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\begin{document}

\title{Speckle tracking imaging combined with myocardial comprehensive index to
evaluate left ventricular function changes in patients with systemic
lupus erythematosus}



\author[1]{Jia Feng}%
\author[1]{Zijing Zhai}%
\author[1]{Zhen Wang}%
\author[2]{Lei Huang}%
\author[2]{ Shanshan Dong}%
\author[2]{Kuichan Liu}%
\author[2]{Wenrong Shi}%
\author[2]{Guilin Lu}%
\author[2]{WenJuan   QIN}%
\affil[1]{Shihezi University}%
\affil[2]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 04, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: To evaluate early changes in left ventricular systolic
function in patients with systemic lupus erythematosus (SLE) using
three-dimensional speckle tracking imaging (3D-STI). Methods: Thirty SLE
patients and 30 healthy people (control group) were selected, the
patients were further divided into subgroups according to their Safety
of Estrogens in Lupus Erythematosus National Assessment version of the
SLE Disease Activity Index (SELENA-SLEDAI) score: SELENA-SLEDAI [?] 12
(mild-to-moderate group), SELENA-SLEDAI \textgreater{} 12 (severe
group). Blood samples were obtained from patients and laboratory
investigations were performed. All participants were examined using
3D-STI, the 3D conventional and strain parameters were obtained. The
above parameters were compared in the three studied groups. Receiver
operating curves (ROC) were prepared for above parameters and analyzed
to identify correlations among LVEF, GLS, GCS, LVtw, Tor, MCI and
hs-TropT. Results: Compared with the control group, the absolute values
of LVEDV, LVEF, GLS, GCS, LVtw, Tor and MCI decreased, LV EDmass, LV
ESmass and PSD increased in the mild-to-moderate and the severe groups
(P2 \textless{} 0.05, P3 \textless{} 0.05). There was statistically
significant difference in terms of strain parameters between the
mild-to-moderate group and the severe group (P1 \textless{} 0.05). The
highest area under the ROC for MCI was 0.909, the highest sensitivity
for MCI was 90.00\%, and the highest specificity for Tor was 86.67\%.
Correlation analysis showed that there was a good correlation between
the MCI and hs-TropT (r = - 0.677). Conclusion: 3D-STI technology may
help detect early changes in left ventricular systolic function in
patients with SLE%
\end{abstract}%



\sloppy


\textbf{1 Introduction}

Systemic lupus erythematosus (SLE) is a diffuse connective tissue
disease that is characterized by an inflammatory immune response. The
mortality rate of SLE is increasing year by year owing to its propensity
to induce severe cardiovascular damage \textsuperscript{{[}1, 2{]}}.
Echocardiography is widely used in the detection of cardiac structure
and function because of its unique advantages such as its dynamic and
non-invasive nature; however, it cannot detect changes in cardiac
function in the early stage of disease
progression\textsuperscript{{[}3{]}}. As a new technique that is
superior to conventional two-dimensional echocardiography,
three-dimensional speckle tracking imaging (3D-STI) can be used to
evaluate left ventricular systolic function in the early stage of
disease progression\textsuperscript{{[}4{]}}. The purpose of this study
was to use 3D-STI to detect the effect of SLE on left ventricular
systolic function, to explore its application value, and to provide an
objective diagnostic basis for clinical use.

\textbf{Materials and Methods}

\textbf{2.1 Study Population}

This study enrolled 30 SLE patients (SLE group) treated from September
2019 to July 2020. The patients were further divided into subgroups
according to their SELENA-SLEDAI score: SELENA-SLEDAI [?] 12
(mild-to-moderate group), SELENA-SLEDAI \textgreater{} 12 (severe
group). All patients met the diagnostic criteria of SLE established by
the American Rheumatology Association (ACR) in 1997. Blood samples were
obtained from all patients and laboratory investigations were performed:
complete blood count, fasting glucose, low-density lipoproteins (LDL),
anti-double stranded DNA (anti-dsDNA), complement component C3 (C3),
complement component C4 (C4) and high sensitivity-TropT (hs-TropT). At
the same time, 30 healthy people were selected as a control group. All
participants were examined using 3D-STI to obtain relevant parameters.
The inclusion and exclusion criteria are as follows: inclusion criteria:
(1) accorded with the SLE classification standard of the ACR; (2) left
ventricular ejection fraction (LVEF) \textgreater{} 55\% in the SLE
group, and age, sex body mass index et al were matched to the control
group; (3) no cardiovascular risk factors and no history of heart
disease or other autoimmune diseases; (4) patients in the SLE group were
treated regularly and their condition was relatively stable. Exclusion
criteria: (1) coexisting hypertension, coronary heart disease, diabetes
mellitus, hyperlipidemia, valvular disease, pericardial disease, atrial
fibrillation, congenital heart disease, or kidney disease; (2) other
autoimmune diseases. All participants were informed of the aim of the
study and agreed to participate. The participants signed an informed
consent form before the examination, and approval was obtained from the
Medical Ethics Committee.

\textbf{Echocardiography}

All participants underwent an echocardiographic examination. The images
were collected by ultrasound diagnostic doctors with more than 10 years
of experience. The participant was instructed to take the left recumbent
position and the electrocardiograph was manually connected. Color
Doppler ultrasonography (GE Vivid E9, probe: 4V, frequency: 1.5--4.0
MHz) was used, and the on-machine 3D-STI analysis software was used for
post-processing. After the patient was instructed to hold their breath
to display a two-dimensional image (clear apical four-chambers), the 4D
mode was selected, and three consecutive and stable complete cardiac
cycles were collected quickly and without interruption. The frame rate
was then adjusted to 40\% of the participant's maximal heart rate, and
the image was stored. In the 4D auto LVQ mode, the software
automatically tracked the boundaries of the left ventricular wall
(endocardium and epicardium) during the complete cardiac cycle. The
following 3D routine parameters were obtained: left ventricular
end-diastolic volume (LVEDV), left ventricular end systolic volume
(LVESV), left ventricular ejection fraction (LVEF), spherical index
(SPI), left ventricular end diastolic mass (LV EDmass), and left
ventricular end systolic mass (LV ESmass). Besides, the following 3D
strain parameters were obtained simultaneously: global longitudinal
strain (GLS), global circumferential strain (GCS), left ventricular
twist angle (LVtw), torsion (Tor), and peak strain dispersion (PSD),
myocardial comprehensive index (MCI = GLS \selectlanguage{ngerman}× LVtw).

\textbf{Statistical Analysis}

\emph{SPSS} 22.0 software was used for statistical analysis, and
measurement data were expressed by\selectlanguage{english}\emph{?χ ± s}\selectlanguage{ngerman} . Single factor analysis
of variance (\emph{ANOVA} ) was used for inter-group comparison and the
\emph{LSD-t}method was used for pairwise comparison. Receiver operating
characteristic (\emph{ROC} ) curve analysis was used to evaluate the
diagnostic efficacy of the 3D-STI parameters on left ventricular
systolic function in patients with SLE, the best cut-off point was
determined, \emph{F} and \emph{P} values were calculated simultaneously.
The correlation between 3D-STI parameters and hs-TropT was analyzed
using Pearson's correlation analysis. Intra-group correlation
coefficients (\emph{ICC} ) were calculated to assess repeatability
between and within observers. The difference was statistically
significant (\emph{P} \textless{} 0.05).

\textbf{Results}

\textbf{3.1} \textbf{Baseline characteristics and laboratory results}

Baseline characteristics of the study population are given in Table 1:
compared with the mild-to-moderate group, the SELENA-SLEDAI was
significantly higher in the severe group (\emph{P} \textless{} 0.05).
Laboratory results of the SLE patients are given in Table 2: compared
with the mild-to-moderate group, the anti-dsDNA, C3, C4 and hs-TropT
were significantly higher in the severe group (\emph{P} \textless{}
0.05).

Table1: baseline characteristics of the study population\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
mild-to-moderate group (n = 16)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
severe group (n = 14)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
control group (n = 30)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
test\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
sex(f/m)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13/3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12/2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
26/4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\selectlanguage{greek}\emph{χ\textsuperscript{2}}\selectlanguage{english} = 0.247\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.884\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
age(years)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
42.38 \selectlanguage{ngerman}± 8.81\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
45.07 \selectlanguage{ngerman}± 7.93\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
46.30 \selectlanguage{ngerman}± 7.30\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{F} = 1.301\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.280\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
BMI (kg/m\textsuperscript{2})\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24.88 \selectlanguage{ngerman}± 3.00\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24.80 \selectlanguage{ngerman}± 3.18\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
25.04 \selectlanguage{ngerman}± 2.65\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{F} = 0.039\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.961\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
HR (bpm)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
75.56 \selectlanguage{ngerman}± 6.69\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
73.50 \selectlanguage{ngerman}± 11.37\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
72.63 \selectlanguage{ngerman}± 6.99\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{F} = 0.669\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.511\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
SBP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
111.06 \selectlanguage{ngerman}± 6.14\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
111.07 \selectlanguage{ngerman}± 6.32\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
112.30 \selectlanguage{ngerman}± 5.85\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{F} = 0.313\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.732\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
DBP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
72.13 \selectlanguage{ngerman}± 5.85\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
71.93 \selectlanguage{ngerman}± 5.33\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
71.87 \selectlanguage{ngerman}± 5.13\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{F} = 0.012\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.988\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Disease duration (months)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
137.25 \selectlanguage{ngerman}± 69.16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
153.93 \selectlanguage{ngerman}± 63.26\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{t} = 0.69\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.499\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
SELENA-SLEDAI\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.75 \selectlanguage{ngerman}± 2.62\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
20.93 \selectlanguage{ngerman}± 7.77\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\emph{t} = 7.37\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: BMI: body mass index; HR: heart rate; SBP: systolic blood
pressure; DBP: diastolic blood pressure

*: \emph{P} \textless{} 0.05

Table2: laboratory results of the SLE patients\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
mild-to-moderate group (n = 16)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
severe group (n = 14)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\emph{t}\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\emph{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hb (g/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
115.69 \selectlanguage{ngerman}± 15.79\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
113.00 \selectlanguage{ngerman}± 12.06\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.518\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.609\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Plt (10\textsuperscript{9} /L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
247.69 \selectlanguage{ngerman}± 64.93\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
218.00 \selectlanguage{ngerman}± 66.90\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.232\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.228\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
glucose (mmol/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.19 \selectlanguage{ngerman}± 0.65\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.30 \selectlanguage{ngerman}± 0.57\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.470\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.642\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LDL (mmol/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.25 \selectlanguage{ngerman}± 0.51\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.32 \selectlanguage{ngerman}± 0.48\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.389\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.700\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
anti-dsDNA (UI/l)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41.39 \selectlanguage{ngerman}± 18.47\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
820.61 \selectlanguage{ngerman}± 326.36\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.956\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
C3 (mg/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.88 \selectlanguage{ngerman}± 0.33\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.63 \selectlanguage{ngerman}± 0.22\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.427\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.022\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
C4 (mg/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.24 \selectlanguage{ngerman}± 0.08\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.10 \selectlanguage{ngerman}± 0.05\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.371\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
hs-TropT (ng/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17.82 \selectlanguage{ngerman}± 8.45\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.03 \selectlanguage{ngerman}± 7.05\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.362\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.039\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: Hb: hemoglobin; PLT: platelets; LDL: low-density lipoprotein
cholesterol; C3: complement component C3; C4: complement component C4;
hs-TropT: high-sensitivity TropT

*: \emph{P} \textless{} 0.05

\textbf{3.2 Comparison of 3D conventional parameters}

There was no statistically significant difference in terms of LVESV and
SPI in the three studied groups (\emph{P} = 0.151, 0.708, respectively).
Meanwhile, LVEDV and LVEF was statistically significantly lower in the
mild-to-moderate and the severe groups compared to the control group
(\emph{P\textsubscript{2}} \textless{} 0.05,
\emph{P\textsubscript{3}}\textless{} 0.05); LV EDmass and LV ESmass was
statistically significantly higher in the mild-to-moderate and the
severe groups compared to the control group (\emph{P\textsubscript{2}}
\textless{} 0.05, \emph{P\textsubscript{3}} \textless{} 0.05). However,
there was no statistically significant difference in terms of LVEDV,
LVEF, LV EDmass and LV ESmass between the mild-to-moderate group and the
severe group (\emph{P\textsubscript{1}} = 0.999, 0.380, 0.144, 0.321,
respectively). (Table 3)

Table3: Comparison of 3D Conventional Parameters\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
mild-to-moderate group (n = 16)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
severe group (n = 14)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
control group (n = 30)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\emph{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVEDV (ml)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
78.48 \selectlanguage{ngerman}± 18.64\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
78.48 \selectlanguage{ngerman}± 9.51\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
105.76 \selectlanguage{ngerman}± 10.66\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.999,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.999,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.999,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.999,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.999,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVESV (ml)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
30.75 \selectlanguage{ngerman}± 3.01\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28.49 \selectlanguage{ngerman}± 4.24\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
31.11 \selectlanguage{ngerman}± 4.67\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.151\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVEF (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
60.19 \selectlanguage{ngerman}± 3.80\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
59.00 \selectlanguage{ngerman}± 3.74\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
62.80 \selectlanguage{ngerman}± 3.57\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.004\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.380,
\emph{P\textsubscript{2}} = 0.025\textsuperscript{*},
\emph{P\textsubscript{3}} = 0.002\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.380,
\emph{P\textsubscript{2}} = 0.025\textsuperscript{*},
\emph{P\textsubscript{3}} = 0.002\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.380,
\emph{P\textsubscript{2}} = 0.025\textsuperscript{*},
\emph{P\textsubscript{3}} = 0.002\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.380,
\emph{P\textsubscript{2}} = 0.025\textsuperscript{*},
\emph{P\textsubscript{3}} = 0.002\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.380,
\emph{P\textsubscript{2}} = 0.025\textsuperscript{*},
\emph{P\textsubscript{3}} = 0.002\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
SPI (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.41 \selectlanguage{ngerman}± 0.04\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.40 \selectlanguage{ngerman}± 0.04\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.41 \selectlanguage{ngerman}± 0.05\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.708\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LV EDmass (g)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
136.66 \selectlanguage{ngerman}± 8.73\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
140.64 \selectlanguage{ngerman}± 5.75\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
123.00 \selectlanguage{ngerman}± 7.21\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.144,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.144,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.144,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.144,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.144,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LV ESmass (g)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
140.51 \selectlanguage{ngerman}± 6.03\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
142.52 \selectlanguage{ngerman}± 4.30\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
128.27 \selectlanguage{ngerman}± 5.65\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.321,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.321,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.321,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.321,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} = 0.321,
\emph{P\textsubscript{2}} \textless{} 0.001\textsuperscript{*},
\emph{P\textsubscript{3}} \textless{} 0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: \emph{P\textsubscript{1}} : compares between mild-to-moderate
group and severe group; \emph{P\textsubscript{2}} : compares between
mild-to-moderate group and control group; \emph{P\textsubscript{3}} :
compares between severe group and control group; *: \emph{P} \textless{}
0.05

LVEDV: left ventricular end-diastolic volume; LVESV: left ventricular
end systolic volume; LVEF: left ventricular ejection fraction; SPI:
spherical index; LV EDmass: left ventricular end diastolic mass; LV
ESmass: left ventricular end systolic mass

\textbf{3.3 Comparison of 3D strain parameters}

There was a statistically significantly decrease in GLS, GCS, LVtw, Tor
and MCI in the mild-to-moderate and severe groups compared to the
control group (\emph{P\textsubscript{2}} \textless{}
0.05,\emph{P\textsubscript{3}} \textless{} 0.05). There was a
statistically significantly increase in PSD in the mild-to-moderate and
severe groups compared to the control group (\emph{P\textsubscript{2}}
\textless{} 0.05, \emph{P\textsubscript{3}} \textless{} 0.05). There was
statistically significant difference in terms of 3D strain parameters
between the mild-to-moderate group and the severe group
(\emph{P\textsubscript{1}} \textless{} 0.05). (Table 4, Figure 1-4)

Table4: Comparison of 3D Strain Parameters\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
mild-to-moderate group (n = 16)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
severe group (n = 14)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
control group (n = 30)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\emph{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
GLS (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18.50 \selectlanguage{ngerman}± 1.97\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16.57 \selectlanguage{ngerman}± 2.38\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20.43 \selectlanguage{ngerman}± 2.36\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.024\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.008\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.024\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.008\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.024\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.008\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.024\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.008\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.024\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.008\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
GCS (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20.56 \selectlanguage{ngerman}± 2.06\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17.29 \selectlanguage{ngerman}± 2.89\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
22.17 \selectlanguage{ngerman}± 2.55\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.044\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.044\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.044\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.044\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} =
0.044\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVtw (\selectlanguage{ngerman}°)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11.36 \selectlanguage{ngerman}± 2.21\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9.59 \selectlanguage{ngerman}± 2.27\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13.76 \selectlanguage{ngerman}± 1.82\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.021\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.021\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.021\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.021\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.021\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Tor (\selectlanguage{ngerman}°/cm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.48 \selectlanguage{ngerman}± 0.25\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.15 \selectlanguage{ngerman}± 0.29\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.83 \selectlanguage{ngerman}± 0.24\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
PSD (ms)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
33.71 \selectlanguage{ngerman}± 4.70\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41.80 \selectlanguage{ngerman}± 4.06\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
23.60 \selectlanguage{ngerman}± 5.77\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
MCI (\% \selectlanguage{ngerman}× °)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
209.08 \selectlanguage{ngerman}± 41.96\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
158.16 \selectlanguage{ngerman}± 39.15\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
281.15 \selectlanguage{ngerman}± 50.47\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.004\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.004\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.004\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.004\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Significance between groups: \emph{P\textsubscript{1}} =
0.004\textsuperscript{*}, \emph{P\textsubscript{2}} \textless{}
0.001\textsuperscript{*}, \emph{P\textsubscript{3}} \textless{}
0.001\textsuperscript{*}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: \emph{P\textsubscript{1}} : compares between mild-to-moderate
group and severe group; \emph{P\textsubscript{2}} : compares between
mild-to-moderate group and control group; \emph{P\textsubscript{3}} :
compares between severe group and control group; *: \emph{P} \textless{}
0.05

GLS: global longitudinal strain; GCS: global circumferential strain;
LVtw: left ventricular twist angle; Tor: torsion; PSD: peak strain
dispersion; MCI: myocardial comprehensive index

Figure 1: Comparison of 3D-STI Strain Parameters GLS in the three
studied groups. A: mild-to-moderate group; B: severe group; C: control
group

Figure 2: Comparison of 3D-STI Strain Parameters GCS in the three
studied groups. A: mild-to-moderate group; B: severe group; C: control
group

Figure3: Comparison of 3D-STI Strain Parameters LVtw in the three
studied groups. A: mild-to-moderate group; B: severe group; C: control
group

Figure4: Comparison of 3D-STI Strain Parameters Tor in the three studied
groups. A: mild-to-moderate group; B: severe group; C: control group

\textbf{3.4 Diagnostic efficiency of 3D strain parameters}

The areas under the curve (\emph{AUC} ) of LVtw, Tor, and MCI were all
\textgreater{} 0.8 (\emph{P}\textless{} 0.05), the sensitivity and
specificity were all \textgreater{} 60\%, and the Youden indices were
all \textgreater{} 0.5. Among them, the \emph{AUC} of the MCI was the
highest (0.909), the sensitivity of MCI was the highest (90.00\%), and
the specificity of Tor was the highest (86.67\%) (Table 5, Figure 5).

Table 5. ROC Curve of 3D-STI Parameters in the Diagnosis of Cardiac
Function in Patients with SLE\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
Parameters & Threshold (\%) & AUC & Sensitivity (\%) & Specificity (\%)
& Youden index\tabularnewline
\midrule
\endhead
LVEF (\%) & 60.0 & 0.720 & 53.33 & 80.00 & 0.33\tabularnewline
GLS (\%) & 18 & 0.818 & 66.67 & 80.00 & 0.47\tabularnewline
GCS (\%) & 21 & 0.789 & 80.00 & 63.33 & 0.43\tabularnewline
LVtw (\selectlanguage{ngerman}°) & 12.9 & 0.874 & 83.33 & 80.00 & 0.63\tabularnewline
Tor (\selectlanguage{ngerman}°/cm) & 1.6 & 0.898 & 86.67 & 86.67* & 0.73\tabularnewline
MCI (\%\selectlanguage{ngerman}×°) & 237.8 & 0.909* & 90.00* & 80.00 & 0.70\tabularnewline
\bottomrule
\end{longtable}

Note: *: \emph{P} \textless{} 0.05

Figure 5: ROC Curve of 3D-STI Parameters in the Diagnosis of Cardiac
Function in Patients with SLE

\textbf{3.5 Correlation analysis between the 3D strain parameters and
hs-TropT}

All parameters were negatively correlated with hs-TropT
(\emph{P}\textless{} 0.01), and the absolute values were as follows: MCI
\textgreater{} Tor \textgreater{} LVtW \textgreater{} GLS \textgreater{}
GCS \textgreater{} LVEF (Table 6).

Table 6: Correlation between 3D-STI Parameters and hs-TropT\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
& LVEF & GLS (\%) & GCS (\%) & LVtw (\selectlanguage{ngerman}°) & Tor (\selectlanguage{ngerman}°/cm) &
MCI\tabularnewline
\midrule
\endhead
\emph{r} & -0.338 & -0.415 & -0.365 & -0.523 & -0.578 &
-0.677\tabularnewline
\emph{P} & \textless{}0.01 & \textless{}0.01 & \textless{}0.01 &
\textless{}0.01 & \textless{}0.01 & \textless{}0.01\tabularnewline
\bottomrule
\end{longtable}

\textbf{3.6 Repeatability test of 3D strain parameters}

The intra-observer and inter-observer parameters showed that the
intra-group repeatability test intraclass correlation coefficient
(\emph{ICC} ) of the left ventricular Tor and MCI were 0.868 and 0.899,
respectively, and the inter-group repeatability test \emph{ICCs} were
0.878 and 0.894, respectively; this indicated that the reliability and
repeatability of the above parameters were relatively high (Figure 6).

Figure 6: 3D strain Parameters: Left ventricular Tor and MCI
repeatability test (Bland--Altman diagram)

\textbf{Discussion}

As an autoimmune disease with the ability to impart chronic damage to
multiple organs, SLE is characterized by remission and deterioration.
Moreover, cardiovascular damage is an important cause of death and is
becoming increasingly serious \textsuperscript{{[}5{]}}. However, heart
damage is often hidden in the early stage and can be easily ignored; if
it can be detected earlier, prevention will be of great significance to
the prognosis of the disease \textsuperscript{{[}6{]}}. At the point
when heart damage in SLE can be detected by two-dimensional ultrasound,
the myocardium is seriously damaged, and the possibility of recovery is
low. The 3D-STI technique eliminates the plane limitation of
two-dimensional ultrasound and allows for comprehensive analysis of left
ventricular wall motion such that the actual situation of the left
ventricle is accurately reflected \textsuperscript{{[}7{]}.}

Compared with the control group, this study showed that LVEF and LVEDV
in the mild-to-moderate and the severe groups decreased significantly,
LV EDmass, and LV ESmass increased significantly. There was no
statistically significant difference in terms of LVESV in the three
studied groups. Moreover, although SPI reflected left ventricular
geometry, there was no significant difference in the three studied
groups, indicating that the early left ventricular systolic function may
be locally impaired in SLE; however, the decline in function is not
obvious, and the overall function is still within the normal range
\textsuperscript{{[}8{]}}. At the same time, there was a statistically
significantly decrease in GLS, GCS and LVtw in the mild-to-moderate and
severe groups compared to the control group, indicating that the left
ventricular systolic function is damaged in the early stage. This may be
due to fact that SLE can lead to the deposition of immune complexes in
the cardiovascular system or inflammatory changes after complement
activation that result in the degeneration of collagen fibers in the
myocardial interstitium. Ultimately, this leads to damage to myocardial
systolic function, which is consistent with the findings of Huang et
al\textsuperscript{{[}9{]}}.

The results also showed that the sensitivity, specificity, and AUC of
Tor were higher than those of GLS and GCS, indicating that LVtw may be a
better index to reflect the changes in left ventricular systolic
function than the three-dimensional strain GLS and GCS, whereas GLS is
more sensitive in the three-dimensional
strain\textsuperscript{{[}10{]}}. This may be due to the high
sensitivity of subendocardial myocardium to ischemia, so coronary artery
lesions, endocarditis and myocardial metabolic disorders occur in
patients with SLE. These lesions are the first to cause longitudinal
myocardial injury, which lead to a decrease in systolic motor function
along the long axis of the myocardium. Therefore, we conclude that the
overall longitudinal strain of the left ventricle should be more
sensitive to changes in ventricular systolic function than the
circumference. Left ventricular torsion is also affected by the degree
of myocardial contraction, the arrangement of endomyocardial muscle
fibers, and the contraction balance. This is because the outer
myocardial torque is larger and the contraction torque is greater. The
left ventricular torsion direction is consistent with the outer
myocardial rotation direction. SLE leads to a decrease in left
ventricular myocardial elastic deformation ability, torsion abnormality,
and amplitude, thus reflecting a decrease in left ventricular systolic
function more accurately \textsuperscript{{[}11{]}}.

However, during collection, we found that the lack of clear anatomical
reference in the apical part of the left ventricle led to differences in
the location of LVtw in different patients, resulting in measurement
errors. Therefore, the left ventricular Tor, which avoids this error,
can be introduced as another index to evaluate left ventricular systolic
function \textsuperscript{{[}12{]}}. It was found that there was a
statistically significantly decrease in Tor in the mild-to-moderate and
severe groups compared to the control group, indicating that Tor can be
used as an effective index to reflect the myocardial damage caused by
SLE in the early stage. The ROC curve also showed that the sensitivity,
specificity, and AUC of Tor were higher than those of LVtw, indicating
that left ventricular Tor may reflect changes in left ventricular
systolic function better than LVtw, with higher repeatability. At the
same time, we found that myocardial deformation in the three-dimensional
space is caused by myocardial strain and torsional motion. Thus, the new
parameter MCI, which is composed of GLS and LVtw, may be used to
evaluate left ventricular systolic function more comprehensively. The
results showed that there was a statistically significantly decrease in
MCI in the mild-to-moderate and severe groups compared to the control
group, and the repeatability was high. The ROC curve showed the highest
area and sensitivity under the left ventricular MCI curve, which was
consistent with the results of Mornos et al, indicating that no single
form of exercise can fully reflect the movement of the left ventricular
myocardium \textsuperscript{{[}13{]}}. At the same time, correlation
analysis showed that there was a good correlation between MCI and
hs-TropT \textsuperscript{{[}14{]}}. Therefore, MCI can be used as a new
sensitive index for the early detection of SLE heart injury and provide
a basis for clinical intervention, timely adjustment, or change of drugs
to avoid aggravation of myocardial damage, resulting in irreversible
myocardial injury.

PSD is the standard deviation of the peak time of the longitudinal
strain in 17 segments of the left ventricle. There was a statistically
significantly increase in PSD in the mild-to-moderate and severe groups
compared to the control group, indicating that the dispersion of
myocardial mechanical motion is increased, that is, myocardial systolic
synchronization is worse \textsuperscript{{[}15{]}}. It has been
suggested that the deposition of SLE-associated immune complexes in the
cardiovascular system may lead to degeneration of cardiomyocytes and
myocardial sympathetic nerves, which directly leads to the damage of the
normal function of cardiomyocytes and the dysfunction of nerve fibers in
the myocardial layer; this, in turn, has a serious impact on myocardial
synchronous movement.

\textbf{Limitations}

The limitations of this study are as follows: (1) the image must be
clear and of high quality; (2) the inspection operation and image
post-processing greatly depend on the accuracy of human operation; (3)
the sample size is small; (4) there are individual differences.

\textbf{Conclusion}

SLE can cause left ventricular systolic function damage in the early
stage, and 3D-STI can be used to monitor myocardial subclinical injury
at the early stage. The new parameters, including MCI and Tor, are
particularly relevant as they can provide an objective imaging basis for
early clinical diagnosis of left ventricular myocardial involvement and
guide prognosis in patients with SLE.

\textbf{Conflict of interest disclosure statement}

The authors declare that they have no conflict of interest.

\textbf{References}

{[}1{]} Gasser E K, Schell-Chaple H M. Systemic lupus erythematosus and
critical illness. AACN Adv Crit Care, 2020, 31(3): 296-307.

{[}2{]} Alpizar-Rodriguez D, Romero-Diaz J. Are cardiovascular events
and mortality in patients with systemic lupus erythematosus predictable
at diagnosis? Rheumatol Oxf Engl, 2020, 59(3): 467-8.

{[}3{]} Pastore M C, Mandoli G E, Aboumarie H S, et al. Basic and
advanced echocardiography in advanced heart failure: an overview. Heart
Fail Rev, 2020, 25(6): 937-48.

{[}4{]} He J, Yang L. Value of three-dimensional speckle-tracking
imaging in detecting left ventricular systolic function in patients with
dilated cardiomyopathy. Echocardiography, 2019, 36(8): 1492-5.

{[}5{]} Fortuna G, Brennan M T. Systemic lupus erythematosus:
epidemiology, pathophysiology, manifestations, and management. Dent Clin
North Am, 2013, 57(4): 631-55.

{[}6{]} Chen J, Tang Y, Zhu M, Xu A. Heart involvement in systemic lupus
erythematosus: a systemic review and meta-analysis. Clin Rheumatol,
2016, 35(10): 2437-48.

{[}7{]} Deng W, Xie M, Lv Q, et al. Early left ventricular remodeling
and subclinical cardiac dysfunction in systemic lupus erythematosus: a
three-dimensional speckle tracking study. Int J Cardiovasc Imaging,
2020, 36(7): 1227-35.

{[}8{]} Gegenava T, Gegenava M, Steup-Beekman G M, et al. Left
ventricular systolic function in patients with systemic lupus
erythematosus and its association with cardiovascular events. J Am Soc
Echocardiogr, 2020, 33(9): 1116-22.

{[}9{]} Huang B T, Yao H M, Huang H. Left ventricular remodeling and
dysfunction in systemic lupus erythematosus: a three-dimensional speckle
tracking study. Echocardiography, 2014, 31(9): 1085-94.

{[}10{]} Di Minno M N D, Forte F, Tufano A, et al. Speckle tracking
echocardiography in patients with systemic lupus erythematosus: A
meta-analysis. Eur J Intern Med, 2020, 73: 16-22.

{[}11{]} El-Sisi A M, Gabr A E A M, Afia A A, et al. Left ventricular
rotational deformation changes by speckle tracking imaging before and
24~hours after transcatheter closure of large secundum atrial septal
defects in children. Echocardiography, 2020, 37(7): 1065-71.

{[}12{]} Bulut M, Acar R D, Acar \selectlanguage{polish}Ş, \selectlanguage{english}et al. Evaluation of torsion and
twist mechanics of the left ventricle in patients with systemic lupus
erythematosus. Anatol J Cardiol, 2016, 16(6): 434-9.

{[}13{]} Hayat D, Kloeckner M, Nahum J, et al. Comparison of real-time
three-dimensional speckle tracking to magnetic resonance imaging in
patients with coronary heart disease. Am J Cardiol, 2012, 109(2): 180-6.

{[}14{]} Winau L, Hinojar Baydes R, Braner A, et al. High-sensitive
troponin is associated with subclinical imaging biosignature of
inflammatory cardiovascular involvement in systemic lupus erythematosus.
Ann Rheum Dis, 2018, 77(11): 1590-8.

{[}15{]} Dedeoglu R, \selectlanguage{polish}Ş\selectlanguage{english}ahin S, Koka A, et al. Evaluation of cardiac
functions in juvenile systemic lupus erythematosus with two-dimensional
speckle tracking echocardiography. Clin Rheumatol, 2016, 35(8): 1967-75.

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