bluuebunny/crossref_metadata_2025 huggingface dataset:
226Earlier surgical myectomy vs. waiting for a Class I indication is associated with improved long-term survival in symptomatic hypertrophic obstructive cardiomyopathy patients
Authors: Alashi A , Smedira N G , Hodges K , Popovic Z B , Thamilarasan M , Wierup P , Lever H M , Desai M Y
Published: October 2019

Background

In patients with severe hypertrophic obstructive cardiomyopathy (HOCM), surgical myectomy (SM) is typically indicated for severe symptoms despite maximal medical therapy.

Aims

We sought to compare long-term outcomes of severe HOCM patients where decision for SM was based on guideline-recommended Class I indication (functional Class or FC ≥3 or exertional syncope despite maximal medical therapy) vs. earlier (FC II and/or impaired exercise capacity on exercise echo with medication intolerance).

Methods

The study included 2268 HOCM patients (excluding <18 years, at least moderate aortic stenosis requiring valve replacement and subaortic membrane, age 56±14 years, 55% men), who underwent SM at our center between 1/02–3/18. Clinical and echo data, including left ventricular outflow tract gradient (LVOTG) were recorded. Cardiac death and/or appropriate internal defibrillator discharge were recorded as composite endpoints.

Results

1318 (58%) patients met Class I indication for SM, while the rest underwent SM for FC II (due to medicine intolerance) or impaired exercise capacity. 535 (24%) and 408 (18%) had history of atrial fibrillation and a family history of HCM. All patients were on maximally tolerated medical therapy. European 5-year sudden death risk score was 3.7±2%. Baseline basal septal thickness, resting and maximal LVOTG were 2.0±0.3 cm, 61±44 mm Hg and 100±31 mm Hg. At 6.2±4 years of follow-up after SM, 248 (11%) had composite events (13 [0.6%] in-hospital deaths). Competing risk survival analysis for composite endpoint is shown in Figure 1a. Patients operated for Class I indication had significantly higher longer-term event rate vs. those operated earlier (182 [14%] vs. 66 [7%], p<0.001, Figure 1B).

Conclusions

In patients with severe HOCM undergoing SM at an experienced center performed by experienced surgeons, delaying surgery till reaching Class I indication was associated with much worse survival than operating earlier for milder symptoms or impaired exercise tolerance on exercise echo.
258Use of low-dose prasugrel vs. clopidogrel in elderly patients undergoing complex or non-complex PCI for acute coronary syndromes: insights from the Elderly ACS 2 study
Authors: Montalto C , Crimi G , Fortuni F , Mandurino Mirizzi A , Piatti L , Morici N , Tortorella G , Grosseto D , Sganzerla P , Ferrario M , De Servi S , Savonitto S
Published: October 2019

Background

Prasugrel was superior to clopidogrel in the setting of acute coronary syndromes (ACS) and recent data highlighted its possible role in the setting of complex percutaneous coronary intervention (PCI). Nonetheless, evidence supporting its use in high bleeding risk population are lacking.

Purpose

The aim of this post-hoc subgroup analysis was to evaluate the impact of prasugrel administration in elderly patients undergoing complex PCI for ACS. A primary composite endpoint of composite of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year and secondary endpoints of all-cause mortality and any bleeding at 1 year were analyzed.

Methods

In the multicenter Elderly ACS 2 Study 1,443 patients aged >74 y were randomly assigned to receive low-dose prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year (Table 1). Complex PCI was defined if ≥3 lesions were treated, if ≥3 stents were deployed, or if any bifurcation, trifurcation, chronic total obstruction or moderate-to-severe calcified lesions were treated.

Results

Patients undergoing complex PCI (n=607) did not experience worse outcome, as compared to those with simpler PCI, in terms of primary endpoint (p=0.21, Figure 1A). Furthermore, in this subgroup, no significant difference was observed with prasugrel vs clopidogrel with regard to the primary endpoint (HR 1.17; CI 0.819–1.67; p=0.39, Figure 1A), all-cause death and bleeding (Figure 1C and 1D). No significant interaction was observed between treatment and PCI complexity (interaction p=0.34).

Table 1 Overall Non-complex PCI Complex PCI p value Age (y) 80.60±4.46 80.00 [77.00, 84.00] 80.00 [77.00, 83.00] 0.215 STE-ACS 595 (41.2) 272 (32.5) 323 (53.4) <0.001 Diabetes mellitus 253 (17.5) 159 (19.0) 94 (15.5) 0.104 LVEF 48.27±9.59 49.08±9.55 47.26±9.54 0.002 Total number of diseased vessels 2.29±1.06 2.22±1.06 2.38±1.05 0.005 Previous Myocardial Infarction 274 (19.0) 171 (20.4) 103 (17.0) 0.122 Randomized to prasugrel 713 (49.4) 404 (48.2) 404 (48.2) 0.307 Data are expressed as mean ± SD or [IQR] and count/valid %).

Figure 1

Conclusions

In elderly patients presenting with ACS low-dose prasugrel was comparable to clopidogrel in terms of all-cause mortality and any bleeding at 1 year.

Acknowledgement/Funding

None
283Endovascular thrombectomy as a means to improve survival in acute ischemic stroke - A meta-analysis
Authors: Lin Y , Schulze V , Brockmeyer M , Parco C , Karathanos A , Krieger T , Heinen Y , Gliem M , Hartung H P , Antoch G , Jander S , Turowski B , Perings S , Kelm M , Wolff G
Published: October 2019

Background and purpose

Although endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) is guideline-recommended to improve functional recovery, thus far there are only inconclusive data from underpowered singular trials of EVT vs. medical therapy (MT) on mortality. We here aimed to perform a meta-analysis on short-term mortality in guideline-relevant EVT vs. MT randomized controlled trials (RCTs).

Methods

All randomized controlled trials (RCT) reporting EVT vs. MT in the latest 2018 American Stroke Association/American Heart Association (ASA/AHA) Guidelines were eligible for inclusion. Data were abstracted by two independent investigators and double-checked by four others. Study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% confidence intervals (CI). Ninety-day mortality and intracranial hemorrhage (ICH) were analyzed.

Results

Ten of the twelve guideline-relevant EVT vs. MT RCTs (DAWN, DEFUSE 3, ESCAPE, EXTEND-IA, MR CLEAN, MR RESCUE, REVASCAT, SWIFT PRIME, THERAPY, THRACE) with 2,313 patients were selected for inclusion. Studies IMS III and SYNTHESIS were excluded due to their very infrequent use of EVT. Stent retrievers (Trevo, Solitaire, Merci) were most frequently applied, followed by thrombus aspiration (Penumbra). Intravenous thrombolysis was administered in addition to EVT in the majority of patients. In the pooled meta-analysis of all eligible RCTs, EVT significantly reduced the risk for 90-day mortality by 3.7% compared to MT (15.0% vs. 18.7%; RR 0.81 with CI 0.68 to 0.98; p=0.03), accounting for a number-needed-to-treat of 27 to prevent one all-cause death. Trends were similar in early-window (RR 0.83) and late-window trials only (RR 0.76). There was no difference in the risk for ICH in EVT vs. MT (4.2% vs. 4.0%; RR 1.11 with CI 0.71 to 1.72; p=0.65). All included trials were published in high-quality journals and risk of bias was judged low.

Conclusions

This meta-analysis lends evidence to EVT benefits for survival already during the first 90 days after acute ischemic stroke. These results further highlight the evolution of interventional techniques in this setting.
296Clinical benefit of assessing cognitive function in frail patients with heart failure: a multicenter prospective cohort study
Authors: Iwatsu K , Adachi T , Kamisaka K , Iida Y , Yamada S
Published: October 2019

Background

Cognitive decline is highly prevalent in patients with heart failure (HF) and increases the risk of hospital readmission or mortality due to poor self-care ability. Although cognitive decline often coexists with physical frailty (PF) in HF, the clinical utility of combined assessment of both cognitive function and PF remains unclear.

Purpose

The aim of this study was to examine the prognostic value of assessing cognitive function and PF in patients with HF.

Methods

This prospective study was performed as a multicenter cohort study in Japan (FLAGSHIP). We enrolled 1611 patients admitted for acute HF or exacerbation of chronic HF and who were able to walk at discharge. Patients with severe dementia [Mini-Mental State Examination (MMSE) scores <18], severe psychological disorders or less than 6-month life expectancy were excluded. From data at discharge, we collected data on cognitive function, PF, age, gender, New York Heart Association class, left ventricular ejection fraction, brain natriuretic peptide, estimate glomerular filtration rate, hemoglobin, depression (5-item geriatric depression scale ≥2) and comorbidities, including atrial fibrillation, diabetes mellitus, stroke, and hyponatremia. PF was defined as ≥2 of the followings based on our previous publication: usual walking speed <0.8 m/s; grip strength <26 kg (men) or <17 kg (women); Performance Measure of Activity in Daily Living-8 ≥21; body mass index <20 kg/m2. Cognitive function was assessed by MMSE. We selected the optimal cutoff point of MMSE that predict a worse outcome by the receiver operating characteristic (ROC) curve analysis. Study outcome was a composite outcome of rehospitalization for worsening HF or all-cause mortality within 2 years after discharge. We used Cox proportional-hazard models to examine the association between the presence of cognitive decline and PF and 2-years prognosis, controlling for potential confound factors.

Results

A total of 507 events (31.5%) were observed (400 HF rehospitalization, 27 cardiac death, 80 non-cardiac death). The optimal cutoff point of MMSE was 28 (the area under the ROC curve: 0.58, p<0.01, sensitivity: 71.0%, specificity: 41.0%). There was a significant difference in event-free survival across the groups stratified by cognitive decline (MMSE <28) and PF (Figure). After adjusting for all variables, coexistence of both cognitive decline and PF was independently associated with 2-years prognosis (hazard ratio: 1.52, 95% confidence interval: 1.19–1.94).

Conclusion

Our data shows that even a slight decline in cognitive function leads to an increased risk of death or HF rehospitalization in frail patients with HF. Combined assessment both cognitive function and PF improves risk stratification for readmission and mortality in patients with HF.

Acknowledgement/Funding

This work was supported by a Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science [16H01862].
393Ischemic burden by vasodilator stress CMR predicts long-term all-cause death and the effect of revascularization in patients with known or suspected stable ischemic heart disease
Authors: Marcos Garces V , Gavara J , Rios-Navarro C , Racugno P , Bellver Navarro A , Ventura Perez B , Aguilar Botella J , Ventura S , Mainar L , Bosch M J , Merlos P , Lopez-Lereu M P , Monmeneu J V , Chorro F J , Bodi V
Published: October 2019

Background

In patients with stable ischemic heart disease (SIHD) the effect of revascularization on all-cause death (the most verifiable clinical event) is unknown.

Objectives

We explored the potential of the ischemic burden as derived from vasodilator stress cardiovascular magnetic resonance (CMR) to guide decision-making in this scenario.

Methods

In a large prospective multicenter registry, we recruited 6389 patients (mean age 65±11 years, 38% female) submitted to undergo vasodilator stress CMR for known or suspected SIHD. Baseline and CMR characteristics were prospectively recorded. The ischemic burden (at vasodilator stress first-pass perfusion imaging) and necrosis extent (at late enhancement imaging) were computed (17-segment model). The effect of CMR-related revascularization (within the following three months) on all-cause death (revised using the unified regional electronic health system registry) was explored.

Results

During a 5.75-year median follow-up, 717 (11.2%) all-cause deaths were documented. In multivariable analyses, more extensive ischemic burden (per 1-segment increase) independently related to all-cause death (1.05 [1.03–1.07], p<0.001). In 1034 patients (517 revascularized, 517 non-revascularized) strictly 1:1 matched for the independent predictors of outcome and of undergoing CMR-related revascularization (age, diabetes mellitus, male sex, LVEF, ischemic burden and necrosis extent), CMR-related revascularization did not significantly alter all-cause death rate (13.3% vs. 13.3%, p=0.54). Nevertheless, a potent interaction existed with the ischemic burden (p<0.001). CMR-related revascularization independently reduced the risk of all-cause death in 430 patients with ischemic burden >5 segments (9.3% vs. 16.3%, HR 0.56 [0.32–0.98], p=0.02) but it independently increased risk in 604 patients with ischemic burden ≤5 segments (16.2% vs. 11.3%, HR 1.59 [1.03–2.45], p=0.037).

Figure 1. CMR-related revascularization

Conclusions

In patients with known or suspected stable ischemic heart disease the ischemic burden as derived from vasodilator stress CMR can be helpful to predict the effect of revascularization on long-term all-cause death.

Acknowledgement/Funding

Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).
405Acute and short-term effects of diesel exhaust fumes exposure on arterial wall properties, inflammatory process and fibrosis-fibrinolysis status
Authors: Fountoulakis P , Oikonomou E , Papaioannou T , Psaltopoulou T , Tsalamandris S , Papamikroulis G A , Kalampogias A , Pallantza Z , Pavlou E , Milliou A , Asimakopoulou M N , Barbaresos N , Giannarakis I , Siamata P , Tousoulis D
Published: October 2019

Introduction

Exhaust fumes from diesel engines are a complex mixture of toxic compounds with a wide variety of harmful effects. The acute effects of diesel exhaust fumes on the cardiovascular system are well-known. However, their short-term impact has not been thoroughly studied.

Purpose

To study the acute and short-term (24 h) effects of diesel exhaust particles (DEPs) on endothelial function, arterial wall properties, inflammatory process and fibrosis-fibrinolysis status.

Methods

In this blind cross over study, 40 healthy volunteers (median age 40 years old) have been exposed to diesel exhaust particles (DEPs) and then to filtered air (FA) over a 2-hour session with a wash out period of 4 weeks. Exposure to DEPs was calibrated based on the mass of microparticles less than 2,5 microns in diameter (PM 2,5). Flow-mediated-dilation (FMD) was used to estimate endothelial function. Pulse wave velocity (PWV) and augmentation index (AIx) assessed central aortic stiffness and arterial reflected waves respectively. C reactive protein (CRP) was measured to determine the inflammatory status, as well as fibrinogen and protein C levels to evaluate the impact on the coagulation cascade. All measurements were performed before each session (T0), at the end of the 2 hours exposure session (T2) and 24 hours after completion of each session (T24). Variables with normal distribution are presented as mean±SD otherwise as median±SEM.

Results

At T0 of DEP and FA exposure there was no significant difference in FMD, PWV, AIX, CRP, protein C and fibrinogen levels. Exposure to DEP decreased significantly FMD (T0: 11.97±4.61% vs T2: 7.71±3.36% vs. T24: 6.17±3.19%, p<0.001) and increased PWV (T0: 6.09±1.03m/sec vs T2: 7.22±1.31m/sec vs. T24: 6.90±1.03m/sec, p<0.001), AIx (T0: 8.17±3.19% vs T2: 12.71±3.36% vs. T24: 13.17±4.61%, p<0.001), CRP (T0: 1.41±0.18 mg/L vs T2: 1.99±0.21mg/L vs. T24: 2.08±0.24mg/L, p=0.04) and fibrinogen levels (T0: 269±44 mg/dL vs T2: 331±75 mg/dL vs. T24: 307±51 mg/dL, p=0.002). Protein C was significantly reduced (T0: 121±26% vs T2: 104±21% vs. T24: 105±20%, p=0.003). Exposure to FA had no significant impact on the study parameters.

Graph of results

Conclusion

Exposure to diesel exhaust fumes may have significant adverse effects on the cardiovascular system with impairment of endothelial function, arterial wall properties, inflammatory status and fibrosis-fibrinolysis parameters not only during the exposure period but as far as 24 hours after exposure.

Acknowledgement/Funding

None
P321A single factor related to left atrial pressure overload is useful for prognosis in elderly patients with heart failure with preserved ejection fraction: PURSUIT HFpEF study
Authors: Hoshida S , Watanabe T , Shinoda Y , Minamisaka T , Fukuoka H , Inui H , Ueno K , Yasumura Y , Yamada T , Uematsu M , Tamaki S , Higuchi Y , Abe H , Hikoso S , Sakata Y
Published: October 2019

Background

E/e' and the ratio of diastolic elastance (Ed)/arterial elastance (Ea) = (E/e')/(0.9 × systolic blood pressure), indices of left atrial (LA) pressure overload, are elevated in elderly women with heart failure with preserved ejection fraction (HFpEF). The severity of diastolic dysfunction is assessed by a combination of several indices of LA volume and pressure overload. However, which overload is more important as a single factor for the prognosis of these patients remains undefined.

Methods

We enrolled patients with HFpEF showing sinus rhythm (n=145; left ventricular ejection fraction >50%; men/women, 56/89; mean age, 80.5 years). Blood examination and transthoracic echocardiography were performed before discharge. All-cause mortality and admission for cardiac events were evaluated after more than 1 year (mean, 370 days).

Results

The all-cause mortality rate was 11% (16/145). There were significant differences in age (p=0.005), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level (p<0.001), LA volume index (p=0.018), E/e' (p=0.022), and Ed/Ea (p=0.016) between patients with and without all-cause mortality. When cutoff points for mortality by receiver operating characteristic curve analysis were examined, the area under the curve in LA volume index (0.564) was slightly smaller than that in age (0.734), NT-proBNP level (0.732), E/e' (0.695), and Ed/Ea (0.709). Kaplan-Meier survival analysis clearly showed that age >85 years (p<0.001), NT-proBNP level >888 pg/mL (p=0.003), E/e' >14.4 (p=0.020), and Ed/Ea >0.153 (p<0.001) were determinant factors for mortality. Cox hazard ratios were also significant in these indices (p=0.002, p=0.012, p=0.028, and p=0.001, respectively). In the case of all-cause mortality or admission for cardiac events, the results were nearly similar as those in the case of all-cause mortality. Ed/Ea exhibited a larger Cox hazard ratio for prognosis than E/e' in the multivariate analysis.

Conclusions

LA pressure overload compared to volume overload was a useful marker for prognosis in elderly patients with HFpEF. As a single index for LA pressure overload in noninvasive echocardiographic findings, Ed/Ea may be more suitable than E/e'.
P342Time-to-isolation-guided cryoballoon pulmonary vein isolation reduces esophageal and mediastinal alterations detected by endoscopic ultrasound
Authors: Ellermann C , Cordes F , Dechering D G , Frommeyer G , Kochhaeuser S , Lange P S , Pott C , Lenze F , Schmidt H , Ullerich H , Eckardt L
Published: October 2019

Background

Pulmonary vein isolation (PVI) is recommended for treatment of symptomatic atrial fibrillation. Cryoballoon ablation is an emerging safe and efficient technique for achieving PVI. Nevertheless, structural alterations of the mediastinum and/or the oesophagus, which seem to be associated with an increased risk of the lethal complication of an atrio-oesophageal fistula, have been described.

Purpose

MADE-PVI (Mediastino-oesophageal Alterations Detected by Endosonography after PVI) aimed at evaluating safety of cryoballoon PVI in relation to two different freeze protocols. As a time-to-isolation (TTI)-guided protocol has been reported to be as effective as a conventional “two freeze protocol”, we hypothesized that a TTI-guided protocol causes less peri-atrial and -oesophageal lesions.

Methods

70 consecutive patients were scheduled for de novo cryoballoon (2nd generation) PVI employing either a conventional freeze protocol (Group A: n=35: 2x180s per vein) or a TTI-guided approach (Group B: n=35; freeze time: TTI+120s per vein or 1x180s in case TTI could not be measured). Structural oesophageal and mediastinal alterations (e.g. ulceration, oedema) were assessed by endoscopy and endosonography blinded prior and post ablation.

Results

Irrespective of used freeze protocol, ablation significantly increased atrio-oesophageal distances, including distance to left and right inferior pulmonary vein ostia as well as to the posterior wall of the left atrium (all p<0.001). In general, postinterventional mediastinal oedematous alterations were detected in 47 patients (70%) with a mean size of 14mm (± 0.9 mm), while only 10 patients (15%) revealed a large mediastinal oedema >20mm. Oesophageal thermal lesions occurred in 3 patients (4%) including 1 deep ulceration, which coincided with a large mediastinal oedema. The two freeze protocols had a distinct impact on mediastinal lesions as mean size of oedematous alterations and occurrence of large mediastinal oedema were significantly increased in Group A vs. Group B (17 mm vs. 11 mm, p<0.001; 26% vs. 6%, p=0.029). Furthermore, every oesophageal lesion was detected in patients in group A. Nonetheless, no major complication occurred in either group.

Conclusions

The present prospective study clearly demonstrates a significant impact of freeze protocol on post-interventional mediastino-oesophageal alterations. A TTI-guided protocol employing 2nd generation cryoballoon reduces mediastino-oesophageal lesions and may reduce complications.

Acknowledgement/Funding

This study was supported by Medtronic by an unrestricted grant (A 1351459).
P575Merging technologies to provide Mexico an innovative nationwide AMI management network
Authors: Mehta S , Botelho R , Fernandez F , Alcocer Gamba M , De Los Rios O , Ricalde A , Acosta H , Villagra L , Perin M , Feres F , Frauenfelder A , Matheus C , Ceschim M , Pinto G , Mazzini J
Published: October 2019

Background

“Cόdigo Infarto”, the vast patient-centric, app-based, educational crusade of the Mexican Society of Interventional Cardiology (SOCIME) has been combined with the Latin America Telemedicine Infarct Network (LATIN) to create a comprehensive, national AMI program for Mexico.

Purpose

To demonstrate the benefits of amalgamating educational initiatives of national cardiology societies with a global telemedicine program for improving AMI management.

Methods

“Cόdigo Infarto” App connects patients to a network of several hundred cardiologists and 250 Primary PCI-capable labs. LATIN provides the partnership with its robust telemedicine platform, a hub-spoke strategy that supports patient's access to appropriate medical management. Remotely located experts, in Colombia, provide urgent EKG diagnosis via tele-consultation to the entire LATIN Mexico network. They activate ambulance dispatch and implement guideline-based protocols.

Results

Numerous “Cόdigo Infarto” sites have incorporated LATIN to provide a simple and accelerated management of AMI patients. Currently, the partnership (7 hubs, 78 spokes) has screened 19,886 patients. A total of 359 STEMI cases (1.8%) have been diagnosed; 118 patients (33%) were urgently reperfused, Primary PCI was performed in 74% of the latter cases. D2B time was 41 min. Reasons for the lack of treatment include delayed presentation, lack of ICU beds and insurance denials. Currently, these constraints are being methodically probed. Updated results will be available at time of presentation.

Conclusions

The synergy of the AMI initiative for Mexico provides a template for similar initiatives in developing countries.
P588Flow profile for a better non-invasive pressure drop in CoA
Authors: Fernandes J , Faraci A , Sotelo J , Urbina J , Bertoglio C , Uribe S , Nordsletten D A , Lamata P
Published: October 2019

Introduction

In cardiovascular obstructions, as Coarctation of the Aorta (CoA), guidelines recommend treatment based on a relevant pressure drop (ΔP). Diagnostic ΔP is estimated by simplified Bernoulli (SB) and is measured as peak-to-peak (PtP) ΔP via catheterization. The divergences amid methods are understood, but it is common practice to widely and positively accept both as valid diagnostic. Recently, simplified advective work-energy relative pressure (SAW) to correct SB by considering the full velocity profile for the ΔP computation.

Purpose

To verify the correctness of peak flow derived pressure drop via maximal velocity (SB), and full flow profile (SAW) versus clinical gold-standard PtP ΔP in a CoA phantom.

Methods

An MRI-compatible and pulsatile CoA phantom was built and tested in eight configurations, with four levels of obstruction (9, 11 and 13 mm CoA diameter and no CoA) under two flow regimes (stress and normal). The ΔP was measured via catheterization between ascending and in descending aorta (DA) as instantaneous and as PtP. Also, MRI 4D-flow velocity vector fields were acquired, enabling the ΔP estimation by SB and SAW at effective orifice area (EOA) and DA catheterization locations. at the point of the effective orifice area (EOA) and at DA catheterization location.

Results

The disparity in ΔP illustrate the fundamental differences between methods (figure and table). Catheterised instant and PtP ΔPs are similar for the CoA phantom configurations, where SB and SAW are valid. The lesser the obstruction, the greater is the temporal acceleration contribution to the ΔP and discrepancies between methods arise. As recognised, SB is an overestimation of the catheterization measurements. The most equivalent ΔPs are the catheterization PtP and SAW. Velocity-based ΔPs (SB and SAW) show a drop in performance when the velocity is captured at the DA instead of the right EOA point, illustrating the sensitivity to the acquisition location.

Peak ΔPs per method and per phantom 9mm CoA 11mm CoA 13mm CoA Normal R2 Linear eq. rest stress rest stress rest stress rest stress Instant ΔP 33.4 45.7 11.5 19.6 12.1 14.5 −2.7 −12.2 0.949 y=1.12x PtP ΔP 29.3 43.5 10.0 16.0 5.8 11.2 −1.8 -3.6 – – SB EOA 37.5 52.3 13.4 22.3 6.1 11.4 1.4 1.4 0.988 y=1.23x SB DA 22.6 59.8 10.7 18.6 5.2 8.5 0.9 1.2 0.893 y=1.15x SAW EOA 29.9 51.4 11.3 19.0 4.9 9.7 0.8 0.8 0.972 y=1.11x SAW DA 11.74 28.3 5.5 9.9 2.7 4.5 0.6 0.7 0.911 y=0.56x Linear comparisons were made against gold-standard catheterised PtP ΔP.

Velocity meshes and ΔPs in cardiac cycle

Conclusions

Initial phantom evidence suggests that the non-invasive ΔP assessments based on flow should consider the full flow profile and be acquired at the point of EOA.

Acknowledgement/Funding

PIC project, European Union's Horizon 2020 Marie Skłodowska-Curie ITN Project under grant agreement No 764738
P589Assessment of cardiac reverse remodelling following mitral valve repair and mitral valve replacement in degenerative mitral regurgitation: a cardiovascular magnetic resonance study
Authors: Chew P G , Dobson L E , Garg P , Richards F J L , Foley J R , Fent G J , Brown L A E , Saunderson C E D , Das A , Kidambi A , Levelt E , Swoboda P P , Dall'armellina E , Plein S , Greenwood J P
Published: October 2019

Background

Mitral valve (MV) repair is currently recommended over replacement (1). The guidelines suggesting this are however based on historic evidence which compared outdated techniques of MV replacement. Recent data cast doubts on its validity in the current era of chordal-preservation techniques in MV replacement.

Purpose

Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MV repair and MV replacement on cardiac left ventricular (LV) reverse remodelling.

Methods

65 patients with moderate-severe and severe mitral regurgitation (MR) were prospectively recruited. Of these, 37 patients (59% men, 65±15 years) to date with paired CMR scans at baseline and at 6 months were evaluated. Patients either underwent MV repair (n=9), MV replacement (n=10) or watchful waiting (n=18). The CMR protocol included cines for left ventricle (LV), left atria (LA), and aortic flow assessment. The LA and LV parameters, and MR fraction were analysed.

Results

At 6 months, both the MV repair and replacement groups exhibited a reduction in LV end-diastolic volume (LVEDV) and LA volumes when compared to the control group. The indexed LVEDV decreased significantly from 129±33ml/m2 to 99±37ml/m2, p<0.001 in the repair group, from 118±24ml/m2 to 90±26ml/m2, p<0.001 in the replacement group and remained unchanged in the control group 115±25ml/m2 to 113±25ml/m2, p=0.53. The absolute reduction in indexed LVEDV was not significantly different between the repair and replacement groups (−30±15ml/m2 vs −29±19ml/m2, repair vs replacement, p=1.00). Similarly, both surgical groups also sustained an equal degree of LA size reduction (−42±26ml/m2 vs −36±23ml/m2, repair vs replacement; p=1.00). There was a decline in the global postoperative LV ejection fraction (Table 1). The degree of reduction in LV ejection fraction however did not differ between the repair and replacement group (−9±6% vs −6±8%, repair vs replacement; p=1.00). Those undergoing surgery experienced a significant reduction in their MR severity, although those with replacement had a more effective reduction in MR severity (MR fraction for repair: 47±9% to 15±10%, p<0.001 vs replacement: 41±13% to 5±4%, p<0.001).

Conclusion

MV surgery leads to atrial and left ventricular reverse remodelling, and a decline in global LV ejection fraction. In this small series, MV replacement with chordal preservation showed similar cardiac reverse remodelling benefits to MV repair. Although residual MR is often seen following repair, this did not lead to less favourable cardiac reverse remodelling.

Acknowledgement/Funding

Leeds NIHR infrastructure
P599Native T1 mapping is useful for detection of myocardial fibrosis in cases with ischemic and non-ischemic myocardial diseases
Authors: Goto H , Takaoka H , Sakai T , Ochi S , Wakabayashi S , Ishikawa K , Kanaeda T , Daimon M , Ueda M , Funabashi N , Sano K , Kobayashi Y
Published: October 2019

Background

Evaluation of myocardial fibrosis (MF) as late gadolinium enhancement (LGE) on MRI is useful for differential diagnosis of various myocardial diseases and prediction of future adverse cardiac events in some specific myocardial diseases. Gadolinium contrast is contraindicated for cases with severe renal dysfunction, therefore non contrast MRI is necessary for detection of MF in cases with both myocardial disease and severe renal dysfunction.

Purpose

We aimed to evaluate diagnostic accuracy of native T1 mapping for detection of MF compared with LGE in cases with various myocardial diseases, including ischemic and non-ischemic myocardial diseases.

Methods

We selected consecutive 40 patients who were suspected of having various myocardial diseases and underwent cardiac MRI, using 1.5T MRI (Ingenia, Philips) in 10 cases (25%) or 3T MRI (Ingenia, Philips) in 30 cases (75%), including native T1 mapping (without contrast) and LGE using contrast media from Jan 2018 to Feb 2019 in our institution. We evaluated diagnostic accuracy for detection of MF in left ventricular myocardium (LVM) of native T1 mapping image compared with LGE as the gold standard, in a patient-based and segment-based analysis. In T1 mapping images, segmental high T1 lesions were defined as MF. In a segment-based analysis, MF was evaluated using 17 LVM segments model in American Heart Association.

Results

MF was detected in 139 LVM segments in 25 (63%) cases. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of native T1 mapping for detection of MF were 90%, 89%, 95%, 80% and 90% in a patient-based analysis, and 63%, 96%, 84%, 89% and 88% in a segment-based analysis (left figure). Native T1-values of LVM with MF were significantly higher than LVM without LGE (1351±79 vs 1093±124 in 1.5T and 1562±131 vs 1291±43 in 3T) (p<0.05 and p<0.01). Interobserver agreement of native T1 mapping and LGE were not significantly different (0.88 and 0.89, P=0.70). Overall diagnostic accuracy of native T1 mapping for detection of MF in a patient-based analysis, was not significantly different in between the cases with ischemic (n=18) and non-ischemic (n=22) myocardial disease (90% and 83.3%, P=0.10).

Conclusion

Native T1 mapping (without contrast) is useful for detection of MF in various myocardial diseases and high diagnostic accuracy is expected especially in a patient-based analysis.
P602Septal function and viability determine response to cardiac resynchronization therapy
Authors: Aalen J , Donal E , Larsen C K , Duchenne J , Kongsgaard E , Hopp E , Penicka M , Galli E , Voigt J U , Smiseth O A
Published: October 2019

Introduction

Cardiac resynchronization therapy (CRT) has evolved as an important treatment in patients with symptomatic heart failure, reduced left ventricular (LV) ejection fraction and wide QRS. However, as one third of patients do not benefit from the therapy, there is need for better selection criteria. Previous studies have shown an association between recovery of septal function and response to CRT.

Purpose

To test the hypothesis that septal dysfunction in the absence of scar predicts response to CRT.

Methods

In 121 patients undergoing CRT implantation according to current European Society of Cardiology guidelines, we performed speckle-tracking echocardiography and estimated LV pressure non-invasively based on a method recently innovated in our lab. Pressure-strain analysis was used to calculate myocardial work. Septal dysfunction with asymmetric LV workload was calculated as the difference between LV lateral wall and septal work. Late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) was performed to assess septal scar. CRT response was defined as ≥15% reduction of LV end systolic volume by echocardiography at 6 months follow-up.

Results

Eighty-eight patients (73%) responded to CRT at 6 months follow-up. Multivariate logistic regression analysis including lateral-to-septal work difference, septal scar, QRS duration and QRS morphology found that only lateral-to-septal work difference and septal scar were significant predictors of CRT response (both p<0.005). Using logistic regression and receiver operating characteristic (ROC) curve analysis, we found that the combined approach of these two parameters identified CRT responders with a sensitivity of 86% and a specificity of 82%. The area under the curve (AUC) for CRT response prediction was 0.85 (95% CI: 0.76–0.94) (Figure). In comparison, the AUC value for QRS duration was 0.63 (95% CI: 0.52–0.75). Furthermore, for the subgroup of patients with QRS duration 120–150 ms (n=27), the AUC value for lateral-to-septal work difference in combination with septal scar was 0.90 (95% CI: 0.78–1.00).

Conclusions

A multimodality approach with strain echocardiography and LGE-CMR was able to detect CRT responders with high accuracy, also in the subset of patients with intermediate QRS duration. A dysfunctional but viable septum appears to be an ideal target for CRT.
P605Correlation of left atrial phasic transport function and arrhythmogenic substrate in patients with atrial fibrillation: cardiac magnetic resonance feature tracking and bipolar voltage mapping
Authors: Schoenbauer R , Tomala J , Kirstein B , Huo Y , Gaspar T , Richter U , Piorkowski J , Schoenbauer M S , Fiedler L , Roithinger F X , Hengstenberg C , Mascherbauer J , Ulbrich S , Piorkowski C
Published: October 2019

Background

Bipolar voltage mapping is a widely accepted approach to identify areas of arrhythmogenic substrate in patients presenting for atrial fibrillation (AF) ablation.

However, until now little is known about the correlation of left atrial (LA) bipolar voltage distribution and LA transport function.

Purpose

To study the impact of LA low voltage zones (LVZ) on LA transport function.

Methods

107 consecutive patients presenting for ablation of symptomatic AF (34 paroxysmal AF, 73 persistent AF) were prospectively enrolled. Each patient underwent cardiac magnetic resonance imaging (CMR) within 24 hours prior to the ablation procedure. 59 patients were in sinus rhythm (SR) and 48 in AF. LA phasic indexed volumes (LAVi) and ejection fractions were calculated using biplane area length formula. In addition LA phasic strains and strain rates were analyzed using dedicated software (Figure 1A & B).

LA bipolar voltage mapping was performed prior to beginning of ablation in sinus rhythm using a 3-dimensional mapping system and LVZ were defined as areas of bipolar voltage <0.5mV.

Results

LVZ were present in 47 patients (23 in SR). The area of LVZ was 14.6cm2 (5.3–34.0). For patients in AF at the time of CMR only elevated minimal and maximal LAVi (p=0.001 and p=0.002 respectively) but no LA functional parameter was predictive for the occurrence of LVZ. In contrast for patients in SR all LA phasic volumes (endsystolic, pre atrial contraction and enddiastolic LAVi) and LA function parameters (passive, active and total ejection fraction (EF), reservoir, conduit and booster pump strains and strain rates) were predictive for the occurrence of LVZ. After clustered and pooled multivariate logistic regression only impaired booster pump strain rate was still predictive for occurrence of LVZ (OR 0.974, 95% CI 0.950–0.998, p=0.036).

In addition Pearson correlation analysis revealed a strong link between LA booster pump functional parameters and cm2 expansion of LVZ areas: LA active EF, LA booster pump strain and SR (r=−0.42, p=0.044; r=−0.47, p=0.024; r=−0.65, p=0.001 [Figure 1C] respectively).

Conclusion

For patients in SR LA transport function is closely linked to the occurrence of LA LVZ and outperforms LA volumetric measurements for the prediction of LA LVZ.

Furthermore LA booster pump function parameters show robust correlation to the extension of LA LVZ.
P611Relation of exercise intolerance and left ventricular diastolic function to myocardial fibrosis in the patients with hypertrophic cardiomyopathy
Authors: Hwang J W , Kim S.U.N.G.M , Park S.U.N.G.-J , Kim E U N K , Chang S.U.N.G.-A , Lee S.A.N.G.-C , Choe Y.E.O.N.H , Park S W O O , Kim D.A.R.A.E , Choi J.I.N.-O.H , Kim H A J , Ok S.E.O.N.H
Published: October 2019

Myocardial fibrosis happened to increased left ventricular (LV) stiffness and higher LV filling pressure likewise diastolic dysfunction, as associated with clinical outcomes in patients with hypertrophic cardiomyopathy (HCMP). Additionally, reduced exercise capacity affected patients along a broad spectrum of clinical severity. The aim of study was to determine the relation between exercise intolerance and LV diastolic parameters to myocardial fibrosis in the patients with HCMP.

We enrolled 289 patients with HCMP and normal LV systolic function (ejection fraction >50%). Study populations underwent both cardiopulmonary exercise test (CPET) as estimating peak oxygen consumption (peak VO2) and cardiac magnetic resonance (CMR) as myocardial fibrosis by late gadolinium delayed enhancement (LGE). NT-proBNP levels were determined at baseline. Basic echocardiography was used to measure the diastolic parameters.

The study population was included with 248 males (85.8%), and the median age of population was 53 years [interquartile range (IQR) 46–60]. Median follow-up was 6.5 years (IQR 3.2–8.6). The median value of Peak VO2 as a representation of exercise tolerance was 29.0 ml/kg/min (IQR 25.0–34.0) in study population. The amount of LGE on CMR was 14.27 mL (IQR 6.30–27.76). The median value of diastolic parameters as left atrium volume index (LAVI) and E/e' ratio, respectively, were 39.10 mL/m2 (IQR 31.30–47.25) and 10.88 (IQR 8.58–13.31). The median NT-proBNP level was 295.40pg/mL (IQR 139.10–687.70). After adjusting for age and gender, peak VO2 was inversely correlated with NT-proBNP (r=−0.274, p<0.001). A linear regression analysis with adjusting age and gender showed that LAVI and E/e' as diastolic parameters could predict the peak VO2 (LAVI: β=−0.082, p<0.001, E/e': β=−0.373, p<0.001) and NT-proBNP (LAVI: β=11.454, p<0.001, E/e': β=55.533, p<0.001), as well as the LGE also could associate the peak VO2 (LGE: β=−0.075, p<0.001) and NT-proBNP (LGE: β=16.194, p<0.001).

In conclusion, through the correlation among exercise tolerance, parameters of diastolic dysfunction, and myocardial fibrosis, we demonstrated that exercise intolerance and parameters of diastolic dysfunction could predict the myocardial fibrosis in patients with HCMP. We inferred the adverse effects of myocardial fibrosis, as assessed by LGE, lead to diastolic dysfunction and reduced the exercise tolerance.

Acknowledgement/Funding

None
P612Multimodal cardiac imaging in patients with suspected ST-elevation myocardial infarction and no obstructive coronary arteries
Authors: Andersson H , Christensen T E , Ahtarovski K , Rasmussen T , Ghotbi A , Thomsen J H , Soeholm H , Nepper-Christensen L , Engstroem T , Vejlstrup N , Grande P , Bang L E , Clemmensen P , Hasbak P , Holmvang L
Published: October 2019

Background

Patients with suspected ST-elevation myocardial infarction (STEMI) and normal coronary arteries comprise a heterogeneous group with various underlying causes of disease.

Purpose

To study pathophysiology and underlying diagnoses in patients with suspected STEMI and normal coronary arteries using multimodal cardiac imaging.

Methods

We consecutively included patients with suspected STEMI, normal coronary arteries on acute coronary angiography, and elevated troponin T levels at a tertiary heart center (2012–14). Patients were examined with echocardiography, cardiac magnetic resonance imaging, and 13NH3/82Rb and 18F-FDG positron emission tomography within one week from symptom onset.

Results

We included 42 patients (60% male, median age 58 (IQR 50–65) years. Median troponin T levels were 783 (IQR 566–1208) ng/l. Multimodal cardiac imaging findings are presented in Table 1. Multimodal cardiac imaging showed signs of cardiac involvement in all but one patient (98%). Underlying diagnoses were acute myocardial infarction (36%), Takotsubo cardiomyopathy (29%), perimyocarditis (10%), and cardiomyopathy (7%). The diagnosis was unclear in 19% of patients.

Echocardiography   Left ventricular ejection fraction <40%, n (%) 12 (29)   Moderate to severe left ventricular hypertrophy, n (%) 3 (7)   Moderate to severe valvular disease, n (%) 3 (7)   Pericardial effusion, n (%) 5 (12)   Apical thrombus, n (%) 1 (2) Magnetic resonance imaging   Left ventricular end diastolic volume, ml (IQR) 157 (125–185)   Left ventricular end systolic volume, ml (IQR) 75 (63–88)   Left ventricular stroke volume, ml (IQR) 73 (57–93)   Edema, n (%) 38 (91)   Late gadolinium enhancement, n (%) 22 (52) 13NH3/82Rb and 18F-FDG positron emission computer tomography   Myocardial perfusion defect, n (%) 29 (69)   Myocardial perfusion-metabolism mismatch, n (%) 12/30 (40)   Reduced myocardial viability, n (%) 6/30 (20)

Conclusion

The majority of patients with suspected STEMI and normal coronary arteries had signs of cardiac involvement by multimodal cardiac imaging and were diagnosed with cardiac disease.

Acknowledgement/Funding

The Danish Heart Foundation, the A.P. Møller Foundation, the Foundation of Reinholdt W. Jorck and Wife, Rigshospitalet's Research Foundation
P615Role of three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR) and to assess the contribution of regional RV function to
Authors: Sen N , Tanwar S , Jain A , Kalra B , Chandra N
Published: October 2019

Background

Chronic obstructive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In COPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging.

Purpose

The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function.

Methods

In a retrospective, cross-sectional study setting, RV volumetric data were studied in 302 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments.

Results

208 patients (69%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.88; RV end-systolic volume, R2=0.81; RV ejection fraction [RVEF], R2=0.69; P<0.004 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −2.8% and −7.8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.29, P=0.003). Among segmental 3D strain variables, inlet area strain (r=−0.48, P<0.002) and outflow circumferential strain (r=−0.37, P<0.003) were independent factors associated with CMR-derived RVEF.

Conclusions

Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements. Severity of COPD influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters.
P617Early global longitudinal strain predicts late infarct size in patients with anterior ST-segment elevation myocardial infarction treated with a primary percutaneous coronary intervention
Authors: Bendary A , Afifi M , Tawfik W , Mahros M , Ramzy A , Salem M
Published: October 2019

Background

Late infarct size (IS) after STEMI is a determinant of subsequent mortality. Late Gadolinium enhancement in cardiac magnetic resonance imaging (LGE-CMRI) is the gold standard for IS measurement, however, it is not readily accessible in many areas.

Aims

To evaluate the value of early baseline 2D-echocardiographic global longitudinal strain (GLS) for prediction of late IS after STEMI.

Methods

From October 2017 to July 2018, we studied 100 patients with their 1st anterior STEMI treated with a PPCI. Baseline GLS calculation was performed within 48 hours of admission. The average value of the 9 segments supplied by the LAD was assessed separately (anterior GLS). Infarct size was assessed 3 months later using LGE-CMRI, and large infarcts were defined as ≥20% LV myocardium covered by scar.

Results

Based on CMRI, patients were divided into 2 groups; 57 patients with large infarcts (group I) and 43 patients with small infarcts (group II). Both groups were matched in all baseline demographics and risk factors. There was a good and significant correlation between GLS and the degree of myocardium affected by scar (r=−0.840, P<0.001). This correlation was even higher for anterior GLS (r=−0.867, P<0.001). ROC analysis showed a cut-off point of GLS (−13%) that identified large late IS with a sensitivity and specificity of 66.7% and 88.4% respectively (AUC= 0.85). For anterior GLS, the cut-off point was −9.6% (Sensitivity 94%, specificity 86%, AUC= 0.9).

Baseline 2D-GLS & Late LGE-CMRI

Conclusion

Baseline GLS significantly predicts and correlates well with late IS after anterior STEMI.