bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 4119: Utility of ECG to Detect Left Ventricular Hypertrophy Defined by Cardiac MRI in Different Ethnic Groups: The Multi-Ethnic Study of Atherosclerosis (MESA)
Authors: Jain Aditya , Tandri Harikrishna , Dalal Darshan , Chahal Harjit , Soliman Elsayed Z , Prineas Ronald J , Folsom Aaron R , Lima Joao A , Bluemke David A
Published: July 2021

Background:
Left ventricular hypertrophy (LVH) is a strong predictor of cardiovascular event risk. We evaluated the ethnicity-specific diagnostic utility of ECG in the detection of LVH measured by MRI as a gold standard.

Methods:
12-lead ECG and MRI of 4498 asymptomatic subjects in the MESA study (49% males, mean age 61 ± 10 years) with no prior cardiovascular disease were analyzed. Left ventricular mass (LVM) was determined from MRI. Body-size predicted LV mass (pLVM) was determined from an allometric height-weight index derived from a subpopulation of 822 normal-weight, normotensive, non-diabetic MESA participants with LVH defined as LVM/pLVM > 1.31 (>95
th
percentile). Prediction of absolute LV mass by ECG was also assessed for whites and blacks based on previously validated prediction models for these groups.

Results:
The study population consisted of 39% Whites, 12% Chinese, 27% Blacks and 22% Hispanics. ECG detection rate for LVH as determined by MRI was significantly more in women than men (12.3% vs 3.9% respectively, p< 0.02). For a specificity >= 90%, the highest overall sensitivity for LVH was shown by Perguia score (28.7%) which increased from the first (17.9%) to fourth quartile (45.3%) of LV mass. At a fixed specificity of 90%, the highest sensitivity was shown by Sokolow-Lyon voltage duration product (SLP) (38.2%). Neither Perguia nor SLP differed significantly across the four ethnic groups with respect to sensitivity and area under the ROC curve (p< 0.27, p< 0.52; p< 0.35, p< 0.88 respectively). Presence of LV strain pattern on ECG showed the highest adjusted odds ratio for LVH across all ethnic groups. ECG predicted LVM correlated significantly with MRI-determined LVM for both whites and blacks (r=0.74, p< 0.001 and r=0.70, p< 0.001 respectively) with no significant difference in LVH detection rates (6.1% vs 9.4% respectively, p< 0.35)

Conclusion:
Based on LVM prediction models, ECG correlates well with MRI. ECG sensitivity to detect LVH is low and it does not differ significantly between whites and blacks. Based on individual criteria like Perguia and SLP, sensitivity and diagnostic performance of ECG did not vary significantly across different ethnic groups.
Abstract 4175: Quantitative Assessment of Myocardial Blood Flow Using Adenosine Triphosphate Stress Multidetector-row Computed Tomography in Coronary Artery Disease
Authors: Shikata Fumiaki , Imagawa Hiroshi , Kido Teruhito , Kurata Akira , Higashino Hiroshi , Inoue Yuma , Ryugo Masahiro , Nagashima Mitsugi , Mochizuki Teruhito , Kawachi Kanji
Published: July 2021

Introduction: The purpose of this study was to test the hypothesis that cardiac multidetector-row computed tomography (MDCT) technology can assess myocardial perfusion quantitatively using adenosine triphosphate (ATP) load technique.

Methods: Ten patients (median age 71 (range 65–79) years) who were scheduled for surgical revascularization, underwent cardiac electrocardiography-gated MDCT using ATP-load technique. The patients with unstable angina and myocardial infraction were excluded. Myocardial infarction was detected by late gadolinium enhancement MRI which was assessed before MDCT. Myocardial blood flow (MBF) was estimated from the slope of the linear regression equation with Patlak plots analysis. MBF results were compared to the presence of stenoses more than 75% on coronary angiography (CAG) and moderate to severe myocardium ischemia on stress thallium-201 myocardial perfusion scintigraphy (MPS).

Results: The overall mean MBF was 1.64±0.61 ml/g/min. Mean MBF in territories with stenosis on CAG was 0.81±0.49 ml/g/min, while mean MBF in territories without stenosis was 1.83±0.64 ml/g/min (p<0.01). Mean MBF in territories with moderate to severe ischemia on MPS was 0.76±0.49 ml/g/min, while mean MBF in territories without ischemia was 2.15±0.66ml/g/min (p<0.01). When the cut off value of MBF was set at 1.5 ml/g/min, there was good correlation between MBF vs CAG, and MBF and MPS. MBF vs CAG: sensitivity=71.4%, specificity=82.6%; MBF vs MPS: sensitivity=85.7%, specificity=87.0%.

Conclusions: This study proposed the possibility of MDCT to quantify myocardial blood flow using ATP in coronary artery disease. Our data suggested that the ATP stress MDCT has an advantage in the assessment of CAD to evaluate both coronary artery stenoses and myocardial perfusion information in one modality.
Abstract 4178: Adenosine Induced Stress Myocardial Perfusion Imaging using Dual Source Cardiac CT:Initial Clinical Experience
Authors: Blankstein Ron , Soni Anand V , Sarwar Ammar , Rogers Ian , Shturman Leon , Petranovic Milena , Mamuya Wilfred S , Bezerra Hiram , Nasir Khurram , Loureiro Ricardo , Okada David , Hoffmann Udo , Brady Thomas J , Cury Ricardo C
Published: July 2021

Intro
: The feasibility and accuracy of performing a comprehensive CT exam incorporating coronary, stress and rest perfusion, and delayed enhancement (DE) imaging is unknown. Our goal was to determine the feasibility of stress DSCT in identifying and quantifying the extent of ischemic and infarcted myocardium as compared to nuclear myocardial perfusion imaging (MPI) and invasive angiography (IA).

Methods
: 12 consecutive pts who had a prior MPI & subsequently underwent IA were included in study. DSCT (2×32×.6) performed as follows:

Stress CT (SCT) - retrospectively gated scan with tube current modulation and pitch adaptation obtained 3 min post adenosine (.14 mg/kg/min) with Isovue @ 4 –5 ml/s;

Rest CT (RCT) - non-helical prospective scan, Isovue @ 4 –5 ml/s;

DE Scan - prospective acquisition 7 min post RCT, 100kV. CT perfusion, CT angiography (CTA), MPI, and IA were each read blinded to results of other tests.

For DSCT & MPI, perfusion defect (pd) severity & reversibility were scored for ea. of the 17 segments. CT interpretation used 10mm multi planar reformation in short axis. Per vessel results of SCT were compared to the following references

S-MPI

IA≥50%

IA≥70%

CTA severe stenosis &

S-MPI & IA≥50.

Results
: Protocol was successfully completed for all 12 pts (44±11 yrs; 10 males; BMI 31.5±7 kg/m
2
) 11/12 pts had prior CAD; 5/12 had a prior MI and 3/12 had a prior PCI. Total contrast dose was 151cc; Average radiation dose of protocol 13mSv (8.8, 2.8, and 1.3mSv for SCT, RCT, and DE respectively). Average HR was 71 for RCT & 80 for SCT. Out of 204 segments (17×12pts), RCT pd were identified in 39 (5tr=transmural), SCT pd in 86 (40tr) and DE in 22 (3tr). S-MPI pd were present in 66 segments. Per vessel analysis: IA>70% lesions in 19/36, SCT identified pd in 25/36 and S-MPI in 21/36. Compared to MPI, SCT had a sensitivity (Sn) of 91% & specificity (Sp) of 43%. When IA>70%, used as the reference the Sn & Sp were: 79 & 41% for SCT, 63 & 47% for S-MPI, 89 & 65% for CTA, and 84 & 71% when abnormal on both CTA & SCT (p=NS).

Conclusions
: Adenosine stress CT can accurately identify both anatomical stenosis as well as reversible and nonreversible perfusion defects. The role of stress CT is unknown at this time and larger datasets will be necessary for accurate comparison with nuclear MPI.
Abstract 4181: Dual-Energy CT of the Heart for Diagnosing Coronary Artery Stenosis and Myocardial Ischemia - Comparison with SPECT
Authors: Ruzsics Balazs , Gebregziabher Mulugeta , Schoepf U. Joseph , Lee Heon , Abro Joseph A , Costello Philip , Zwerner Peter L
Published: July 2021

A single dual-energy CT (DECT) scan can assess coronary anatomy and detect myocardial perfusion defects (PD) seen on SPECT. 28 patients underwent SPECT myocardial perfusion imaging, invasive coronary angiography (ICA), and a single contrast medium-enhanced, retrospectively ECG-gated DECT scan using a dual-source CT system with simultaneous acquisition of high and low x-ray spectra. Scan data was used to reconstruct anatomic coronary CT angiographic (cCTA) images and to map the myocardial iodine distribution on virtually non-contrast enhanced long- and short-axis views of the left ventricle. Two independent observers analyzed all DECT studies for coronary artery stenosis and myocardial blood-pool deficits. Segmental comparison was performed between DECT, ICA, and SPECT. Data were analyzed using the Bayesian model. 484 myocardial segments were evaluated. 135 segments in 21 patients showed blood-pool deficits on DECT. In all territories where DECT showed blood-pool deficits, SPECT or catheter angiography confirmed PD or critical stenosis. Overall, DECT had 94.4% sensitivity and 95.2% specificity with 95% accuracy for detecting PD seen on SPECT. In patients without significant stenosis and negative SPECT (n=7), DECT showed no sign of blood-pool deficits. Interobserver agreement was very good (weighted kappa = 0.87). Compared with ICA, cCTA reconstructions had 98% sensitivity, 88% specificity and 92% accuracy for detection of >50% stenosis. Initial experience suggests that DECT may be promising for the comprehensive analysis of coronary artery morphology and the myocardial blood pool in good agreement with ICA and SPECT.
Abstract 4189: The Amount of Myocardial Fibrosis by Contrast-Enhanced Magnetic Resonance Imaging Predicts Mortality Late after Aortic Valve Replacement in Patients with Severe Aortic Valve Disease: Validation against Quantitative Histopathology
Authors: Azevedo Clerio F , Nigri Marcelo , Tarasoutchi Flávio , Pommerantzeff Pablo M , Sampaio Roney O , Parga José R , Ávila Luiz F , Spina Guilherme S , Grinberg Max , Higuchi Maria L , Rochitte Carlos E
Published: July 2021

INTRODUCTION: Severe aortic valve disease (AVD) is characterized by progressive accumulation of interstitial myocardial fibrosis (MF). The relationship between the amount of MF and mortality after aortic valve replacement (AVR) surgery in largely unknown.

OBJECTIVES: Determine whether the quantitative assessment of MF by delayed-enhanced magnetic resonance imaging (deMRI) can predict mortality late after AVR in patients with severe AVD.

METHODS: Fifty-four patients scheduled to undergo AVR surgery were examined by cine and deMRI. From the deMRI dataset, the amount of MF was automatically determined as the sum of pixels with signal intensity (SI) above a threshold value calculated as: mean SI of total myocardium + 2SD of a remote area SI + 2SD of air SI. The remote area was manually delineated in a myocardial region free of hyper-enhancement. In addition, interstitial MF was quantified by histological analysis of myocardial samples obtained during AVR surgery and stained with picrosirius red. Patients were classified in 3 groups according to the degree of MF accumulation. A second deMRI study was performed 27 ± 22 months after surgery to assess LV functional recovery and all patients were followed for 43 ± 23 months to evaluate survival after AVR.

RESULTS: There was a good correlation between the values of MF measured by MRI and those obtained by histopathology (r = 0.69; y = −3.10x + 13.0; p < 0.0001). The amount of MF, either by MRI or by histopathology, exhibited a significant inverse correlation with LV ejection fraction before surgery (r = −0.63 e −0.67 respectively; p<0.0001). Additionally, the amount of MF displayed a significant inverse correlation with the degree of LV functional recovery after AVR (r = −0.42, p = 0.04 for histopathology; r = −0.47, p = 0.02 for deMRI). Most importantly, Kaplan-Meier analyses revealed that higher degrees of MF accumulation were associated with worse survival after AVR surgery (log-rank test: χ2=6.32; p=0.01 for histopathology; χ2=5.85; p=0.02 for deMRI).

CONCLUSIONS: DeMRI allows for the non-invasive quantification of MF with good accuracy when compared with histopathology in patients with severe AVD. Most importantly, quantification of MF can predict LV functional recovery and all-cause mortality late after AVR surgery.
Abstract 4205: Left Atrial Volume Index and Left Ventricular Geometry Independently Predict Mortality in 47,865 Patients with Preserved Ejection Fraction
Authors: Patel Dharmendrakumar A , Lavie Carl J , Milani Richard V , Ventura Hector O
Published: July 2021

Background:
LV geometry predicts CV events but it is unknown whether left atrial volume index (LAVi) predicts mortality independent of LV geometry in patients with preserved LVEF.

Methods:
We evaluated 47,865 patients with preserved EF to determine the impact of LAVi and LV geometry on mortality during an average follow-up of 1.7±1.0 years.

Results:
Deceased patients (n=3,653) had significantly higher LAVi (35.3 ± 15.9 vs. 29.1 ± 11.9, p<0.0001) and abnormal LV geometry (60% vs. 41%, p<0.0001) than survivors (n=44,212). LAVi was an independent predictor of mortality in all four LV geometry groups [Hazard ratio: N= 1.007 (1.002–1.011), p=0.002; concentric remodeling= 1.008 (1.001–1.012), p<0.0001; eccentric hypertrophy= 1.012 (1.006 –1.018), p<0.0001; concentric hypertrophy=1.017 (1.012–1.022), p<0.0001; Figure

]. Comparison of models with and without LAVi for mortality prediction was significant suggesting increased mortality prediction by addition of LAVi to other independent predictors (Table

).

Conclusion:
LAVi is higher and LV geometric abnormalities are more prevalent in deceased patients with preserved systolic function and are independently associated with increased mortality. LAVi predicts mortality independent of LV geometry and has synergistic influence on all cause mortality prediction in large cohort of patients with preserved ejection fraction.
Abstract 4206: Microvascular Dysfunction and Left Ventricular Chamber Stiffness after Successful Percutaneous Coronary Intervention Critically Determine Left Ventricular Remodeling in Patients with Acute Myocardial Infarction
Authors: Yamamuro Atsushi , Akasaka Takashi , Kaji Shuichiro , Tamita Koichi , Katayama Minako , Kinoshita Makoto , Ehara Natsuhiko , Kobori Atsushi , Kitai Takeshi , Yamane Takafumi , An Yoshimori , Kim Kite , Funakoshi Syunsuke , Kimura Noriyuki , Tani Tomoko , Tanabe Kazuaki , Morioka Shigefumi , Furukawa Yutaka
Published: July 2021

In patients with acute myocardial infarction (AMI), the short deceleration time of left ventricular (LV) early filling by Doppler is a powerful independent predictor of LV remodeling. On the other hand, recent studies have shown that microvascular dysfunction in recanalized infarct-related coronary arteries may predict progressive LV dilation. The purpose of this study was to examine the effects of both microvascular dysfunction and LV chamber stiffness on LV remodeling after successful percutaneous coronary intervention (PCI) in AMI patients. Two hundred and one consecutive patients with first anterior AMI were studied following successful PCI. Microvascular injury was evaluated on the basis of coronary flow velocity patterns immediately after successful PCI using Doppler guidewires. We defined the presence of microvascular dysfunction as diastolic deceleration time ≤600 ms and the presence of systolic flow reversal. LV filling patterns were determined by mitral inflow pulsed-wave Doppler examination on day 3 after AMI. Deceleration time ≤130 ms was defined as restrictive. We classified the patients into three categories: without restrictive and microvascular dysfunction (group 1, n=116), with restrictive or microvascular dysfunction (group 2, n= 38), and with restrictive and microvascular dysfunction (group 3, n=47). Left ventriculograms were obtained immediately and 6 months after PCI. LV remodeling was defined as an increase in end-diastolic volume index ≥20%. Group 3 was at the highest risk of LV remodeling, while group 1 was at the lowest (Table

). Assessment of both microvascular dysfunction and LV chamber stiffness enable accurate prediction of LV remodeling in AMI patients after successful PCI.

LV remodeling in each group
Abstract 4211: Depth of Myocardial Bridges on Computed Tomographic Angiography is Associated with Myocardial Perfusion Defects on Single Photon Emission Computed Tomography
Authors: Jang James J , Krishnaswami Ashok , Go Mateo , Battaglia Kenneth S
Published: July 2021

Although considered a relatively benign congenital coronary anomaly, myocardial bridges have been associated with myocardial ischemia, infarctions, and sudden cardiac death. The aim of this study was to identify characteristics of myocardial bridges on computed tomographic angiography (CTA) associated with abnormal defects on myocardial perfusion imaging (MPI). A retrospective study was performed to identify patients who had myocardial bridges detected by 64-slice multidetector cardiac CTA and prior stress single photon emission computed tomography (SPECT) MPI. Using axial, oblique, and curved multi-planar reformatted images, myocardial bridge characteristics, including length and maximum depth of the tunneled segments, were compared in patients with and without corresponding coronary perfusion defects on SPECT MPI. From a total of 272 patients who had both SPECT MPI and cardiac CTA performed, 23 patients (8%, males= 9, mean age= 57 years) were identified with myocardial bridges. The left anterior descending artery was the predominant affected coronary artery (20/23, 87%). Eight patients (35%) with myocardial bridges had corresponding perfusion defects on SPECT MPI. Increased depth of the tunneled segment was significantly associated with abnormal SPECT MPI compared to normal SPECT MPI (4.1 ± 2.0mm vs. 1.9 ± 0.9mm, respectively, p< 0.002). The length of the tunneled segment did not differ in patients with or without abnormal SPECT MPI (27.8 ± 15.6mm vs. 20.9 ± 12.6mm, respectively, p=0.26). This is the first study to correlate SPECT MPI and 64-slice multidetector cardiac CTA in the evaluation of myocardial bridges. Increased maximum depth of the tunneled segment on cardiac CTA is significantly associated with myocardial perfusion defects.
Abstract 4218: Usefulness of 64-Row Multi-Detector Computed Tomography for the Evaluation of Patients with Variant Angina
Authors: Yamaji Kyohei , Arita Takeshi , Soga Yoshimitsu , Shirai Shinichi , Ando Kenji , Sakai Koyu , Iwabuchi Masashi , Yokoi Hiroyoshi , Yasumoto Hitoshi , Nosaka Hideyuki , Nobuyoshi Masakiyo
Published: July 2021

Invasive coronary angiography is useful in patients with suspected variant angina to document an episode of coronary artery spasm with provocative test. Previous studies have demonstrated that atherosclerosis is present at the sites of vasospasm. The aim of this study was to clarify the relation between 64-row Multi-detector Computed Tomography (MDCT) findings of coronary artery and vasospasm. A total of 58 patients with suspected variant angina (32 females and 26 males, aged 49 to 87 years, mean 65 ± 9 years) who have no evidence of luminal narrowing in major coronary artery with MDCT and underwent ergonovine test to detect the presence of coronary artery spasm were enrolled in this study. Two patients were excluded because of poor images of MDCT. The criteria of positive ergonovine test was total occlusion or localized occlusive spasm associated with chest pain and ST segment elevation after administration of ergonovine into the left coronary artery. The existence of plaques and calcifications in major coronary artery were evaluated with MDCT. 23 of 56 (41.1%) patients were positive with ergonovine test. 9 of 23 (39.1%) were total occlusion and 14 of 23 (60.9%) were localized spasm. Using MDCT, atherosclerotic lesions were observed at all coronary spasm sites. Among the 33 patients with negative ergonovine test, 7 (21.2%) had no plaques in the coronary artery. Presence of plaques was significant factor for positive ergonovine provocation test (p = 0.03). Patients with positive ergonovine test had coronary artery plaques at the site of coronary spasm sites. Absence of coronary artery plaques with MDCT could rule out variant angina.

Correlation between ergonovine provocation test and MDCT findings
Abstract 4225: Periadventitial Adipose Tissue Inflammation Assessed By 64-slice Computed Tomography Is Associated With Coronary Artery Atherosclerosis
Authors: konishi masaaki , Sugiyama Seigo , Nakaura Takeshi , Awai Kazuo , Yamashita Yasuyuki , Nagayoshi Yasuo , Sumida Hitoshi , Matsuzawa Yasushi , Hirota Shinichi , Ohba Keisuke , Matsubara Jun-ichi , Sugamura Kouichi , Nozaki Toshimitsu , Kimura Kazuo , Umemura Satoshi , Ogawa Hisao
Published: July 2021

Background
It has become increasingly evident that adipose tissue is a multifunctional organ that produces and secretes various paracrine and endocrine factors. Periadventitial cardiac adipose tissue (PCAT), which exists closely around coronary arteries, is now recognized as a rich source of a number of bioactive molecules. There have been some reports that highlight local chronic inflammation of PCAT as a potential contributing factor to the pathogenesis of coronary artery disease (CAD) and adipose tissue with inflammation is known to have high density in computed tomography (CT). We assessed CT density of adipose tissues to evaluate the inflammatory activity and investigated the association between PCAT inflammation and CAD.

Methods and results
We assessed the CT density of periadventitial adipose tissues in consecutive 69 patients suspected of CAD ( 51% men, 65 ± 11 years) using 64-slice CT. By using the image scanned for coronary CT angiography, adipose tissue and presence of CAD (>75% organic stenosis) were confirmed in the same scan. We measured CT density of PCAT around the proximal right coronary artery (Coronary-PCAT), pericardial fat apart from coronary arteries (between ascending and descending aorta as the control site; Cont-PCAT), and thoracic subcutaneous fat. In each of these sites, the CT density measurements in two or more regions of interest were randomly performed and the mean value was recorded. The mean of CT density was −81 ± 11 Hounsfield Unit (HU) in Coronary-PCAT, −99±11HU in Cont-PCAT, −103±7HU in the subcutaneous fat, which were significantly different values (p < 0.01). The difference of CT density between Coronary-PCAT and the Cont-PCAT was significantly greater in patients with CAD (n = 30) than those without CAD (n=39) (22±16 versus 16±10 HU, p < 0.05) but the difference between Cont-PCAT and subcutaneous fat was not related to the presence of CAD (6 ± 12 versus 3 ± 14 HU, p = 0.22).

Conclusions
Coronary-PCAT had significantly higher CT density than the Cont-PCAT and subcutaneous fat. The difference of CT density between Coronary-PCAT and Cont-PCAT was significantly greater in patients with CAD than non-CAD patients. The inflammatory actively of local PCAT rather than whole pericardial fat may implicate in the development of CAD.
Abstract 4226: Elevated Levels of Lp(a) Predict Coronary Atherosclerosis as Detected by Coronary Artery Calcium Scanning with Computed Tomography
Authors: Akram Kamran , Kasim Manoefris , Voros Szilard
Published: July 2021

INTRODUCTION Lipoprotein (a) [Lp(a)] has been established as an independent cardiac risk factor. There is considerable variation among different races and the association between Lp(a) and coronary artery calcium (CAC) is unknown in Asians.

METHODS 104 patients (pts) from Jakarta, Indonesia underwent CAC scoring and measurements of various biomarkers including Lp(a) (DAIICHI Pure Chemicals, Japan). Lp(a) >20mg/dl were defined as abnormal; CAC was expressed as Agatston score. Lp(a) values were not normally distributed and Kruskal-Wallis test and median values were used to test Lp(a) levels across CAC ranges (0, 1–100, 101– 400, >400). ROC curve analysis tested the performance of Lp(a) to predict presence of any CAC.

RESULTS 53/104 (51%) pts had an abnormal Lp(a) level. Clinical characteristics were similar between the two groups (60% male, 14% DM, 57% HTN, 30% smoker). Pts with abnormal Lp(a) had higher mean total cholesterol (220±48 vs. 199±147, p=0.01), LDL (147±40 vs. 130±38, p =0.02) and Lp(a) level (10.2±5.2 vs. 40.8±5.2, p=0.001) but similar HDL (46±10 vs. 45±9, p=NS) and triglyceride (154±113 vs. 145±95, p=NS) levels. Lp(a) was a good test in predicting presence of CAC as evidenced by an area under the curve (AUC)=0.7 with the optimal cut-point of >17mg/dl (sensitivity 73%, specificity 73%, p<0.001). Kruskal-Wallis analysis showed median Lp(a) levels to be significantly higher across rising CAC ranges: 0=41.5, 1–100=54.9, 101– 400=62.1, >400=64 mg/dl (p=0.026). After adjusting for the above clinical characteristics and biochemical markers in a multivariate logistic regression model Lp(a) levels remained a significant predictor of CAC (p=0.007).

CONCLUSION This is the first study to demonstrate a significant relationship between Lp(a) levels and presence of CAC in an Asian population.
Abstract 4243: Assessment Of Physiologic And Pathologic Cardiac Hypertrophy By Two-dimensional Strain And Torsion Analysis
Authors: Vitarelli Antonio , Bernardi Mauro , Placanica Giuseppe , Conde Ysabel , D’Orazio Simona , Stellato Simona , Battaglia Daniela , Caranci Fiorella , Continanza Giovanna , Dettori Olga , Placanica Attilio , Vitarelli Massimo , Capotosto Lidia
Published: July 2021

PURPOSE
. We sought to determine whether speckle tracking imaging (STI) could distinguish between subjects with athletic LVH and those with pathological LVH, such as occurs in hypertensive heart disease, hypertrophic cardiomyopathy (HCM), or aortic stenosis.

METHODS
. A total of 127 participants were studied, comprising competitive athletes (30), hypertensive heart disease (30), HCM (12), aortic stenosis (25), and healthy volunteers (30). Left ventricular mass index, ejection fraction, diastolic wall thickness, wall thickness ratio and diastolic and systolic wall-to-volume ratios were determined. LV longitudinal peak systolic strain (L-ϵ), peak systolic strain rate (SR-S), peak early diastolic strain rate (SR-E), and peak late diastolic strain rate (SR-A) values were measured by STI in the basal, mid and apical segments in apical 4-chamber view. LV radial strain (R-ϵ) in parasternal short-axis view was determined by STI. Averaged LV rotation and rotational velocities from the base and apex were also obtained (EchoPac, General Electric), and used for calculation of LV torsion (LVtor).

RESULTS
. Left ventricular (LV) mass indices were similar for all forms of LVH (p>.05), which were higher than those obtained in healthy volunteers (p<.05). Athletes had no significant differences in L-ϵ, SR-E and R-ϵ compared with control subjects (p = .21, .85, and .67, respectively). Patients with pathologic LVH had significantly decreased L-ϵ, SR-E, and R-ϵ (average septum: −15.9 ± 3.4%, 1.71 ± 0.35 s
−1
, and 24.5 ± 11.6%, respectively) compared with control subjects (−22.4 ± 3.3%, 2.51 ± 0.49 s
−1
, and 37.6 ± 15.2%, respectively; all p<.0005). LVtor increased significantly in pathologic LVH and in athletes compared to normals (p<.005 and .0001, respectively). In pathologic LVH LVtor increased mainly as a result of reduced basal rotation (−3.6±1.2 vs −6.4±1.5 degrees, p=.03). In athletes the LVtor increase was the result of an increase in both basal and apical rotation (basal rotation, −6.2±1.4 vs −9.1±1.6 degrees, p=.05; apical rotation, 16.9±3.1 vs 26.5±4.2 degrees, p=.08).

CONCLUSIONS
. Pathologic LVH has significant strain and SR-E reduction versus controls and a different pattern of LV torsion compared to athletes.
Abstract 4274: Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent-Graft Placement- Insights from the European Registry on EVAR Complications (EUREC)
Authors: Eggebrecht Holger , Thompson Matt , Rousseau Herve , Czerny Martin , Lönn Lars
Published: July 2021

Background: Thoracic endovascular aortic repair (TEVAR) is increasingly applied in the treatment of aortic dissections and aneurysms. Single center reports have addressed retrograde ascending aortic dissection (rAAD) as a potentially lethal complication unique to TEVAR. We used data from a European multi-center registry to determine possible etiological factors and outcomes of this dreadful complication.

Methods: So far 15 European sites and 1 Chinese center are contributing to the European Registry on EVAR Complications (EUREC) which is an open, independent, ongoing multi-center registry. Between 01/1998 and 05/2008 these centers performed a total of 3074 TEVAR procedures.

Results: 33 rAAD cases (56.3±11.6 yrs, 20 males) were reported (incidence 1.1%). Indications for TEVAR were: acute type B dissection (n=17), chronic dissection (n=10), thoracic aneurysm (n=4), and aortic ulcer (n=1). 20 procedures were performed as emergency TEVAR. Stent-grafts with proximal bare springs were used in 26/33 (79%) cases. Additional balloon inflations were performed in 6 (18%) cases. rAAD occurred intraoperatively (n=5, 15%), during the index hospitalization (n=7, 21%), and during follow-up (n=21, 64%). 9 (27%) patients were asymptomatic, the remaining patients presented with acute chest pain (n=11, 33%), syncope (n=10, 30%), or sudden death (n=5, 15%). Emergency or elective surgical repair was performed in 19 and 4 patients, respectively. Conservative therapy was chosen in the remaining 10 patients. Outcome was fatal in 14/33 (42%) patients. The most probable cause of rAAD as reported by the investigators was stent-graft induced in 58%, procedure related in 9%, and underlying undiagnosed aortic disease in 15% of patients. In 16/33 patients direct evidence of stent-graft induced rAAD was obtained by surgery or necropsy.

Conclusion: Although the incidence of rAAD was low (1.1%) in the present EUREC analysis, it was associated with significant mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone rAAD. As suspected, the majority of rAAD cases was associated with the use of proximal bare spring stent-grafts and in almost half of the patients direct evidence of stent-graft induced injury was obtained from surgery or necropsy.
Abstract 4278: Angiotensin II Receptor Antagonism and Transforming Growth Factor Beta and SMAD Signalling in Thoracic Aortic Aneurysm: Implications for Aneurysm Progression
Authors: Nataatmadja Maria , West Jennifer , West Malcolm
Published: July 2021

Increased expression of transforming growth factor-beta (TGFβ) and Smad3 is associated with fibrosis and inflammatory cell infiltration in abdominal aortic aneurysm. In Smad3-null mice there is reduced extracellular matrix (ECM) deposition but enhanced neointimal hyperplasia in response to vascular injury suggesting a TGFβ/Smad3 role in ECM regulation and cell proliferation. In vitro studies show that exogenous TGFβ administration leads to phosphorylation and nuclear translocation of Smad3 while angiotensin II (AngII) induces fibrosis through TGFβ and Smad3 pathways. We investigated TGFβ/Smad3 signaling using immunohistochemical and cell culture studies in thoracic aortic aneurysm tissue derived from subjects with Marfan syndrome (MFS; 3M, 2F, 46±24yr, mean +/−SD) and bicuspid aortic valve malformation (BAV; (3M, 2F, 65±13yr) as well as normal aorta from organ donor subjects (3M, 2F 40±11yr). MFS and BAV tissue showed co-localisation of TGFβ1–3 and Smad3 in myofibroblasts, vascular smooth muscle cells (VSMCs) and chronic inflammatory cells in the subintimal layer and tunica media and in fibroblasts in tunica adventitia. In normal aortic wall there was minimal TGFβ and Smad3 staining. Cultured VSMCs (passage 1–5) from MFS and BAV showed nuclear Smad3 and strong cytoplasmic TGFβ1–3 expression in numerous vesicles and in areas of exocytosis and extracellular localisation. In control cells there was much weaker TGFβ1–3 staining compared to aneurysm derived cells. Smad3 staining in normal cells was located in the cytoplasm alone. Compared to normal tissue and cells AngII receptor type1 and 2 (ATR1 and 2) expression was increased in both aneurysm tissue and in cultured VSMCs derived from aneurysm. Cultured VSMCs were treated for 48h with the ATR1 antagonist losartan (10μM). This caused disappearance of TGFβ1–3 vesicle localisation and nuclear expression of Smad3. The findings of increased TGFβ1–3 and Smad3 expression in aneurysm tissue and cultured cells are consistent with aberrant TGFβ signalling and with activation of the Smad3 signalling pathway. Furthermore reduction in extracellular TGFβ and de-activation of Smad3 expression associated with losartan treatment supports a role for ATR1 antagonism in inhibition of aneurysm progression.

Figure 1:

Risk of IMH Conversion to Typical Dissection
Abstract 4280: Combination of Doxycycline and Losartan is an Effective Secondary Prevention Treatment for the Thoracic Aortic Aneurysm in Marfan Syndrome
Authors: Yang Hh C , van Breemen Cornelis , Chung Ada
Published: July 2021

Losartan, an antihypertensive drug, has been shown to prevent thoracic aortic aneurysm (TAA) in Marfan syndrome (MFS) through the inhibition of transforming growth factor (TGF)-β. Recently we have suggested doxycycline, a non-specific inhibitor of matrix metalloproteinases (MMPs), suppressed aneurysm and normalized vasomotor function in TA. We hypothesized that a combination of doxycycline and losartan could be effective in the secondary prevention to ameliorate TAA in MFS. A well-defined mouse model of Marfan syndrome (Fbn1
C1039G/+
) were untreated (n=20), given doxycycline (0.24g/L, n=15), losartan (0.6g/L, n=15), or doxycycline+losartan (0.12g/L+0.3g/L, respectively, n=15) from drinking water at the age of 4 months. The littermate Fbn1
+/+
mice served as control (n=20). Ascending thoracic aortae from each group at 9 months were studied. Mortality (2%) and TAA (increase in diameter by >35%) were observed in the untreated group. Mild aneurysm (diameter of aorta was increased by 15% compared with controls) was evident in either losartan-or doxycycline-groups, but TAA was prevented by the combined treatment. From the aortic media of untreated, losartan- and doxcycline-groups, elastic fiber degeneration shown on Movat’s histology was pronounced, which accompanied with increased aortic stiffness. Combined treatment attenuated elastic fiber degradation and normalized the aortic elasticity to the control levels. The impairment of smooth muscle contraction and endothelial-dependent relaxation in the untreated group were also completely normalized by the combined treatment. Either losartan- or doxcycline-groups improved aortic contractility by 75% compared with the untreated, but was not effective in improving endothelium-dependent relaxation. Combined treatment reduced activities of MMP-2 and -9 in the aortic media by 60 – 80%, and activation of TGF-β by 70%. Delayed treatment reduced effectiveness of both losartan and doxycycline in the prevention of TAA. Combination of doxycycline and losartan is effective in the secondary prevention to preserve elastic fiber integrity and normalize vasomotor function, indicating that both MMP and TGF-β are crucial mediators in TAA formation in MFS.
Abstract 4287: Mitral Leaflet Adaptation to Ventricular Remodeling: Prospective Changes in a Model of Ischemic Mitral Regurgitation
Authors: Chaput Miguel , Handschumacher Mark D , Guerrero J L , Holmvang Godtfred , Dal-Bianco Jacob P , Sullivan Suzanne , Johnson Benjamin , Vlahakes Gus J , Hung Judy , Levine Robert A
Published: July 2021

Background:
Ischemic mitral regurgitation (IMR) is caused by systolic traction on the mitral leaflets related to ventricular distortion. Little is known about how chronic tethering affects leaflet area, in part because it cannot be measured repeatedly in situ. Recently, a new method for 3D echo measurement of mitral leaflet area was developed and validated in vivo against sheep valves, later excised. Clinical studies (n=80) showed that mitral leaflet area increased by >30% in patients with inferior myocardial infarction (IMI) and dilated cardiomyopathy versus normal; greater adaptation independently predicted less MR. This study explored whether mitral valve area changes over time
within the same heart
with IMR.

Methods:
Twelve sheep were studied at baseline and 3 months after IMI by 3D echo and MRI; 6 were untreated and 6 were treated initially with an epicardial patch to limit LV dilatation and MR.

Results:
Untreated sheep developed LV dilatation at 3 months with global dysfunction (EF 24±10% vs. 43±11% with patching, p=0.02) and moderate MR (vena contracta 5.0 vs 0.8 mm, p<0.0001). In untreated sheep, total diastolic leaflet area increased from 13.0±1.9 to 18.1±2.5 cm
2
, p=0.0077. In patched sheep, leaflet area at 3 months was not significantly different from baseline sheep values (12.9±0.9 cm
2
, p=0.77).

Conclusion:
Mitral valve area, independent of systolic stretch, increases over time as the LV remodels after IMI. This increase, however, fails to compensate adequately for tethering to prevent MR. Understanding the mechanism of valve adaptation can potentially suggest new biological and surgical therapeutic targets.
Abstract 4291: Left Atrial Appendage Occlusion: Early Clinical Results with a New Clip
Authors: Salzberg Sacha P , Plass Andre , Alkadhi Hatem , Grunenfelder Jurg , Jenny Rolf , Genoni Michele
Published: July 2021

Background:
Atrial fibrillation (AF) is a common arrhythmia and as such a significant risk factor for stroke originating from the left atrial appendage (LAA). The purpose of this study is to evaluate surgical LAA occlusion with a new clip in patients with AF undergoing open heart surgery (OHS) at 3 month follow-up with cardiac multidetector computed tomography (MDCT).

Patients and Methods:
From 9/2007 to 5/2008, patients undergoing OHS with AF were enrolled in a trial for concomitant clip placement (LAA clip, Atricure Inc., Westchester, Ohio (USA)). The LAA clip is composed of titanium rods with nitinol hinges, surrounded by polyester braiding, applied epicardially on the LAA. LAA geometry and perfusion was assessed by trans-esophageal echocardiography (TEE). Postoperative and 3 month follow-up MDCT was compared to preoperative data to assess Clip location, LAA perfusion and cardiac anatomy.

Results:
30 patients underwent LAA Clip placement through a median sternotomy. Clip deployment was successful in all (n=30), no device related complications occurred. LAA measurement and clip placement took less than 30 seconds and one attempt. After deployment TEE confirmed absence of LAA perfusion in all. Operative mortality was 6% (n=2) and was unrelated to clip placement. Pre-discharge (n=28) and 3 month follow-up (n=18) MDCT demonstrated stable clip location, absent LAA perfusion and normal surrounding cardiac structures.

Conclusion:
LAA Clip occlusionis safe, easy and straightforward. LAA occlusion remains effective and durable, per TEE and MDCT. When applied in a minimally invasive fashion LAA clip occlusion might offer a valuable tool for stroke prevention in selected patients.
Abstract 4310: Chronic Effects of Surgical Ventricular Restoration on Left Ventricular Function: 6 Months Follow-Up by Pressure-Volume Loops
Authors: ten Brinke Ellen A , Klautz Robert J , Tulner Sven A , Engbers Frank H , Verwey Hariette F , Atsma Douwe E , Schalij Martin J , van der Wall Ernst E , Bax Jeroen J , Putter Hein , Dion Robert A , Steendijk Paul
Published: July 2021

Previous studies have demonstrated beneficial acute effects of surgical ventricular restoration (SVR) on mechanical dyssynchrony and left ventricular (LV) function, and improved mid- and long-term clinical parameters. However, chronic effects on systolic and diastolic LV function are still largely unknown. We studied 9 patients with ischemic dilated cardiomyopathy who underwent SVR. In all patients, invasive hemodynamic measurements by the conductance catheter (pressure-volume loops) were obtained during catheterization before and 6 months after surgery. In addition, NYHA classification, Minnesota Quality of Life (QoL)-score and 6-minute-hall-walk-test (6min-HWT) were assessed. At 6 months follow-up, all patients were alive and clinically significantly improved: NYHA class from 3.3±0.5 to 1.4±0.7, QoL-score from 46±22 to 15±15 and 6min-HWT from 302±123 to 444±78 m (all p<0.01). Hemodynamic data at fixed paced heart rate (80 bpm), showed improved cardiac output (4.8±1.4 to 5.6±1.1 L/min) (p =0.09), stroke work (6.5±1.9 to 7.1±1.4 mmHg.L) (p =0.05) and LV ejection fraction (36±10 to 46±10%) (p <0.001). LV surgical remodeling was sustained at 6 months: end-diastolic volume decreased from 246±70 to 180±48 mL and end-systolic volume from 173±77 to 103±40 mL (both p<0.001). LV mechanical dyssynchrony decreased from 29±6 to 26 ±3% (p<0.001) and ineffective internal LV flow fraction decreased from 58±30 to 42±18% (p<0.005). Early relaxation (tau, −dP/dt
MIN
) was unchanged, but diastolic stiffness constant (K
ED
) increased from 0.012±0.003 to 0.023±0.007 mL
−1
(p<0.001) at 6 months follow-up. SVR leads to maintained LV volume reduction at 6 months follow-up. In addition, we observed improved systolic function and unchanged early diastolic function, but impaired passive diastolic properties. Clinical improvement, supported by decreased NYHA class, improved QoL-score and improved 6-min-HWT may be related to improved systolic function and reduced mechanical dyssynchrony.
Abstract 4336: Interrogating the Human Myocardial Interstitium during Myocardial Arrest and Reperfusion: Dynamic Changes in Cytokines and Protease Activity
Authors: Stroud Robert E , Koval Christine N , Gengler Isabelle , Deschamps Anne M , Ikonomidis John S , Spinale Francis G
Published: July 2021

Background.
Cytokines, such as the interleukins (IL1β, IL2, IL6) and tumor necrosis factor (TNF) can modulate myocardial structure and function with ischemia/reperfusion (I/R) but dynamic assessment of these biological molecules within the human myocardial interstitium with I/R has not been performed, and the inter-relationship to matrix metalloproteinases activity (MMPact) remains unexplored. Accordingly, a fluorogenic microdialysis method was used to simultaneously measure myocardial interstitial cytokine levels and MMPact in patients during and following I/R.

Methods
. MMPact was measured in patients (n=13) undergoing cardio-pulmonary bypass (CPB) at baseline, during myocardial arrest and CPB (on-CPB), and immediately following reperfusion and separation from CPB (post-CPB) by a validated in-line microdialysis fluorescent detection system. Myocardial interstitial fluid was subjected to cytokine analysis by high sensitivity multiplex suspension array.

Results
. Interstitial MMPact increased by over 30% post-CPB and was accompanied by a specific change in cytokine profiles (Figure

). The classical pro-inflammatory molecules such as TNF and IL6 were either not detectable or unchanged, whereas IL1β and IL2 which can be proinflammatory, were increased.

Conclusions.
These unique results demonstrated that a dynamic cytokine signature occurs within the human myocardial interstitium following I/R and is temporally related to heightened MMP activity. Direct interrogation of the human myocardial interstitium may provide a unique insight into critical signaling pathways which may evoke adverse structural and functional events following I/R.
Abstract 4337: Best Outcome Predictor Post Myocardial Infarction: Can Blood Glucose Defeat Left Ventricular Ejection Fraction?
Authors: Monteiro Silvia , Antonio Natalia , Lourenço Carolina , Teixeira Rogério , Batista Rui , Jorge Elisabete , Saraiva Fátima , Monteiro Pedro , Gonçalves Lino , Freitas Mário , Providência Luís
Published: July 2021

Introduction: Ventricular dysfunction in acute myocardial infarction (AMI) is a recognized predictor of in-hospital and post-discharge morbidity and mortality. Recently, admission hyperglycaemia has also been considered an important marker of poor prognosis in this patient population.

Aim: To compare the predictive value of left ventricular dysfunction with admission glycaemia (GLY) on prognosis of AMI patients and to identify independent predictors of 1-year major acute cardiac events (MACE) and mortality.

Population and methods: Retrospective analysis of 583 consecutive patients admitted to a single coronary care unit for AMI. Patients were followed during twelve months after AMI. Re-hospitalization by worsening heart failure, non programmed revascularization, new ACS and death were considered as MACE.

Results: After multivariate analysis, age, previous diabetes, necrosis markers, and low ejection fraction (EF) were independent predictors of 1-year mortality, while PCI performance and admission GLY, in addition to parameters listed before were independent predictors of MACE at 1-year of follow-up. We then compared, by multivariate regression analysis, the predictive value of admission GLY and EF in this population. The receiver-operator curves showed that both parameters were equally predictive of both short and long-term MACE and mortality.

Conclusion: In this population, admission GLY was as predictive of outcome as EF, a well recognized and strong prognosis determinant post-AMI. This fact, never before described, underlies the importance of metabolic abnormalities and its control in the prognosis of AMI patients.
Abstract 4342: The RethinQ Trial Echocardiographic Sub Study: Insights from Analysis of TDI Data on Mechanical Dyssynchrony in a Randomized Clinical Trial of Cardiac Resynchronization Therapy in Narrow QRS Patients with Heart Failure
Authors: Grimm Richard , Beshai John , Nagueh Sherif , Baker James , Beau Scott , Greenberg Steven , Pires Luis , Tchou Patrick
Published: July 2021

Tissue Doppler Imaging (TDI) of myocardial velocities is the method of choice to characterize mechanical dyssynchrony (MD) in the failing heart. TDI identified candidates for the RethinQ trial, a prospective, randomized, multicenter, double-blind, parallel-controlled trial evaluating the efficacy of Resynchronization Therapy (CRT) in pts with EF <35%, NHYA class III, QRS <130 ms and MD by TDI. Peak MVO
2
at 6 months was the primary endpoint. The purpose of this study was to determine whether:

degree of MD by TDI and opposing wall delay (OPWD) correlated with outcome;

resynchronization by TDI parameters of MD was achieved by CRT; and

if other TDI parameters of MD were predictive of outcome.

Methods: A retrospective analysis of prospectively acquired echo data. Pts underwent an echo exam at baseline and 6 months which included color TDI enabling determination of the OPWD ≥65 ms required for enrollment into the trial. Other recognized parameters of MD such as the pre-ejection period (PEP) and 12 segment standard deviation of time-to-peak myocardial velocity were collected but not part of the selection criteria used to randomize pts to CRT. For the purpose of this analysis responders (R) were defined by improved MVO
2
and reduction in LVESV> 15%. All echo data was adjudicated by a Core Lab.

Results: Degree of dyssynchrony pre implant (OPWD > 65, > 80, > 100ms) did not impact response to CRT. Both R and Non responders (NR) exhibited a decrease in OPWD at 6 months though R had a greater median change than NR -33(−29+42) ms vs 0(−3+45) ms, p=0.01. When pts exhibited OPWD ≥65ms, 12 segment standard deviation ≥34ms and PEP > 100ms there was a trend toward being able to identify R to CRT pre implant. 18/65 (28%) pts receiving CRT and meeting all 3 MD criteria were categorized as R vs. 6/47 (13%) not receiving CRT, p=0.052.

Conclusions: Analysis of the echo TDI data revealed that degree of MD did not impact outcome, improvement of dyssynchrony was achieved with CRT and a combination of OPWD≥65ms, 12 segment standard deviation ≥34ms and pre ejection period > 100ms showed promise in predicting improvement in pts with narrow QRS, low EF and MD.