bluuebunny/crossref_metadata_2025 huggingface dataset:
P1702 Libman-Sacks endocarditis of the mitral valve combined with right atrial thrombus formation
Authors: Klappacher G , Beitzke D
Published: January 2020

Case presentation

A 46-years old female with a history of systemic lupus erythematosus (SLE) was admitted to hospital care after the manifestation of a tonic-clonic generalized seizure. Since this had been the first neurological event, a thorough diagnostic work-up was performed. CT- and MRI-imaging of the brain revealed cerebral microangiopathy and two small fresh ischemic lesions in the left frontal and temporobasal regions, respectively. While the microangiopathy could be reconciled with cerebral SLE-vasculitis, the ischemic lesions pointed to thromboembolism whose source could be potentially cardiogenic.

Findings. In fact, the transesophageal echocardiogram showed a small vegetation (5x8 mm) on the posteromedial cusp of the posterior mitral leaflet (P3) with moderate regurgitation, likely to represent Libman-Sacks endocarditis and a potential source of systemic embolization. In addition, a mass of was visible protruding from the fossa ovalis into the right atrium, see figure. It represented a thrombus according to MRI which was subsequently performed. Since no interatrial passage of microbubbles occurred, the foramen ovale was unlikely to be patent and to allow for paradoxical embolism into the brain. However, the right atrial thrombus was compatible with a history of repeated deep venous thrombosis and pulmonary embolism in the recent past.

Discussion

This case exemplifies the combination of Libman-Sacks endocarditis on the mitral valve with right atrial thrombus formation and ensuing embolism both into the venous and arterial system. It demonstrates the importance of closely monitoring and treating coagulopathies in SLE patients which makes them prone to thrombus formation both in the systemic and pulmonary circulation.

Abstract P1702 Figure.
P1707 Strain imaging - resolving the diagnostic conundrum of cardiac amyloidosis
Authors: Somarakis K , Ahmed H
Published: January 2020

Introduction

Cardiac amyloidosis is a common cardiac condition and is still significantly underdiagnosed. Autopsy studies revealed that myocardial tranthyretin amyloid deposition is found in up to 30% of patients with HFpEF (heart failure with preserved ejection fraction). A study in 2015 reported that 13% of patients hospitalised due to HFpEF (older than 60 years old and with left ventricular hypertrophy - LVH) had moderate to severe uptake on the Technetium DPD scintigraphy. Strain imaging through Echocardiography can be a useful diagnostic tool and can provide valuable clues towards the aetiology of LVH. Relative "apical sparing" pattern of longitudinal strain has been reported to have good sensitivity and specificity in differentiating patients with cardiac amyloidosis from controls.

Case

A 66 year old man presented with progressive breathlessness and peripheral oedema. His past medical history included peripheral neuropathy, bilateral decompression procedures for carpal tunnel syndrome and IgM Monoclonal Gammopathy of Undetermined Significance (MGUS). His B-type natriuretic peptide levels were elevated and his ECG showed normal sinus rhythm, RsR" pattern on the anterior leads and no evidence of LVH. The transthoracic echocardiogram showed moderate concentric LVH, normal left ventricular systolic function and mildly impaired left ventricular diastolic function. No evidence of pericardial effusion. Urine protein:creatinine ratio findings were consistent with nephrotic range proteinuria. He had a cardiac MRI that confirmed normal biventricular wall motion and systolic function and a moderate increase in the wall thickness of both ventricles, but showed no evidence of late gadolinium enhancement.

At this point, we repeated his transthoracic echocardiogram with the use of strain imaging and it revealed a pattern of apical sparing suggestive of cardiac amyloidosis. After collaboration with the Haematology team, a bone marrow biopsy was performed that showed that the MGUS had progressed to IgM multiple myeloma. There was however no evidence of amyloid deposits. He was subsequently referred to the national amyloidosis centre (as per family request), where a SAP (serum amyloid P) scan showed renal and splenic amyloid deposits confirming Light-chain Amyloidosis. To exclude the possibility of TTR Amyloidosis, he also had a 99mTc-DPD scintigraphy which did not detect any amyloid deposits. He was treated under the care of the Haematology team with Velcade/Cyclophosphamide/Dexamethasone chemotherapy.

Conclusion

In patients with a clinical suspicion of cardiac amyloidosis, Echocardiography with strain imaging can be very useful and should be performed routinely. Furthermore, in patients with high clinical suspicion of cardiac amyloidosis, diagnostic investigations should persist even if the initial workup does not yield specific findings.

Abstract P1707 Figure. Strain imaging findings
P1710 Reverse right ventricular remodeling using right ventricular strain and strain rate after mitral clip implantation in functional mitral regurgitation, an echocardiographic study
Authors: Abdo Naeim H , Amoudi O , Alharbi I H , Mahmood ABEER , Elasfar A , Khedr L , Waleed M S , Abuelatta REDA
Published: January 2020

Funding Acknowledgements

none

OnBehalf

none

Background

Chronic mitral regurgitation (MR) leads to right ventricular dysfunction because of volume and pressure overload over a long time. Mitral valve repair with a mitral clip will reduce the (MR) but how much its effect on the right ventricle.

Aim

The aim of the present study is to assess the impact of Mitral Valve Clipping on right ventricular (RV) remodeling (RV strain and strain rate) at med term after Mitral Clip implantation in high-risk surgical patients with severe functional mitral regurgitation (MR).

Methods

Study population included 62 patients with severe functional MR. All the patients underwent full echocardiographic evaluation before MV clip, and at 12-month follow-up. RV systolic function was assessed using tissue Doppler and TAPSE. Using Tom-Tec software the RV endocardium is traced in the apical 4 chamber view to get the RV strain and strain rate. RV after load was evaluated using systolic pulmonary artery pressure.

Results

In our cohort, 62 patients had percutaneous mitral valve clip and completed at least 12 months of follow-up. The average age was 60.56 years, 24.19 were females, 50% were diabetic, 46.77 were hypertensive, 12.90 had ESRD and 11.29 % had anemia. Coronary artery disease (CAD) was present in 59.41 %, prior CABG in 11.67% and prior PCI in 35.48%. All parameters value was compared pre MV clip and 12 ± 4.6 months after MV clip. The RV longitudinal strain was -12.4 ± 2.6% and improved to -14.6 ± 3.1% (P 0.005) (Figure A and B). The RV strain rate was -1.1 ± 0.41 and improved to -1.3 ± 0.57 (P 0.004) (Figure C and D). The tricuspid annulus plane systolic excursion (TAPSE) was 1.76 ±0.57 mm, and improved to 1.82 ±0.63 mm (P 0.4). The systolic velocity at the tricuspid annulus was 9.50 ±2.33cm/sec and improved to 9.64 ±2.72 cm/sec (P 0.269). The systolic pulmonary artery pressure (SPAP) was 50.49 ±13.92 and improved to 42.33 (P 0.036).

Conclusion

Mitral Clip implantation induces a significant reverse remodeling of RV. It produces significant improvement in the hemodynamics of the right side indicated by the significant reduction in SPAP and a significant increase in longitudinal RV strain and strain rate. Those changes could be a direct reflection of the concomitant reduction in LV filling pressure produced by the significant reverse remodeling of the LV caused by Mitral Clipping.

Abstract P1710 Figure.
P1715 Aortic stenosis with concomitant LVOTO: an alternative treatment to surgery
Authors: Silva C , Ribeiras R , Teles R , Brito J , Nolasco T , Oliveira A , Horta E , Mendes M
Published: January 2020

The dilemma of the patient with both aortic stenosis (AS) and significant left ventricular outflow tract obstruction (LVOTO) is usually managed through conventional surgery. Patients included in TAVI studies are highly selected, and the presence of LVOTO is a common exclusion criteria. Permanent pacing is referred as a possible treatment in medically refractory symptomatic patients with obstructive hypertrophic cardiomyopathy. We report a case of AS and LVOTO that was submitted to transcatheter aortic valve replacement (TAVR) due to high surgical risk, and submitted to a definitive pacemaker implantation after the procedure.

This case is about a female patient with 82 years old and a history of a severe aortic stenosis with a significant ventricular hypertrophy that causes LVOTO. She had a previous history of hypertension, dyslipidemia, osteoporosis and breast cancer. The patient presented with angina (grade II in Canadian Cardiovascular Society Angina Grade), dyspnea and weakness (classe II of New York Heart Association functional classification). Transthoracic Echocardiography (TTE) presented with severe aortic stenosis with a basal septal ventricular hypertrophy of 18 millimeters, a systolic anterior motion of the mitral valve (SAM) both conditioning LVOTO (maximal gradient of 75 mmHg at rest) and moderate mitral regurgitation (MR). Coronariography showed no coronary lesions. Transfemoral TAVR was successfully implanted under general anesthesia and transesophageal echocardiography monitoring (TOE). During ballooning pre-dilatation a complete atrioventricular block developed. Immediately after the valve implantation TOE showed a well-positioned prothesis without intra or peri-prosthetic regurgitation but with an intraventricular gradient (IVG) above 50mmHg and a moderate to severe MR. SAM, IVG and MR were medically managed and the patient went to the intensive cardiac unit (ICU) with a IVG of 50mmHg and a moderate MR. In the next 24H in the ICU, the patient had a clinical deterioration and TTE found an increased intraventricular gradient (140 mmHg) and a severe mitral regurgitation. It was decided to implant a Dual Chamber pacemaker (DDD PM) and adjust beta-blocker and fluid therapy. A progressive clinical improvement was observed and clinical stabilization attained after 48H. At discharge (7 days after TAVR), TTE showed decreased intraventricular gradients (30 mmHg at rest, 50 mmHg with Valsalva maneuver), telesystolic SAM and a moderate mitral regurgitation. At 6 moths follow up, patient was free of cardiovascular events and had no symptoms of heart failure.

This case shows that TAVR is a safe procedure in patients with LVOTO, but we have to be aware of potentially severe hemodynamic consequences of sudden reduce in after load pressure in these patients. In high risk surgical patients, DDD-PM can accomplish acute and at least medium term clinical and hemodynamic stabilization.

Abstract P1715 Figure. Echocardiography images
P1721 Reversible heart right failure. Pulmonary hypertension induced by Tyrosine Kinase Inhibitors
Authors: Fernandez Valledor A , Cepas Guillen P , Izquierdo M , Vidal P , Arjona R , Carbonell B , Flores Umanzor E , Lorenzatti D , Jorda P
Published: January 2020

BACKGROUND

Pharmacologically induced pulmonary hypertension (PH) is infrequent nowadays and it is included in the type 1 of the classification of PH.

Tyrosine kinase inhibitors (TKI) are the cornerstone of the treatment of many haemotopoietic stem cell diseases. Dasatinib is a second-generation TKI used in chronic myeloid leukemia (CML) and as an infrequent cardiovascular side-effect (< 0,50%) could induce PH, usually reversible but life threatening. Only a few case series are published.

CASE DESCRIPTION: We present a 51-year-old woman who was diagnosed of a CML when she was 46. Initially, she underwent therapy with imatinib but after 5 years of treatment she developed resistance to this drug, and dasatinib was prescribed as a second line drug. After 3 months of continuous treatment, she started with dry cough and effort dyspnea. Blood analysis, EKG and Chest X-Ray were made but did not show outstanding findings. An unspecific viral infection was the final diagnosis. The patient clinical condition deteriorated with major dyspnea and edemas in the lower limbs. A TTE showed moderate tricuspid regurgitation and severe HP systolic pulmonary artery pressure (sPAP) of 80 mmHg. The pulmonary acceleration time was shortened and a mesosistolic knock was present. Systolic dysfunction of the right ventricle and pericardial effusion (image 1,2,3,4) were noted. The right atrium was not dilated. Cava vein was dilated but with inspiratory collapse >50%. The left ventricular function was preserved, but first degree diastolic dysfunction was found. Other causes of PH were excluded (types 2, 3, 4). A CT pulmonary angiogram did not show segmental perfusion defects. Finally, a right heart catheterization confirmed the TTE findings: severe precapillary PH without postcapillary component. After the diagnosis was confirmed, TKI was stopped and double targeted therapy with ambrisentan + tadalafil was started. After 6 months of treatment a new TTE was made with complete reversal of the secondary changes in the myocardium induced by the PH. No tricuspid regurgitation was detected nor any indirect sign of PH was found. (image 5,6).

CONCLUSIONS

Drug-induced PH is rare nowadays and most cases were described in the seventies in the USA related with the epidemic of anorexigenic drugs. Although the pathogenesis still remains unclear, treatment includes immediately stopping the offending agent.

Echocardiography due to its accessibility, reproducibility, consistence and low cost should be the first diagnostic tool to be considered, because as it is known, in the early stages of the disease, before developing right disfunction, clinical and conventional tests are non-specific.

Abstract P1721 Figure. Echo images: previous and afte treatment
P1723 Spectacular left ventricle post infarction aneurysm
Authors: Bednarek A , Wieczorek J , Elzbieciak M , Deja M , Mizia-Stec K
Published: January 2020

Sixty six-y.o. woman 2 months after anterior wall ST-segment elevation myocardial infraction and PCI LAD + 3DES (TIMI 1) was re-admitted to the clinic because of progressive severe heart failure (NYHA III/IV). In admission NT-proBNP level was 14 000 pg/ml, INR 1,7, bilirubin 4,5mg/dl. The electrocardiogram showed persistent ST elevation on anterior leads. Transthoracic echocardiography (TTE) revealed spectacular finding: aneurysm of left ventricle (LV) involving ½ distal part of interventricular septum, apex, inferior, anterior and lateral wall with LVEF 24%, LVEDV 272ml. Thickness of intraventricular septum (IVS) on aneurysm level was only 2,5-3,5mm. In the middle part of IVS a minimal ventricular septal defect (VSD) was showed. Cardiac magnetic resonance examination confirmed TTE findings. The course of the disease was dynamic. The diameter of VSD was increased during consecutive days of hospitalization with maximum width 6,5mm. The patient was hemodynamical unstable, she needed pressure amines, diuretics and intra-aortic balloon pumping. The patient underwent several Heart Team consultations. She was disqualified from percutaneous VSD closing because of thickness of IVS and spiral shape of VSD. Due to potentially too small LV volume after LV plastic surgery the patient was also disqualified from that procedure. We reported the patient to heart transplantation (HTX). There was no transplant donor. In next days we observed progressive signs of a cardiogenic shock with right ventricle decompensation secondary to widening of VSD. Because of unstable stage and growing decompensation, no possibility of HTX patient had life—saving cardiac surgery of LV with mitral valve and tricuspid valve anuloplasthies. The patient survived operation.

Abstract P1723 Figure.
P1724 Bidimensional echocardiographical radial strain abnormalities mandate differential diagnosis between athlete heart syndrome and incipient genetic cardiomyopathy
Authors: Cojocaru C , Pupaza A , Radu D A , Onciul S , Vatasescu R G
Published: January 2020

Background

Left ventricular dilation and mild systolic dysfunction at rest in young endurance athletes may mandate differential diagnosis between adaptive physiology and various forms of incipient non-ischemic dilated cardiomyopathies, especially if family history is positive. Multimodal imaging (i.e. bidimensional echocardiography (TTE), speckle tracking echography (STE) and cardiac magnetic resonance (CMR)) can accurately diagnose "true" underlying heart disease.

Purpose

We sought to outline the efficacy of multimodality imaging in dilated left ventricular phenotypes with mild systolic dysfunction of athletes.

Methods

We present the case of a 45 year old Caucasian male, rock climbing athlete (14 hours of training per week), with no prior personal medical history, who was admitted for fast palpitations leading to syncope immediately after a training session. Family history revealed maternal non-ischemic cardiomyopathy with complete atrioventricular (AV block requiring permanent pacing at a similar age. Stable, clinically asymptomatic, nodal complete AV block ∼ 40 bpm was diagnosed by ECG. TTE revealed a dilated LV (61 mm left ventricular end-diastolic diameter (LVIDd)) with no hypertrophy, with decreased diffuse contractility (LVEF ∼ 43%). Exercise echocardiography showed no improvement in LVEF, despite transition from complete AV block to first AV grade block. Moreover, moderate mitral regurgitation by posterior mitral leaflet (PML) prolapse was discovered. STE demonstrated normal global longitudinal strain (GLS), but decreased interventricular septum (IVS) radial strain (RS) (figure A). Late gadolinium enhancement was evident along the interventricular septum and the right ventricular insertion points in CMR (figure B), with no edema.

Results

The association of LV dilation (with multiple apparent causes – endurance training, genetic substrate, PML prolapse) with mild systolic dysfunction that persisted during echocardiographic exercise testing and a reduced IVS RS (with physiological GLS) was observed. Subsequently, mid-myocardial septal scarring in CMR was consistent with a diagnosis of "true" dilated cardiomyopathy. A cardiac resynchronization defibrillator device was implanted and genetic testing is in progress (lamin disease suspicion).

Conclusions

Athlete’s heart syndrome phenotypes may overlap with forms of genetic dilated cardiomyopathy.

1. The diagnostic suspicion of structural heart disease derived from echocardiography (radial strain & exercise echocardiography abnormalities), with subsequent confirmation by late gadolinium enhancement myocardial fibrosis.

2. The prospective sudden cardiac death risk requires careful assessment. The presence of clinical arrhythmic syncope, septal CMR fibrosis and specific genetic mutation lead to the decision of ICD (internal cardioverter defibrillator) implantation.

Abstract P1724 Figure. A - 2D Radial strain B - LGE CMR
P1734 Surprising image in the aortic root, is it zebra ?
Authors: Alak C , Cirgamis D , Badak O , Ozpelit E
Published: January 2020

CASE

80 year old-man patient was admitted our emergency department with dyspnea and chest pain. Transthoracic echocardiography (TTE) was performed.Ejection fraction was %60.Severe tricuspid regurtation was observed and pulmonary artery pressure was 55 mmHg.TTE showed mobile, hyperdense, flap-like appearance (Figure 1-A) Thorax computerized tomography (CT) angiography scan was performed with the suspicion of aortic dissection.CT angiography showed that there is no aortic dissection.(Figure 1-B) Transesophageal echocardiography (TEE) was planned. TEE showed an appearance consistent with the prosthetic material extending from the ascending aorta to the left main coronary artery.(Figure 1-C,D) When the patient"s history was investigated in detail, it was learned that the patient underwent coronary angiography six months ago.The patient was recommended bypass surgery, but he refused bypass surgery. Due to his rejection of bypass surgery, percutaneous intervention was attempted to the left anterior descending artery. Percutaneous coronary intervention was unsuccessful due to the severely calcified lesions. After learning this information, it was decided to perform imaging with fluoroscopy and chest CT without contrast.Because the image mimicking aortic dissection was thought to be the material related to previous unsuccesfull percutaneous coronary intervention. CT showed linear, hyperdense metallic densities that mimicked aortic dissection,extending form the left main coronary artery orifice to the ascending aorta. (Figure 1-E) The patient underwent imaging under fluoroscopy. In the imaging of the patient under fluoroscopy, it was observed that the image was consistent with the stent extending from the aorta to the left main coronary. (Figure 1-F) The mystery was solved and it was understood that during the unsuccessfull percutaneous coronary intervention the stent was removed from the balloon in the ascending aorta.

CONCLUSİON

In patients presenting with shortness of breath and chest pain, differantial diagnoses should always be life-threatening conditions such as aortic dissection, myocardial infarction and pulmonary embolism. When you hear hoofbeats, think of horses not zebras as taught in the early years of medical schools. Everything is never as it seems.Sometimes the sound of hoofbeats may also belong to the zebras.It is very important to evaluate the patient and medical history together with different perspectives.

Abstract P1734 Figure.
P1739 Diameter of the pulmonary artery in relation to the ascending aorta: a promising parameter for the diagnosis of pulmonary hypertension
Authors: Schneider M , Ran H , Pistritto A M , Gerges C , Heidari H , Hengstenberg C , Bergler-Klein J , Lang I , Binder T , Goliasch G
Published: January 2020

Background

Pulmonary hypertension (PH) is a disease with significant morbidity and mortality. The first imaging modality in the diagnostic algorithm is transthoracic echocardiography (TTE). Despite significant technological advances in recent years, there are still patients with PH who are missed by TTE. The pulmonary artery to ascending aorta ratio (PA/Ao-R) has been evaluated in cardiac magnetic resonance (CMR) and computed tomography (CT) studies. The ratio was able to detect patients with PH, it correlated with hemodynamics, and it was predictive for mortality. We sought to evaluate the diagnostic accuracy of PA/Ao-R measured by TTE in the detection of PH.

Methods

We evaluated consecutive patients who received quasi-simultaneous transthoracic echocardiography and right heart catheterization (RHC) for evaluation of pulmonary hypertension between July 2015 and July 2016.

Results

A total of 84 patients fulfilled the inclusion criteria, 47 were female, mean age was 65 years. Median PA/Ao-R was 0.8 (Q1;Q3 0.69;0.94). Seventy patients had PH (median mean pulmonary artery pressure (mPAP) was 35.5 mmHg, Q1;Q3 27;47). The area under the curve for the diagnosis of PH via PA/Ao-R was 0.853. A cut-off of 1 was chosen for further analysis. Sensitivity for the diagnosis of PH was 100%, specificity was 23%. PA/Ao-R correlated with mPAP (r = 0.65, p < 0.001), and pulmonary vascular resistance (r = 0.68, p < 0.001). In the subgroup of patients with PH, those patients with a PA/Ao-R of ≥1 had significantly (p < 0.001) higher pulmonary pressures than those below, with a mean mPAP of 53 mmHg as compared to 38.5 mmHg.

Conclusion

PA/Ao-R correlates with mPAP. A ratio of ≥1 should prompt suspicion for the presence of PH. PA/Ao-R should be reported in every patient who is evaluated for PH.
P1742 Occurrence of right ventricle dysfunction in patients with Brugada syndrome: a follow-up study by echocardiography and electrophysiological examination
Authors: Mizumoto A , Amano M , Kamakura T , Hashimoto S , Oonishi E , Tanaka N , Izumi C
Published: January 2020

Background

Brugada syndrome (BrS) has been characterized by no apparent structural abnormalities in both ventricles, but, recently, the presence of subtle right ventricular (RV) structural abnormalities in patients with BrS has been reported.

Purpose

The aim of this study was to evaluate the occurrence of RV dysfunction in patients with BrS and their characteristics.

Methods

We enrolled 49 consecutive patients (54 ± 11 years old) diagnosed with Brs and underwent echocardiography from 2017 to 2018. The echocardiographic parameters and electrophysiological examinations were evaluated including RV size and function such as RV outflow and inflow tract diameter, TAPSE, S’, and FAC. Abnormality threshold for parameters of RV dysfunction is defined as followed: a TAPSE of <17 mm, an S’ of <9.5 cm, and an FAC of <35%.

Results

Among 49 patients, one patient showed a TAPSE of <17 mm, 5 patients an S’ of <9.5 cm, and 10 patients an FAC of <35%. Evaluating characteristics of Brs patients with RV dysfunction, all patients were divided into 2 groups by the value of RV FAC; 39 patients showing FAC >35% (group A), 10 patients FAC ≤35% (group B). The comparison of each parameter between 2 groups is shown in Table. TAPSE and S’ in group B were lower than in group A. RV inflow tract diameter in group B was larger than in group A, although there was no differences in RV out tract diameter. There were no significant differences in left ventricular parameters, and grade of tricuspid regurgitation. QRS duration prolonged and the rate of ICD implantation was higher in group B than in group A. Moreover, all patients in group B showed RV wall motion abnormalities and the distribution was as followed: diffuse (n = 2), RV mid (n = 2), RV apex (n = 6).

Conclusions

BrS patients frequently showed RV dysfunction during follow-up, and it may be related to the prolongation of QRS duration. We should pay much attention to the occurrence of RV dysfunction in follow-up echocardiography.

Group A (FAC >35%) N = 39 Group B (FAC ≤35%) N = 10 p-value TAPSE, mm 22.9 ± 2.1 20.4 ± 2.6 0.009 S", cm/s 12.8 ± 2.0 11.1 ± 1.4 0.010 RV outflow tract, mm 29.7 ± 4.4 31.2 ± 5.0 0.49 RV mid inflow tract, mm 30.4 ± 2.9 33.8 ± 3.7 0.008 RV basal inflow tract, mm 38.5 ± 3.2 43.7 ± 4.0 0.001 QRS duration, ms 112.9 ± 12.9 136.3 ± 28.4 0.006 Late potential positive, n (%) 25 (64) 8 (80) 0.34 ICD implantation, n (%) 19 (68) 9 (90) 0.019
P1744 Motion and velocity of the different parts of the AV plane. Relation to site and wall length
Authors: Stoylen A , Molmen H E , Dalen H E
Published: January 2020

Background

Displacement (MAPSE) and peak systolic velocity (S") of the various parts of the mitral annulus differ. Also, both indices are higher in the right ventricular free wall. We aimed to investigate the relations between wall motion, wall lengths and sites in the left ventricle, as well as comparing to the right ventricle to assess the influence on systolic deformation of the AV-plane.

Methods

The HUNT study examined 1266 subjects without evidence of heart disease from a mixed urban/rural population of North Trøndelag county, S", linear diastolic left ventricular annulus to apex distance (WL) and MAPSE was measured in the septal, anterior, lateral and inferior points of the mitral annulus. Intra individual variance and relative variance (variance / mean) of S" and MAPSE was calculated and compared to the same variance of the values normalised for wall length (S"/WL and MAPSE/WL).

Results

Wall lengths, velocities and MAPSE are shown in figure 1. Wall lengths were associated with both MAPSE and S". Both wall lengths and motion were greatest in the free walls of the LV, but smallest in the septal parts of the AVplane. Variances are shown in table 1. Even if intra-individual variances are larger for S" than MAPSE, relative variance for both decreased by 80 - 90% when normalised for wall length.

Conclusion

There is an intra-individual variability of MAPSE and S" of the LV, corresponding to WL, when the values normalised for WL most of the variability disappears. Intra individual variability of strain and strain rate per wall is less than MAPSE and S" as shown earlier. As the apex is located centrally, walls corresponding to the free walls are longer than those closest to the septum, thus motion and wall length are both greatest corresponding to the LV free walls.

Motion of the right ventricular free wall was higher than the LV free wall; TAPSE 2.8 cm, and S" 12.6 cm/s as shown previously. The relation of TAPSE and S" of the right ventricle to wall length will be different, as the afterload in the RV is far less. But as both lateral parts of the AV plane move more than the centre, givinga systolic bending of the AV-planealso as the central part of the AV-plane is centrally anchored to the large arteries as shown in fig. 1.

Table 1 WL (cm) MAPSE (cm) MAPSE / WL (% points) S" (cm/s) S" / WL (/s) Mean of 4 walls 9.5 1.6 0.16 8.4 0.87 Variance 0.04 0.04 0.0004 1.2 0.01 Relative variance (%) 2.8 2.7 0.25 12.1 1.4 Wall lengths (WL), displacement(MAPSE), Systolic velocity (S") and mAPSE and S" normalised for WL. Means and intra individual variances.

Abstract P1744 Figure. Fig. 1
P1745 Changes in diastolic function in patients with heart failure with reduced ejection fraction treated with sacubitril/valsartan
Authors: Mas Llado C , Ramis Barcelo M F , Pericas Ramis P , Valadron Sucasas C I , Noris Mora M , Forteza Alberti J F , Pasamar L , Morcuende A , Rodriguez Fernandez A , Gonzalez Codino R , Peral Disdier V
Published: January 2020

Introduction

Sacubitril/valsartan (S/V) has shown to improve mortality and reduce hospitalizations for heart failure in patients with reduced ejection fraction (HFrEF). It has been analysed its improvement in ejection fraction and left ventricle volumes. Very few studies have analysed its effect on diastolic dysfunction. The aim of this study is to determine if the treatment with S/V in patients with HFrEF produces changes in diastolic function.

Methods

We performed a prospective observational study in ambulatory patients with HFrEF and sinus rhythm that, according to the ESC guidelines, had indication to initiate S/V. An echocardiographic examination was done previous to start with S/V and 6 month after having been treated with it.

Results

A total of 67 patients were included in the study (Figure 1). After six months of starting with S/V, there was a statistically significant improvement in diastolic parameters (results are illustrated in table 1): it was observed better values of E/A, E/e’, left atrial maximal volume and deceleration time, leading to a reduction in filling pressures and diastolic dysfunction. Furthermore, we analysed recent parameters that have been postulated as new predictors of diastolic dysfunction, such as left atrial minimal volume (LAVmin), left atrial ejection fraction (LAEF) and left atrial strain (LAStr). There was a statistically significant reduction in LAVmin and values of LAStr after treatment with S/V, but no significant differences were observed in LAEF (table 1).

Conclusion

Treatment with S/V in patients with HFrEF leads to an improvement in diastolic function. More studies need to be done to analyse if S/V could have the same effect in patients with heart failure and preserved ejection fraction.

Figure 1: Population characteristics Gender (male, %) 74.6 High blood pressure (%) 53.7 Age (mean) 59.7 Diabetes mellitus (%) 40.3 Cardiomyopathy (%) Dyslipidaemia (%) 56.7 Ischemic 61.2 Smokers (%) 17.9 Non Ischemic 38.8 Treatment (%) Functional class (%) Beta-blockers 98.5 I 3 Aldosterone antagonists 91 II 71.6 Ivabradine 23.9 III 23.9 Diuretics 71.6

Abstract P1745 Table 1
P1748 Left atrial diastolic and systolic functions modulate the response to the standardised Valsalva maneuver in normal subjects
Authors: Musci R , Teodone G , Pollice P , Guaricci A I , Barbier P
Published: January 2020

Background

Although the Valsalva maneuver (VM) is being advocated by current guidelines to identify with echocardiography patients with increased left ventricular (LV) filling pressures using a decrease in mitral E/A velocity > 0.5 as cutoff, there are limited published data for both patients and the normal response to the maneuver in healthy subjects.

Purpose

To assess LV and left atrial (LA) physiology during a standardized VM (VMs) in normal subjects.

Methods

The VMs was performed in 50 healthy subjects (M:F 38:12; age 40 ± 12 y.; HR 70 ± 11 bpm; BSA 1.81 ± 11 m2), instructed to forcefully exhale for 20 seconds without an initial deep breath into a tube connected to a sphygmomanometer, maintaining a 25-35 mmHg pressure. The VM was repeated 2 times at 5 minute intervals to record sequentially in the apical 4-chamber view: 1. LV and LA volumes; 2. Transmitral flow velocities. LA diastolic reservoir function (LAres) was calculated as: (maximum – minimum volume) / minimum volume x 100. Results. During the VMs, in all subjects LV indexed end-diastolic (-14 ± 7 ml/m2, -31 ± 15 %) and end-systolic (-6 ± 4 ml/m2, -31 ± 18 %) volumes, and stroke volume index (-9 ± 5 ml/m2, -30 ± 15 %) decreased similarly with unchanged LV ejection fraction %, and LA maximum and minimum volume indices both decreased (respectively -8 ± 6 ml/m2, -3 ± 3 ml/m2;-32 ± 25 %) with high variability. Mitral peak E velocity also decreased (-22 ± 13 cm/s, -27 ± 14 %) in all subjects, whereas peak A velocity change varied, such that a "pseudo-abnormal" decrease of E/A > 0.5 was seen in 18 subjects (37 %). At baseline, this subgroup had lower heart rate (66 ± 11 vs 73 ± 10 bpm, p= .026), higher LAres (193 ± 67 vs 145 ± 47 %, p= .006), lower peak A velocity (50 ± 12 vs 58 ± 12 cm/s, p= .04) and higher E/A (1.8±.6 vs 1.4±.3, p= .004). During VMs, LV and LA volumes decreased similarly in all subjects, but increase in heart rate was higher (12 ± 8 vs 6 ± 5 bpm, p= .023), and peak A wave increased instead of decreasing (20 ± 20 % vs -8 ± 18 %, p< .001) in the subjects with "pseudo-abnormal" decrease of E/A. During VMs, decrease in E/A was mainly determined (regression analysis, r: .76, p= .029) by baseline LAres (B= -.71) and change in LAres during VMs (B= -.47), whereas an increase in peak A velocity (r: .46, p= .031) was mainly determined by degree of HR increase (B= .41) and baseline LV EF (B= .3).

Conclusions

During VMs, a "pseudo-abnormal" decrease of the E/A velocity ratio is present in almost 40 % of normal subjects, and is determined by the interplay of the baseline diastolic compliance and the increase in systolic function of the LA during VM. These results may influence the accuracy of the VMs in the detection of increased LV filling pressures in patients.
P1758 Global left ventricular myocardial work efficiency as a prognostic marker for clinical responders one year after edge-to-edge mitral valve repair in patients with functional mitral regurgitation
Authors: Papadopoulos K , Ikonomidis I , Chrissoheris M , Chalapas A , Kourkoveli P , Vardas P , Spargias K
Published: January 2020

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has been proven to be effective for treating patients with functional MR (FMR). However it remains to be answered which patients will benefit more from this method. Novel echocardiographic markers like myocardial work efficiency can be quantified non-invasively and have never been analyzed in this subgroup of patients before.

Purpose

The purpose of this study is to analyze the myocardial work efficiency in patients treated with PMVR for FMR and identify predictors of clinical response.

Methods

We retrospectively analyzed 22 high surgical risk (logistic EuroSCORE 28.9 ± 18.2%) consecutive patients (aged 72 ± 8yrs) with functional moderate-to-severe and severe mitral regurgitation (EROA 28.6 ± 14.6mm2, RV 41.7 ± 15.8ml) and reduced LV contractility (EF 32.7 ± 7.5%, GLS -8.8 ± 3.4%). At baseline and 1-year after PMVR or optimal medical treatment (OMT) we assessed echocardiographic parameters such as MR severity, Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE), along with BNP levels and NYHA class status.

Results

One year after PMVR there was a significant reduction of MR (3.6 ± 0.5 vs 1.8 ± 0.8, p = 0.009) and BNP levels (901 ± 610pg/ml vs 479 ± 385pg/ml, p < 0.001) and significant improvement of NYHA class status (3.0 ± 0.6 to 2.2 ± 0.4, p < 0.001). On the other hand, patients treated with OMT didn’t have any significant change of their MR (3.6 ± 0.5 vs 3.3 ± 1.0), BNP levels (296 ± 114 vs 241 ± 183pg/ml) or NYHA class status (2.6 ± 0.5 vs 2.4 ± 0.5). In device group, there was a preservation of GWI (572 ± 290 vs 609 ± 299mmHg%) and GCW (757 ± 310 vs 789 ± 316mmHg%) and non significant change of GWW and GWE (140 ± 70 vs 150 ± 73mmHg% and 79 ± 9 vs 79 ± 10% respectively, p < 0.05 for all comparisons). On the other hand in medical treatment group there was a significant impairment of GWI (635 ± 263 vs 564 ± 267mmHg%, p = 0.08) and GWE (83 ± 9 vs 76 ± 11%, p = 0.03) and significant increase of GWW (123 ± 90 vs 162 ± 74mmHg%, p < 0.001). Further, baseline GCW was reversely associated with the difference in BNP (r=-0.559, p = 0.038), NYHA class (r=-0.501, p = 0.06) and 6MWT (r=-0.577, p = 0.08) after PMVR, meaning that patients with worse energetics will respond better.

Conclusions

PMVR is an effective method for treating patients with FMR and preserves myocardial work index after one year of FU in contrast to medically treated patients in whom deterioration is observed.
P1765 Cardiac myxomas: echocardiographic findings and clinical correlation, a 15-years single-center experience
Authors: Gripari P , Giambuzzi I , Fusini L , Saccocci M , Mantegazza V , Tamborini G , Muratori M , Ricciardi G , Zanobini M , Pepi M
Published: January 2020

Background

Cardiac myxomas, the most frequent primary benign cardiac tumours, are in some cases lethal due to impaired cardiac dynamics and thromboembolic potential. When tumors are diagnosed and surgically resected in a timely manner, they lose their deleterious potential and patients are cured, except for rare cases of recurrence.

Purpose

We sought to describe the association of clinical presentation, course and echocardiographic findings, dividing myxomas on the basis of location, morphology, size, mobility, echocardiographic appearance.

Methods

We reviewed the medical records and retrospectively analyzed the transthoracic echocardiograms of 51 patients (31female, aged 63 ± 14), who underwent cardiac surgery and were diagnosed at histology with myxoma, between 2004 and 2019. Myxomas were classified according to their location (typical when attached to the interatrial septum in the left side, or atypical), diameters, shape (solid and round shape, or irregular and multilobulated), echocardiographic appearance (homogeneous or heterogeneous), mobility (high mobile pedunculated, or nonmobile), obstruction (no or impaired mitral/ tricuspid dynamics). Depending on symptoms patients were referred to emergency or elective surgery.

Results

In 28 patients (55%) myxomas were incidental echocardiographic findings (Figure 1 A), 23 patients (45%) reported symptoms at presentation (dyspnea in 15 cases, embolic symptoms in 5 cases, syncope in 3 cases) (Figure1 B). A total of 41 myxomas (80%) were tipically located on the interatrial septum in the left side, followed by the left atrium (5 patients,10%), the right atrium (4 patients, 8%) and the tricuspid valve (1 patient).

Symptoms were associated with large size (41 ± 15 mm vs 29 ± 15 mm, p = 0.004 ), high mobility (76% vs 24%, p< 0.001, ), obstruction (75% vs 25%, p = 0.004), heterogeneous aspect (75% vs 25%, p = 0.006) and were not related to location and shape. A maximum diameter > 39 mm distinguished patients with or without symptoms.

In patients with symptoms surgery was based only on echo. In the other cases cardiac CT (20 cases) or MRI (8 cases) was performed.

All patients received a complete surgical resection, recurrency was observed in one case.

Conclusions

Clinical presentation relates to the ultrasound characteristics of myxomas: small, non mobile, homogeneous lesions probably benefit of elective surgery. Large size, high mobility, heterogeneous aspect and impaired valves dynamics correlate with symptoms at presentation and emergency surgery is mandatory.

Abstract P1765 Figure 1
P1773 Cohort of HER2 positive breast cancer and subclinical cardiotoxicity by speckle tracking echocardiography. Does chemotherapy sequence matter?
Authors: Guzman Ayon A M , Aceves Velazquez E D , Armengol Alonso A , Vasquez Ortiz Z Y
Published: January 2020

A cohort of patients with breast cancer HER2 positive are exposed to chemotherapy with cardiotoxic drugs like anthracyclines (A) and trastuzumab (T). The decrease in longitudinal strain is a helpful tool to predict clinical cardiotoxicity. The purpose of this paper is to determine if echocardiographic parameters like longitudinal strain with speckle tracking predict subclinical cardiotoxicity compared to conventional echocardiographic parameters.

This was a retrospective, observational cohort study that involved 20 patients with breast cancer HER2+ who were treated with a chemotherapy reverse sequence (TH-A). We made a basal echocardiogram, 3, 6, 9 and 12 months after chemotherapy with a cumulative dose of 240mg/m2 of doxorrubicin. Cardiotoxicity was defined as a decrease in left ventricular ejection fraction of 10% below 53%, and subclinical cardiotoxicity as a decline of >15% of longitudinal strain.

5 patients (25%) developed decline in longitudinal strain (subclinical cardiotoxicity) 3 months after initiation of chemotherapy, despite 2 of them had normal LVEF (p = 0.01), with the use of heart failure medication they showed partial reversibility. Lineal regression analysis showed that patients with GLS >-19% at baseline did not present cardiotoxicity during the follow up (p = 0.03). Changes in GLS were independent of left ventricular mass, E/A and peak s’ wave velocity (p = 0.01).

The diagnosis of subclinical cardiotoxicity by the decrease of GLS is a useful tool with possible therapeutic implications and possible reversibility of cardiotoxicity in patients with reverse chemotherapy sequence.

Significant results Binary analysis of echocardiographic variables Value LVEF p GLS p Basal 62.4 ± 6.7 -19.8 ± 1.8 3 months 59.4 ± 11.1 0.615 -18.1 ± 3.9 0.01 6 months 60.2 ± 8.7 0.354 -18.9 ± 3.3 0.185 9 months 61.6 ± 6.0 0.862 -19.65± 1.9 0.408 12 months 61.1 ± 5.7 0.379 -19.8 ± 1.9 0.859 Binary analysis of echocardiographic variables

Abstract P1773 Figure. Sequence of chemotherapy
P1777 Circulating microRNAs are associated with myocardial damage in patients with coronary artery disease: implications for a role of microRNA in myocardial matrix remodeling
Authors: Gheorghiu L , Ciobanu A , Macarie R , Vadana M , Ciortan L , Tucureanu M , Butoi E , Simionescu M , Vinereanu D
Published: January 2020

Background

Recent studies have reported that circulating microRNA (miR) can target different metalloproteases involved in matrix remodelling and plaque vulnerability. Consequently, they might have a role in the diagnosis and prognosis of cardiovascular diseases.

Aim. To quantify circulating miRs (miR126, miR146) which are suggested to have possible cardiovascular implications, as well as levels of MMP-1 and MMP-9, and to determine their association with left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), and arterial function, in patients with stable and unstable coronary artery disease (CAD).

Methods

90 patients with CAD (61% men, 58+/-12 years), including 60 patients with ST elevation acute myocardial infarction (STEMI) and 30 patients with stable CAD were assessed within 24 hours of admission by serum microRNA quantification (TaqMan PCR analysis), and serum MMP-1 and MMP-9 analysis (ELISA kits). 2D and 3D echocardiography were used to assess LVEF; speckle tracking was used to asses GLS; echo tracking, CAVI, and peripheral Doppler were used to assess arterial function (Young"s elastic modulus - EP and β index, arterial stiffness, and ABI).

Results

Circulating levels of miR146, miR126, MMP1, and MMP9 were significantly increased in patients with STEMI vs. stable CAD (95% CI 1.92-8.43, p = 0.002). miR126 correlated with LVEF (r=-.41, p = 0.03) and arterial stiffness (r=.44, and r=.42, p = 0.02 for L-CAVI and R-CAVI respectively) in patients with STEMI, and with arterial stiffness (r=-.72, p = 0.04, r=-.72, p = 0.01 for L-CAVI and R-CAVI respectively) and ABI (r=-.62, p = 0.04, r=-.62, p = 0.03 for L-ABI and R-ABI respectively) in patients with stable CAD. miR146 did not have any significant correlations. Both MMP-1 and MMP-9 correlated with LV function, LVEF ( r=-.27, p = 0.04, r=-.40, p = 0.01) and GLS (r=-.27, p = 0.03, r=-.26, p = 0.04) in patients with STEMI, and with arterial stiffness (r=.40, p = 0.03, for L-CAVI and r = 0.42, p = 0.02 for R-CAVI) in patients with stable CAD.

Conclusion

miR126 and both MMP1 and MMP9 are potential biomarkers of LV function in STEMI patients. Meanwhile, they correlate with arterial function in patients with stable CAD. However, further studies are needed to establish whether these new biomarkers have diagnosis and prognosis significance.

Abstract P1777 Figure.
P1779 Myocardial work is a predictor of exercise tolerance in patients with dilated cardiomyopathy and left ventricular dyssynchrony
Authors: Galli E , Schrub F , Schnell F , Hubert A , Donal E
Published: January 2020

Background

the assessment of myocardial work (MW) by pressure-strain loops is a recently introduced tool for the assessment of myocardial performance. Aim of the present study is to evaluate the relationship between myocardial work and exercise tolerance in patients with dilated cardiomyopathy (DCM)

Methods

51 patients with DCM (mean age 57 ± 13 years, left entricular ejection fraction : 32 ± 9%) underwent cardiopulmonary exercise test (CPET) to assess exercise performance. Trans-thoracic echocardiography (TTE) was performed CPET. The following indices of myocardial work (MW) were measured regionally and globally: constructive work (CW), wasted work (WW), and work efficiency (WE). Left ventricular (LV) dyssynchrony (DYS) was defined by the presence of septal flash or apical rocking at TTE.

Results

LV-DYS was observed in 16 (31%) patients and associated with lower LV ejection fraction (LVEF), GLS, global and septal WE, and higher global and septal WW (Table 1). In patients with LV-DYS, septal WE was the only predictor of exercise peak VO2max at multivariable analysis (Figure 1), whereas LVEF (β=0.47, p = 0.05) and age (β=-0.42, 47, p= 0.04) were predictors of exercise capacity in patients without LV-DYS.

Conclusions

In patients with DCM, LV-DYS is associated with an heterogeneous distribution of myocardial work. Septal WE is the best predictor of exercise performance in these patients.

Table 1 All n = 51 No-dyssynchrony n = 35 (69%) LV-Dyssynchrony n = 16 (31%) p-value LVEF, % 32 ± 9 34 ± 10 28 ± 7 0.04 GLS, % -12 ± 3 -13 ± 3 -10 ± 3 0.001 GCW, mmHg% 1325 ± 398 1342 ± 354 1287 ± 491 0.65 GWW, mmHg% 201 ± 147 154 ± 95 304 ±191 <0.0001 GWE, % 85 ± 9 88 ± 7 78 ±10 <0.0001 CWsept, mmHg% 1172 ± 459 1274 ± 398 949 ± 516 0.017 CWlat, mmHg% 1518 471 1472 ± 386 1620 ± 622 0.30 WWsept, mmHg% 283 ± 275 174 ± 98 522 ±376 <0.0001 WWlat, mmHg% 135 ± 88 117 ± 81 176 ± 92 0.02 WEsept, % 78 ± 16 84 ± 9 62± 18* <0.0001 WElat, % 90 ± 7 91 ± 7 88 ± 7 0.16

Abstract P1779 Figure.