC
and EF had a better correlation (r=0.925). GL, GA, and GR showed
decreased levels compared with healthy controls when the EF of patients
with CKF was normal. The myocardial weight of the left ventricle was
significantly higher than in the control group. However, the EF of the
left ventricle was normal, and the myocardial contraction function was
impaired. Myocardial reconstruction had occurred. GC was not considered
statistically significant in four strain-related parameters. The
myocardial surface was in the normal range in the strain of the
circumferential direction. The shortage could be due to the small sample
used in this study. GL, GA, and GR were more sensitive than GC when the
myocardial function was impaired in the compensatory stage. We provided
a better method to evaluate impaired myocardial functions in CKF
patients.

During CKF, the clinical and biochemical results were not statistically
significant for differentiating CKF patients with hypertension from CFK
patients without hypertension. However, using three-dimensional
speckle-tracking technology, we found that EF, GL, GC, GA, and GR in CKF
patients with hypertension were significantly lower than in CFK patients
without hypertension. Furthermore, the left ventricular myocardial
weight was significantly higher in CFK patients with hypertension
compared to CKF patients without hypertension. Thus, hypertension could
aggravate myocardial impairment and lead to myocardial reconstruction.
We found that, unlike the clinical and biochemical results,
three-dimensional speckle-tracking technology could detect myocardial
impairment. Thus, our method is suitable for clinicians.

This study did not analyze heart changes before and after dialysis in
CKF patients. Because of this, we only obtained a few troponin values of
cases with myocardial impairment. Most cases did not display the result
that is the gold standard for myocardial impairment.

\textbf{Conclusion}

We found that myocardial impairments and reconstruction had occurred in
CKF patients. In addition, hypertension could aggravate myocardial
impairment. Three-dimensional speckle-tracking technology can
quantitatively evaluate cardiac function in CKF patients early and had
good repeatability. Thus, we present an enhanced method that can
evaluate cardiac function in CKF patients.

\textbf{Acknowledgements}

Not applicable.

\textbf{Author's contributions}

KL, YBW: Data collection and analysis, manuscript writing. XBB: Data
collection, project development, manuscript editing. HH, SL, MJH, LJH,
JW, YHW, JYW: Data collection, manuscript editing. All authors read and
approved the final manuscript.

\textbf{References}

{[}1{]} Perk G, Kronzon I. Non-Doppler two-dimensional strain imaging
for evaluation of coronary artery disease. Echocardiography 2009, 26:
299.

{[}2{]} Pecoits-Filho R\selectlanguage{english},Barberato\selectlanguage{english},SH, et al\selectlanguage{english}.Echocardiography in
chronic kidney disease\selectlanguage{english}:diagnostic and prognostic implications\selectlanguage{english}.Nephron
Clin Pract 2010, 114: 242-247.

{[}3{]} Glassock RJ, Pecoits-Filho R, Barberato SH, et al. Left
ventricular mass in chronic kidney disease and ESRD. Clin J Am Soc
Nephrol 2009, 4: 679-687.

{[}4{]} Parfrey PS\selectlanguage{english},Foley RN\selectlanguage{english}.The clinical epidemiology of cardiac
disease in chronic renal failure\selectlanguage{english}.J Am Soc Nephrol 1999, 10: 1606-1615\selectlanguage{english}.

{[}5{]} Peng T, Li X, Hu Z, et al. Predictive role of endothelin in left
ventricular remodeling of chronic kidney disease. Renal Failure 2018,
40(1):183-188.

{[}6{]} Amundsen BH, Helle-Valle T, Edvardsen T, et al. Noninvasive
myocardial strain measurement by speckle tracking echocardiography:
Validation against sonomicrometry and tagged magnetic resonance imaging.
J Am Coll Cardiol 2006, 47: 789--793.

{[}7{]} Liu YW, Su CT, Wang SP, Yang CS, et al. Application of
speckle-tracking echocardiography in detecting coronary artery disease
in patients with maintenance hemodialysis. Blood Purif 2011, 32: 38-46.

{[}8{]} Liu YW, Tsai WC, Su CT, et al. Evidence of left ventricular
systolic dysfunction detected by automated function imaging in patients
with heart failure and preserved left ventricular ejection fraction. J
Card Fail 2009, 15: 782-786.

{[}9{]} Tsai WC, Liu YW, Huang YY, et al. Diagnostic value of segmental
longitudinal strain by automated function imaging in coronary artery
disease without left ventricular dysfunction. J Am Soc Echocardiogr
2010, 23: 1183-1202.

{[}10{]} Perez de Isla L, Balcones DV, Fernandez-Golfin C, et
al.Three-dimensional-wall motion tracking: A new and faster tool for
myocardial strain assessment: Comparison with two-dimensional-wall
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{[}11{]} Saito K, O kura H, Watanabe N, et al. Comprehensive evaluation
of left ventricular strain using speckle tracking echocardiography in
normal adults: Comparison of three-dimensional and two-dimensional
approaches. J Am Soc E chocardiogr 2009, 22: 1025--1030.

{[}12{]} Baccouche H, Maunz M, Beck T, et al. Echocardiographic
assessment and monitoring of the clinical course in a patient with
Tako-Tsubo cardiomyopathy by a novel 3D-speckle-tracking-strain
analysis. Eur J Echocardiogr 2009, 10: 729-734.

{[}13{]} Kleijn SA, Brouwer WP, Aly MF, et al. Comparison between
three-dimensional speckle-tracking echocardiography and cardiac magnetic
resonance imaging for quantification of left ventricular volumes and
function. Eur Heart J Cardiovasc Imaging 2012, 13: 834-839.

{[}14{]} Nesser HJ, Mor-Avi V, Gorissen W, et al. Quantification of left
ventricular volumes using three-dimensional echocardiographic speckle
tracking: comparison with MRI. Eur Heart J 2009, 30: 1565-1571.

Table 1: The measurement of several parameters in CKF patients compared
to healthy controls.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Parameters & CKF group (30 cases) & Control group (25 cases) &
\emph{P}\tabularnewline
\midrule
\endhead
EF (\%) & 48.07\selectlanguage{ngerman}±12.73 & 59.00\selectlanguage{ngerman}±6.75 & 0.0004\tabularnewline
GL (\%) & 12.43\selectlanguage{ngerman}±3.42 & 18.80\selectlanguage{ngerman}±3.08 & \textless{} 0.0001\tabularnewline
GC (\%) & 13.07\selectlanguage{ngerman}±3.40 & 16.80\selectlanguage{ngerman}±3.34 & 0.0002\tabularnewline
GA (\%) & 22.73\selectlanguage{ngerman}±5.63 & 31.16\selectlanguage{ngerman}±4.32 & \textless{} 0.0001\tabularnewline
GR (\%) & 35.90\selectlanguage{ngerman}±11.25 & 50.64\selectlanguage{ngerman}±10.46 & \textless{} 0.0001\tabularnewline
\bottomrule
\end{longtable}

EF, ejection fraction; GL, global peak longitudinal strain; GC, global
circumferential strain; GA, global area strain; GR, global radial
strain. Data are expressed as mean \selectlanguage{ngerman}± SD.

Table 2: The measurement of EF is normal in CKF patients compared to
healthy controls.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Parameters\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
CKF with normal EF (19 cases)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Controls group (23 cases)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\emph{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
EF (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
56.26\selectlanguage{ngerman}±5.26\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
57.65\selectlanguage{ngerman}±5.37\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.4160\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
GL (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
14.26\selectlanguage{ngerman}±1.86\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18.48\selectlanguage{ngerman}±2.98\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
GC (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
14.11\selectlanguage{ngerman}±1.68\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
16.43\selectlanguage{ngerman}±3.29\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.0094\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
GA (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25.95\selectlanguage{ngerman}±2.72\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30.65\selectlanguage{ngerman}±4.19\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.0002\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
GR (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
42.79\selectlanguage{ngerman}±5.66\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
49.22\selectlanguage{ngerman}±9.81\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.0179\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
ED Mass (g)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
179.74\selectlanguage{ngerman}±61.09\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
119.04\selectlanguage{ngerman}±20.47\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
ES Mass (g)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
165.47\selectlanguage{ngerman}±48.48\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
112.91\selectlanguage{ngerman}±18.32\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

EF, ejection fraction; GL, global peak longitudinal strain; GC, global
circumferential strain; GA, global area strain; GR, global radial stain;
ED, end-diastole; ES, end-systole. Data are expressed as mean \selectlanguage{ngerman}± SD.

Table 3: Parameters calculated in the CKF group with normal blood
pressure by three-dimensional speckle-tracking software compared with
hypertension in the CKF group.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Parameters & CKF with normal blood pressure (16 cases) & Hypertension in
the CKF group (14 cases) & \emph{P}\tabularnewline
\midrule
\endhead
EF (\%) & 56.88\selectlanguage{ngerman}±5.38 & 38.00\selectlanguage{ngerman}±11.14 & \textless{}0.001\tabularnewline
GL (\%) & 14.25\selectlanguage{ngerman}±2.02 & 10.36\selectlanguage{ngerman}±3.52 & 0.0011\tabularnewline
GC (\%) & 15.31\selectlanguage{ngerman}±1.72 & 10.50\selectlanguage{ngerman}±2.99 & \textless{} 0.0001\tabularnewline
GA (\%) & 26.00\selectlanguage{ngerman}±2.92 & 19.00\selectlanguage{ngerman}±5.66 & 0.0003\tabularnewline
GR (\%) & 43.63\selectlanguage{ngerman}±5.73 & 27.07\selectlanguage{ngerman}±9.35 & \textless{} 0.0001\tabularnewline
ED Mass (g) & 201.09\selectlanguage{ngerman}±60.82 & 112.6\selectlanguage{ngerman}±31.06 & 0.0122\tabularnewline
ES Mass (g) & 182.00\selectlanguage{ngerman}±36.97 & 115.80\selectlanguage{ngerman}±31.69 & 0.0059\tabularnewline
Cr (umol/L) & 598.09\selectlanguage{ngerman}±432.98 & 642.31\selectlanguage{ngerman}±357.20 & 0.4350\tabularnewline
UA (umol/L) & 433.18\selectlanguage{ngerman}±186.25 & 477.43\selectlanguage{ngerman}±155.80 & 0.3560\tabularnewline
Urea (mmol/L) & 28.73\selectlanguage{ngerman}±11.85 & 27.34\selectlanguage{ngerman}±19.47 & 0.4700\tabularnewline
Time of the disease (mouth) & 58.32\selectlanguage{ngerman}±50.47 & 46.46\selectlanguage{ngerman}±39.21 &
0.4170\tabularnewline
\bottomrule
\end{longtable}

EF, ejection fraction; GL, global peak longitudinal strain; GC, global
circumferential strain; GA, global area strain; GR, global radial stain;
ED, end-diastole; ES, end-systole; Cr, creatinine; UA, uric acid. Data
are expressed as mean \selectlanguage{ngerman}± SD.

Table 4 Intraobserver and interobserver ICCs for parameters of left
ventricular EF, GL, GC, GR, GA, and ES.\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& \textbf{Intraobserver} & \textbf{Interobserver}\tabularnewline
EF & 0.884 & 0.825\tabularnewline
GL & 0.923 & 0.896\tabularnewline
GC & 0.857 & 0.792\tabularnewline
GA & 0.897 & 0.834\tabularnewline
GR & 0.935 & 0.901\tabularnewline
ED Mass & 0.882 & 0.836\tabularnewline
ES Mass & 0.846 & 0.855\tabularnewline
\bottomrule
\end{longtable}

EF, ejection fraction; GL, global peak longitudinal strain; GC, global
circumferential strain; GA, global area strain; GR, global radial stain;
ED, end-diastole; ES, end-systole.

\textbf{Figure Legends}

\textbf{Figure 1:} 3D offline analysis of the control group. (A) LV
global longitudinal strain was -18\%; (B) LV global circumferential
strain was -18\%; (C) LV global radial strain was -54\%; (D) LV global
area strain was -33\%.

\textbf{Figure 2:} 3D offline analysis of the CKF group. (A) LV global
longitudinal strain was -8\%; (B) LV global circumferential strain was
-7\%; (C) LV global radial strain was -18\%; (D) LV global area strain
was -14\%.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

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\end{figure}

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