bluuebunny/crossref_metadata_2025 huggingface dataset:
P1781 Cardio-protective role of dexrazoxane co-administered with anthracyclines: long-term echocardiographic follow-up in adult survivors of pediatric cancer
Authors: Filomena D , Cimino S , Maestrini V , Petronilli V , Cantisani D , Mattiucci C , Schiavetti A , Fedele F , Agati L
Published: January 2020

Background Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer treated with anthracyclines. A decrease in left ventricular (LV) ejection fraction (LVEF) and fractional shortening may be observed during follow-up. Previous studies reported non-negligible prevalence of subclinical systolic dysfunction assessed with deformation imaging at short-, mid- and long-term follow up. Co-administration of Dexrazoxane has been shown to significantly reduce short-term and mid-term cardiotoxicity. The usefulness of dexrazoxane in preventing late (>10 years) anthracycline cardiotoxicity remains under discussion.

Purpose Aim of this study was to assess cardiac function in long-term (>10 years) survivors of childhood tumors treated with dexrazoxane/anthracycline association.

Methods Twenty cancer survivors previously treated with co-administration of anthracyclines and dexrazoxane for childhood renal tumors or sarcoma and a control group of 20 healthy non-athletic subjects matched for age, sex and body surface area were enrolled in the study. Echocardiographic measurements included 3D LVEF and LV and right ventricular (RV) global longitudinal strain (GLS). Cancer survivors were evaluated at median follow-up time of 21.5 years (range 10-26).

Results No evidence of cardiac toxicity, as defined by current guidelines, was reported in all survivors. None of survivors presented LVEF < 50% or abnormal longitudinal strain, defined as a value >2 SDs below the mean using sex-specific and age-specific strain values. No significant differences in standard and deformation imaging parameters were observed between survivors and controls (3D LVEF 58 ± 3 % vs 60 ± 5 % p = NS; LV GLS -21 ± 1 % vs - 21 ± 2 % p= NS; RV GLS - 23 ± 2 % vs - 23 ± 5 % p= NS). Moreover, considering subjects who received a cumulative dose of anthracyclines above the median (doxorubicin-equivalent dose ≥208 mg/m2) no significant differences were found as compared to the group receiving a lower dose.

Conclusions No evidence of cardiac toxicity was detected in all survivors. Our findings support the cardio-protective role of dexrazoxane in children undergoing anthracycline-based treatment.

Parameters Cancer survivors (n= 20) Controls (n= 20) P 3D LVEF (%) 58 ± 3 60 ± 5 NS LV GLS (%) -21 ± 1 -21 ± 2 NS RV GLS (%) -23 ± 2 -23 ± 5 NS 3 D LVEF: Three-Dimensional Left Ventricular Ejection Fraction, LV GLS: Left Ventricular Global Longitudinal Strain; LV; RV GLS: Right Ventricular Global Longitudinal Strain.

Abstract P1781 Figure. LV strain analysis in a survivor
P1785 Hemodynamic determinants of left atrial function in patients with primary mitral regurgitation
Authors: Tencer T , Bakkestroem R , Banke A , Moeller J E
Published: January 2020

Background

2D speckle tracking (2DSE) has been recently used as an advanced method for assessment of left atrial (LA) function.

Purpose

The aim of the study was to determine the association between LA function assessed with 2DSE and severity of mitral regurgitation, filling pressures and symptomatic status in patients with primary mitral regurgitation (MR).

Methods

61 patients (age 65 ± 9 years, 77% males) with primary mitral prolapse and moderate to severe MR (effective regurgitant orifice (ERO) > 0.30 cm2) and left ventricular ejection fraction > 60% were enrolled. Right heart catheterization during rest and exercise, and transthoracic echocardiography during rest was performed. Pulmonary capillary wedge pressure (PCWP) was measured at rest and peak exercise. Echocardiographic average values of LA peak contractile, conduit and reservoir strain were obtained using 2DSE in the apical 4 and 2 chamber views.

Results

LA volume index was less than 34 ml/m2 in 54 patients, and LA function based on 2DSE was abnormal in majority. LA function was associated with ERO (Figure). Patients with severe MR defined as ERO > 0.40 cm2 had significant higher reservoir strain (27.5 ± 5.1% vs. 24.5 ± 5.1 %, p = 0.02) and conduit strain (16.0 ± 4.9 %, vs. 13.1 ± 3.2 %, p = 0.008), but LA peak contractile strain was unchanged (11.4 ± 3.4 % vs. 11.8 ± 3.5 %, p = 0.69). In contrast no association between LA function, symptoms and PCWP at rest or exercise was found in our cohort. In linear regression analysis MR (ERO > 0.40 cm2) was associated with conduit (β=2.8, p = 0.02) and reservoir strain (β=3.0, p = 0.04) after adjustment for age, gender, symptoms and PCWP with exercise, whereas LA peak contractile was not.

Conclusions

LA function assessed with 2DSE was affected in patients with primary MR. Strain parameters were associated with severity of mitral regurgitation, but there was no association with symptomatic status or filling pressure at rest or exercise.

Abstract P1785 Figure
P1788 Prognostic value of stress echocardiography in preoperative risk stratification and management
Authors: Almeida I , Pereira R , Cruz I , Quadrado M , Almeida A R , Fazendas P , Joao I , Pereira H
Published: January 2020

Introduction

The prognostic value of pharmacologic stress echocardiography has been extensively demonstrated in patients undergoing noncardiac surgery since 42% of the perioperative complications are cardiac. Coronary artery stenoses can became flow-limiting due to hemodynamic fluctuations in this period leading to myocardial ischemia.

Purpose

Evaluation of prognostic value of pharmacologic stress echocardiography in preoperative risk stratification.

Methods

Single center retrospective analysis of patients’ data referred to perform a preoperative risk stratification through pharmacological stress echocardiography between January 2014- December 2018. Data was collected regarding clinical and echocardiographic parameters to predict perioperative cardiac complications (myocardial infarction and development of arrythmias) and evaluate the impact of the result of DSE in patients´ clinical management.

Results

Of 910 pharmacological stress echocardiograms, 106 were performed to evaluate preoperative risk. Patients´ mean age was 66 ± 11 years, 85% males. 64% had hypertension, 45% dyslipidaemia, 38% current smokers and 18% diabetes. 189% had previously myocardial infarction and 9% stroke. All patients were proposed to intermediate-high risk surgeries: 73% to vascular surgery, 14% to kidney transplant and 13% to other type of surgery (especially abdominal surgery). Most of the stress tests (64%) were performed with dobutamine and the others 34% with dipyridamole. 91% of stress echocardiography were negative, 6% positive and 4% inconclusive. The patients with a positive stress test was submitted to coronary angiography to treat relevant lesions and cardiovascular risk factors were optimized. 72% of the patients has already been submitted to the proposed surgery; in this population, there was a 5% rate of cardiac complications following the surgery, all in patients with previous negative stress echocardiography. Complications were non-ST elevation myocardial infarction in 1% and de novo atrial fibrillation in 4%. Half of the patients with a positive stress echocardiography were operated with no cardiac perioperative complications, possibly related to patient´s optimization before the surgery; in the other half it was decided not to perform the surgery due to the potential cardiac risk. Predictor factors for perioperative cardiac complications, evaluated through univariate and multivariate analysis, were age (odds ratios (OR) 1.232, confidence interval (CI) 1.043-1.456, p 0.007) and stroke (OR 0.057, CI 0.947-44.592, p 0.033).

Conclusion

In our study, patients with a positive stress echocardiography were optimized before the surgery leading to none cardiac perioperative complications, emphasizing the importance of this test in preoperative patients´ management.
P1790 Is there any role of exercise Doppler echocardiography to unmask pulmonary hypertension (PH) in patients with systemic sclerosis and baseline echocardiographic measurements for PH in the gray zone?
Authors: Rallidis L , Papangelopoulou K , Anthi A , Makavos G , Konstantonis D , Tsangaris I , Orfanos S , Iliodromitis E
Published: January 2020

Background

The usefulness of exercise Doppler echocardiography (EDE) is uncertain in identifying patients with pulmonary hypertension (PH). Recently the cut off value for the definition of PH was changed and was set at the level of mean pulmonary arterial pressure (PAP) >20 mmHg, measured by right heart catheterization (RHC).

Purpose

We examined whether EDE can unmask the presence of PH in patients with systemic sclerosis (SSc) whose baseline echocardiographic assessment for PH is non-diagnostic.

Methods

Forty-one patients with SSc (2 men and 39 women; mean age 61.2 ± 10 years) underwent treadmill symptom-limited EDE using a modified Bruce protocol. Tricuspid regurgitation velocity (TRV) was recorded within 60 seconds after the termination of the test. Inclusion criteria comprised: preserved left (ejection fraction >50%), and right ventricular function (tricuspid annulus plane systolic excursion >15 mm), lack of left side moderate or severe valvulopathy, presence of mild or moderate TR, satisfactory exercise tolerance and baseline TRV in the range of 2.6-3.0 m/s. All patients had RHC within 48 hours after EDE.

Results

In 5 cases the quality of post-exercise TRV was poor and further analysis was confined to 36 patients. RHC confirmed the presence of PH (mean PAP >20 mmHg) in 14 cases (38.9%). All patients had pulmonary capillary wedge pressure <15 mmHg. The increase in TRV from baseline to post-exercise was 1.25 ± 0.6 m/s. Ten patients developed post-exercise TRV ≥3.7 m/s of whom in 8 RHC validated PH. Post-exercise TRV was positively correlated with mean PAP obtained by RHC (r = 0,652, p < 0.001). A cut-off value of post-exercise TRV ≥3.7 m/s had a sensitivity of 57.1%, a specificity of 90% and a diagnostic accuracy of 77.8% in detecting PH validated by RHC.

Conclusions

EDE has a moderate diagnostic accuracy for the identification of PH in patients with SSc whose baseline echocardiographic measurements for PH lie in the gray zone.
P254 Congenitally corrected transposition of the great arteries with an ebstenoid tricuspid valve, aortic atresia, hypoplastic aortic arch and a dysplastic pulmonary valve
Authors: Rittey L A , Parry H , Willcoxson F
Published: January 2020

Funding Acknowledgements

No financial support received

Introduction

Congenitally corrected transposition of the great arteries (CCTGA) is a rare cardiac malformation accounting for around 0.5% of congenital heart disease. Common associations are ventricular septal defects (VSD), pulmonary stenosis and heart block. CCTGA associated with aortic atresia is very rarely described in the literature.

Description

We present a case of a term neonate weighing 2.5kg. Fetal echo had initially made the diagnosis at 21/40.

The baby was born in good condition and the postnatal echo confirmed the diagnosis of CCTGA. There were 2 secundum atrial septal defects, the sub-systemic tricuspid valve was ebstenoid with remarkably trivial regurgitation, there were multiple muscular ventricular septal defects with predominantly left to right flow, although flow appeared bi-directional in some views. The atretic aortic valve was anterior and to the left of the dysplastic, bicuspid pulmonary valve. The pulmonary valve leaflet motion was restricted with peak velocity of 2.4m/s and mild incompetence. The hypoplastic aortic arch filled retrogradely via the arterial duct. There was discrete coarctation with peak velocity of 2.2m/s down the descending aorta. The persistent left SVC drained to the coronary sinus.

Following several discussions there was agreement that the most appropriate management for him would be to receive palliative care. He was discharged home at a week of age and continued to have intensive support from his local hospice and the cardiac team, until he passed away peacefully at home at 16 days of age.

Discussion

The multidisciplinary team decided surgery was extremely high risk due to the anatomy described above particularly in the context of his dysplastic, bicuspid pulmonary valve, which would have provided systemic outflow if intervention had been undertaken.

Figure 1: 4 chamber view showing reverse offsetting of the atrioventricular valves, arch view showing a hypoplastic aortic arch with restrograde flow from the arterial duct, short axis view showing the semilunar valves and their relative positions, long axis view showing aortic atresia with retrograde flow into the ascending aorta

Abstract P254 Figure 1
P255 A fall from the tractor: a case report
Authors: Habjan S , Cantisani D , Scarfo` I S , Avitabile V , Romeo F , Guarneri M C , La Canna G
Published: January 2020

Introduction

Pulmonary artery aneurysms (PAAs) are rare and infrequently diagnosed clinical conditions. They can have congenital, acquired or idiopathic causes. PAAs can be asymptomatic or present with non-specific manifestations even at large diameters up to 70 mm. Rupture and dissection are the main life threating complications. The optimal treatment remains uncertain. There are no clear guidelines regarding the therapeutical approach.

Case presentation

A 78-year-old male presented at our medical facility to investigate further a pulmonary artery aneurysm discovered accidentally after a traumatic fall from a farmer tractor. He had no important chronic diseases, but in his medical history it was reported that he was excluded from the military service on top of a cardiac murmur, never investigated with an echocardiography exam. The fall from the tractor caused a fracture of the second and third costal ribs with hematoma and a commotional cranial trauma. At the thoraco-abdominal computed tomography (CT) scan conducted after the fall emerged an important fusiform dilatation of the principal pulmonary trunk and the left pulmonary artery (3.8 cm and 5 cm respectively). There was also a mild dilatation of the right pulmonary artery (3 cm), thickening of the pulmonary valve cusps and dilatation of the right cardiac chambers with flattening of the interventricular septum. Pulmonary embolism was excluded.

Transthoracic and transesophageal echocardiography revealed a dysplastic pulmonary valve, with thickened cusps and moderate stenosis with insufficiency. The jet of the right ventricular outflow tract was eccentric with an anterolateral direction and a correlated dilatation of the common pulmonary trunk (3.8 cm) and the left pulmonary artery (5 cm). The right ventricle appeared not dilated and the tricuspid regurgitation was mild with a normal systolic pulmonary artery pressure. The dilated pulmonary artery did not interfere with the flow in the left main coronary artery. We concluded that the pulmonary artery aneurysm was mainly due to the congenital pulmonary valvulopathy. The patient underwent successful pulmonary trunk, left pulmonary artery and pulmonary valve replacement with a bioprosthetic valved conduit.

Conclusion

Congenital pulmonary valvulopathy can remain clinically silent lifelong and is commonly discovered during exams performed due to other clinical circumstances. The eccentric jet caused by the valvulopathy can be the reason for dilatation of the pulmonary trunk and pulmonary arteries. Transthoracic and transesophageal echocardiography are competent tools for clarifying the cause of the pulmonary artery aneurysm and therefore are essential in the decision making regarding the treatment strategy.

Abstract P255 Figure. Transesophageal echocardiography images
P1810 Impact of pulmonary hypertension on survival in patients with degenerative aortic stenosis, prospective clinical trial
Authors: Mercea D , Ianos R , Pop C , Pop D , Zdrenghea D , Cozma A
Published: January 2020

Introduction

Aortic stenosis has become the most common degenerative valvular heart disease, due to aging of the population. It represents 43% of degenerative valvular disease.

Methods

We prospectively followed 196 patients with degenerative aortic stenosis, for a period of 6 years. Of these, 106 had mild aortic stenosis, 28 had moderate aortic stenosis and 62 patients had severe aortic stenosis. Of the 196 patients, 54 had mild pulmonary hypertension (PH), 22 had moderate PH and 7 had severe PH. The survival data were estimated by the Kaplan - Meier method and the logrank test. The Cox proportional- hazards regression was performed to assess the differences between the groups.

Results

During the follow-up period, of a total of 196 patients, 61 patients died. We studied if the presence of PH has an influence on survival in patients with aortic stenosis and we found out that the patients who had PH had reduced survival rates, compared with those who hadn"t. The survival rate at 5 years was lower in the group with mild PH compared with the group with normal pulmonary pressure ( p = 0.045, HR 1.84, 95%CI 1.01-3.36). In the group with mild PH, 20 patients (37.03%) died at 5 years, compared with 23 in the group without PH (20.35%). The survival rate at 5 years was also lower in the group with moderate PH compared with the group with normal pulmonary pressure ( p = 0.001, HR 5.82, 95% CI 3.02-11.22). At 5 years, 15 patients with moderate PH died ( 68.18% compared with 20.35 in the group without PH). Comparing the group with severe PH with the group with normal pulmonary pressure the results showed a reduced survival rate in those with severe pulmonary hypertension ( p = 0.139, HR 2.48, 95% CI 0.74-8.27). At 5 years, 3 patients with severe PH died (42.85% compared with 20.35 in the group without PH).

Conclusion

The presence of PH in patients with degenerative aortic stenosis has a negative impact on survival, highly statistically significant (p <0.001, HR 1.03, 95% CI, 1.02-1.04). Given these findings, perhaps an increased attention should be paid to the treatment of the patients with PH compared to those without PH.
P1812 The effect of pre-procedural significant mitral regurgitation upon mortality after transcatheter aortic valve implantation
Authors: Soulaidopoulos S , Drakopoulou M , Oikonomou G , Stathogiannis K , Toskas P , Xanthopoulou M , Toutouzas K , Tousoulis D
Published: January 2020

Background

The presence of concomitant mitral regurgitation (MR) is a common issue in patients with severe aortic stenosis and negatively affects patient outcome. Available data regarding MR reduction due to aortic gradient reduction and left ventricular reverse remodeling after transcatheter aortic valve implantation (TAVI) are contradictory.

Purpose

To investigate the prognostic impact of both pre- and post-procedural MR in patients undergoing TAVI.

Methods

Patients with severe and symptomatic aortic stenosis stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. Patients were stratified into two groups according to MR severity : ≤ grade 1 were defined as non-significant and ≥ grade 2 as significant. Change in MR was determined by comparison between baseline and 30-day echocardiogram. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

263 consecutive patients (136 men, mean age : 80 ± 7.5 years) were included in the analysis. Significant (grade≥2) MR was present in 65 (24,7%) patients, while 198 (75,3%) patients had mild or no ( ≤ grade 1) MR. Comparing the two groups, patients with significant MR had higher systolic pulmonary pressure (51.3 ± 14.6mmHg versus 42.8 ± 11.2mmHg, p < 0.001), lower ejection fraction (47.4 ± 10.8% versus 51.2 ± 8.2%) and were more dyspnoic (New York Heart Association class IV 18.5% vesrus 2.5%, p < 0.001). The primary clinical end point occurred in 63 (24%) patients during a follow-up period of 26.6 ± 26.8 months. Patients with significant pre-procedural MR displayed greater cumulative mortality (40% versus 18.8%, p = 0.001). Perioperative risk assessed by logistic EuroScore, NYHA class and pre-procedural MR were found to significantly associate to cumulative mortality in a univariate analysis. Performing a multivariable analysis demonstrated that preprocedural MR severity could independently predict cumulative mortality [OR 2.38, B = 0.869 (95% CI 1.2 – 4.6, p = 0.01)] (Figure).

Conclusion

Significant MR is not infrequent in patients undergoing TAVI and appears to independently associate with high increased all-cause mortality.

Abstract P1812 Figure.
P1817 The effect of permanent pacemaker implantation following transcatheter aortic valve replacement upon survival
Authors: Oikonomou G , Drakopoulou M , Soulaidopoulos S , Toskas P , Stathogiannis K , Xanthopoulou M , Toutouzas K , Tousoulis D
Published: January 2020

Background

Transcatheter aortic valve replacement (TAVR) is often followed by conduction abnormalities, leading to a permanent pacemaker implantation (PPI). Data regarding the clinical impact of PPI following TAVR is yet to be established.

Purpose

To determine the effect of PPI after TAVR on long-term survival.

Methods : Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. Patients were stratified into two groups according to the need for PPI after TAVR and were followed up postoperatively with clinical and echocardiographic assessment. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results : In total, 276 patients were included (male : 48.9%, mean age : 80 ± 7.5years) in our study . Of these, 107 (38.8%) underwent PPI simultaneously or shortly after TAVR. The median follow-up period was 26.6 [min. 0, max 116] months. In this period, all-cause mortality showed no significant difference between patients with and those without PPI after TAVR (log-rank p = 0.862). Subgroup analysis also showed no difference in survival between patients with low ejection fraction (<50%) and those with preserved (≥50%) receiving a permanent pacemaker after TAVR (log-rank p = 0.360). Including factors that were found to associate to PPI in univariate analysis (pre TAVR - ejection fraction, pulmonary artery systolic pressure and New York Heart Association functional class) in a multivariate model, pre TAVR pulmonary artery systolic pressure was found to be an independent predictor of peri-procedural PPI [Exp(B) : 0.974, 95% Confidence Interval : 0.953- 0.995, B= - 0.027, p= 0.015].

Conclusion : PPI following TAVR was not associated with survival at 26 months of follow-up, independently from the pre TAVR ejection fraction.

Abstract P1817 Figure.
P257 Multiple clinical manifestations of catecholamine secreting paraganglioma
Authors: Garibaldi S , Suma S , Coli S , Buratti S , Gaibazzi N
Published: January 2020

A 37 years old woman was referred to our hospital due to the onset since the previous day of vertigo associated with nausea and headache.

Her previous history revealed an hospitalization ten years before for Tako Tsubo Cardiomyopathy, during which the diagnosis of left temporo-jugular catecholamine secreting paraganglioma was made.

Subsequently, there were several hospitalizations for multiple cardiac manifestations, such as acute coronary syndrome during hypertensive crisis, acute pulmonary oedema, one relapse for TakoTsubo syndrome and then an episode of torsade de pointes (TdP) during hypokalemia and elongated QT.

The surgical removal of the mass was always rejected by the patient, and therefore, only radiotherapy was performed with significant reduction of the tumour dimensions. Moreover, alpha and beta adrenergic blockers were always administrated.

At the admission, she complained neurological symptoms, in particular balance disorder and dysmetria.

Brain Computed tomography (CT) was performed and it showed left posterior cerebellar infarction in late acute clinical phase, without haemorrhage. The patient underwent angiography that excluded cerebral artery dissection but showed acute occlusion of posterior internal cerebral artery. Echocardiogram showed moderate left ventricular hypertrophy with normal global and segmental kinetics, left atrial dilatation; besides, left ventricular apical thrombus was excluded.

Holter ECG monitoring showed very frequent polymorphic ventricular and supraventricular extrasystolic beats.

Urinary metanephrines were markedly increased. In particular urinary normetanephrine was up to 9 times the upper limit of normality (4874 ug/L, normal range 162-527 ug/24 h).

Since the surgical intervention was always refused, this case is a rare documentation of the several different cardiovascular clinical manifestation due to catecholamine secretion in a single patient. Paraganglioma could be a catecholamine secreting tumour that arises from cromaffin tissue of the sympathetic nervous system.

Clinical manifestations of paraganglioma are extremely variable leading to its designation as "great mimic". Adrenal tumours are associated with several cardiovascular diseases including LV hypertrophy, myocardial infarction, cardiac arrhythmias, heart failure and Tako Tsubo cardiomyopathy. Cerebral accident is a rare manifestation of adrenergic crisis with several possible aetiologies such as vasospasm or cardioembolic events. In our clinical case, considering the type and localization of the cerebral ischemic injury, the stroke is likely to have a cardioembolic etiology. Apical left ventricular trombus and PFO were excluded.

Therefore, in view of left atrial enlargement and the frequent supraventricular ectopy, even in the absence of documented arrhythmia, an undiagnosed episode of catecholamines induced atrial fibrillation was suspected, with subsequent cardioembolic event.

Abstract P257 Figure.
P638 Short term reverse remodeling and exercise capacity improvement in a patient with valvular heart failure treated with Sacubitril Valsartan
Authors: Mapelli M , Mantegazza V , Volpato V , Sassi V , De Martino F , Salvioni E , Mattavelli I , Fusini L , Vignati C , Paolillo S , Corrieri N , Alimento M , Magini A , Pepi M , Agostoni P
Published: January 2020

Background

Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) recommended in the guidelines to reduce morbidity and mortality in patients with symptomatic heart failure (HF) with reduced ejection fraction (HFrEF). Although the recent widespread use of the drug, data on left ventricle (LV) reverse remodeling and improvement in functional capacity (FC) under treatment are still lacking.

Case presentation

A 73 years old man with a known HFrEF was admitted to the hospital for clinical review due to progressive worsening dyspnea in the last 6 months (NYHA class III) with high NTproBNP values. Echocardiography showed dilated LV (EDVi/ESVi 137/98 ml/m2) with severe reduction in ejection fraction (EF), moderate/severe aortic incompetence, moderate functional mitral regurgitation. A maximal, ramp-protocol, cardiopulmonary exercise test (CPET) showed a moderate reduction in FC with signs of cardiogenic limitation. He was started on Sacubitril/Valsartan 24/26mg b.i.d. with progressive up-titration of the dose until a maximum dose of 97/103mg b.i.d. and without any other change in the therapy. ARNI was well tolerated without hypotension, worsening renal function or hyperkaliemia. After 3 months the echocardiography showed a reduction in LV volumes (EDVi/ESVi 112/72 ml/m2) with mild improvement in EF (from 28% to 34%) and increased FC, leading to a 56% reduction in estimated HF mortality at 2 years assessed through MECKI Score (See tab. 1 and Fig. 1). NTproBNP value was also reduced compared to baseline.

Conclusion

We present a case of a short term improvement in LV and atrium volumes and FC after 3 months of treatment with Sacubitril/valsartan in a patient with HFrEF. More studies are needed to assess LV volumes and CPET values response to ARNI.

Tab.1 Basaline 3 months Δ NYHA Class II III - MECKI Score (%) 5.12 2.23 -56-4% Peak VO2 /% of predicted) 60 72 +20% Maximal Work (W) 68 83 +22.1% Mitral regurgitation ++ + - eGFR (ml/min/1,73m2) 64 65 +1.6% Potassium (mmol/L) 4.26 4.20 -1.4% Aortic regurgitation +++ ++ - Clinical changes after the 3 months follow-up

Abstract P638 Figure. Fig. 1
P973 Predictive value of galectin-3 for cardiac remodelling in patients with acute heart failure
Authors: Lala I R , Darabantiu D A , Lungeanu D , Pilat L , Puschita M
Published: January 2020

Background and objectives

Heart failure is responsible for high mortality rates. Galectin-3 has been suggested as a potential heart failure development and progression mediator. This study aimed to show the relationship between galectin-3 and time evolution of left ventricular remodelling.

Methods

A total of 69 patients hospitalized with primary diagnosis of acute heart failure were enrolled and followed up for 6 months. For each, serum galectin-3 and echocardiographic parameters were measured at baseline and after 6 months.

Results

Mantel-Haenszel test showed highly significant association between pathological evolution of left ventricular end-diastolic diameter, left ventricular end-diastolic volume, relative wall thickness and increased or increasing galectin-3 levels over time (p < 0.001). High baseline galectin-3 levels (>16.5ng/ml) were associated with lower transmitral E peak velocity (68.59 ± 20.5; p = 0.021). Increased baseline galectin-3 levels (>16.5ng/ml) were associated with systolic dysfunction expressed by lower rates of dp/dt ratio (p = 0.018) and raised systolic pulmonary artery pressures (p = 0.046). There was a association between increased baseline galectin-3 levels and type I diastolic dysfunction (E/A < 1, p = 0.042) and this association tended to remain the same after 6 months.

Conclusions

Increased galectin-3 levels contribute to left ventricular evolutionary remodelling by its association with left ventricular chamber volume and diameter changes over time. Its levels also correlated with both systolic and diastolic dysfunction parameters.
P1488 Anomalous origin of left coronary artery from right pulmonary artery in association with scimitar syndrome
Authors: Aly S , Lizano Santamaria R , Yoo S J
Published: January 2020

Clinical Presentation

A full-term neonate was referred to our institution because of respiratory distress. CXR was significant for right lung hypoplasia and mild cardiomegaly. ECG showed normal sinus rhythm, right atrial enlargement, and right ventricular hypertrophy with no signs of ischemia.

Imaging Findings

The initial echocardiogram demonstrated PAPVD with the right upper pulmonary vein draining into IVC/RA junction with flow acceleration (mean gradient= 7 mmHg), moderate ASD, small muscular VSD with left-right shunting, moderate PDA with bidirectional shunting. Forward flow was seen in the proximal part of left main coronary artery (LMCA). RV systolic pressure was supra-systemic with a qualitatively moderately reduced RV systolic function.

The patient was taken to the catheterization lab where MPA angiography revealed an antegrade flow from the RPA into LMCA supplying both the anterior descending and the circumflex arteries. A selective injection within the scimitar vein showed drainage of the right lung into a vertical vein connecting with stenosis to IVC.

A follow up echocardiogram to re-examine the coronary origin revealed an anomalous origin of LMCA from proximal RPA; 3 mm distal to branch pulmonary artery bifurcation with mainly antegrade low velocity flow into LMCA and LAD. (Image 1)

Role of Imaging in Patient Care

- Imaging of the coronary origin in patients with ALCAPA can be challenging especially if the LMCA originates from RPA. Also, the presence of pulmonary hypertension might contribute to maintain coronary perfusion and lead to misinterpretation of the antegrade flow in LMCA and its branches.

- In certain situations, cardiac catheterization is essential to make the diagnosis of ALCAPA which prevented a potentially catastrophic outcome. Catheter intervention with a series of balloon dilations of the stenotic scimitar vein was successful in relieving the stenosis.

Summary/Discussion Points:

- Extensive review of the available literature revealed only three cases of Scimitar syndrome associated with ALCAPA. In all of these cases, the LMCA originated from the posterior sinus of MPA. Our case is the first to report ALCAPA from RPA in association with Scimitar syndrome. This presentation might have led to the initial misinterpretation of the echocardiography images.

- The presence of pulmonary hypertension in our patient maintained an adequate antegrade flow across the LMCA preventing significant coronary steal and signs of myocardial ischemia.

- The report highlights the challenges in making the diagnosis of ALCAPA with echocardiograms. Moreover, we discuss the role of cross-sectional and invasive imaging to rule out potential coronary arteries anomalies in patients with Scimitar syndrome, as this a rare although a very significant association that may have important implications in their outcomes.

Abstract P1488 Figure. ALCAPA origin from RPA
P277 RV remodeling by echo parameters in endurance and strength sport training
Authors: Moshkani Farahani M , Shirdel M
Published: January 2020

Introduction

With regular and long-term exercises, the heart undergoes changes that are called the adaptation of the heart in response to exercise or physiological changes, which contrasts with the pathological changes caused by hypertension and aortic valve stenosis. However, the exact effects of exercise on the structure and function of the heart depend on the type, intensity and duration of exercise, the amount of physical fitness, inheritance, and gender.

Materials and Methods

In this prospective clinical trial study, 40 subjects, including 20 in the endurance exercise group and 20 in the exercise group, were evaluated. Echocardiography was performed for all of these subjects before and after the exercises that was performed professionally for 8 weeks under the supervision of the trainer and the changes were recorded. The data were analyzed statistically by SPSS20 software. A significant level of 0.05 was considered.

Results

The mean ± standard deviation of the age was 20/80 ± 1/42 years. Significant decrease in mean RVSM was observed only in the strength group (P = 0.008). There was no significant difference in the endurance group . There was no significant difference between the two groups before the test in the mean TAPSE (P = 0.46). The mean of TAPSE in the endurance group was 0.22 ± 1.99 and in the strength group was 0.31 ± 1.95. There was no significant difference between the two groups (P 0.46). There was no significant difference between the two groups before the test in the mean E / e (P = 0.51). The mean E / e "in the endurance group was 0.47 ± 4.75 and in the strength group was 0.54 ± 5.50, and there was a significant difference between the two groups (P <0.001). The mean SWDT in the endurance group was 0.12 ± 0.95 and in the strength group was 0.11 ± 1.06, and there was a significant difference between the two groups (P = 0.002). There was a significant increase in mean SWDT in the strength group after the test (P <0.001) .There was a significant increase in mean PAP in the strength group (P = 0.007) .

There was a significant increase in mean LV mass index in the strength group (P <0.001),with no significant difference between the two groups in mean FAC.

Conclusion

It seems that any kind of strength and endurance exercise affects the performance status, however, strength exercises have more effects which causes RV dysfunction. All indexes measured changed within normal level except for PAP that had abnormal changes after endurance exercise .
P278 Does recanalization of chronic total occlusion reflect on myocardial function?
Authors: Petrovic O , Juricic S , Trifunovic-Zamaklar D , Paunovic I , Rakocevic I , Gavrilovic N , Jovanovic I , Boskovic N , Aleksandric S , Ivanovic B , Djordjevic-Dikic A , Beleslin B , Vukcevic V , Stankovic G , Stojkovic S
Published: January 2020

Background

Percutaneous coronary intervention for chronic total occlusion (PCI CTO) is still high risk procedure and it is doubtful will it become standard of care. There is evidence that it can reduce angina but even silent ischemia represent ischemic burden that ultimately lead to left ventricle remodeling and electrical instability.

Purpose

Our aim was to access effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) on myocardial function.

Methods

We compared two groups of pts. First patients with percutaneous coronary intervention of chronic total occlusion with optimal medical therapy and second group - patients with only optimal medical therapy (control group). Echocardiographic exam was performed before randomization and after 6 months of follow-up. Doppler intervals- isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT) and ejection time (ET) were measured. MPI (Myocardial performance index) is equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral wave (E) was divided by average peak early diastolic annular velocity (e"). Peak longitudinal strain was assessed in 17 left ventricular segments. Time intervals from start Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time intervals from 17 segments, reflecting myocardial contraction heterogeneity.

Results

A total of 94 age matched CTO patients (48 in PCI + OMT group and 46 in OMT) were analyzed. Changes in ejection fraction (EF), diastolic function represented by E/e", global cardiac function represented by MPI, global longitudinal strain (GLS) and myocardial dispersion changes were compared between groups. At follow up between groups in there was no significant change in ejection fraction (EF), diastolic function, GLS and mechanical dispersion, but there was improvement in MPI.

Conclusion

Myocardial performance index is sensitive marker which can detect subtle improvement in global myocardial function after recanalization of chronic total occlusion..

Variable PCI + OMT (n = 46) OMT (n = 48) ΔOMT vs. ΔPCI + OMT p value baseline At 6month follow up P value baseline At 6month follow up P value EF (%) 55.69 ± 8.56 54.83 ± 8.44 0.10 50.22 ± 11.71 51.42 ± 10.45 0.06 0.71 MPI 0.676 ± 0.99 0.632 ± 0.96 <0.01* 0.593 ± 0.14 0.604 ± 0.12 0.22 <0.01* E/e" 13.10 ± 6.90 12.05 ± 5,08 <0.05* 14,12 ± 5.70 13.02 ± 5.62 <0.05* 0.23 GLS (%) -14,38 ± 3,38 -15,22 ± 3,68 <0.05* -13.33 ± 3.43 -13.29 ± 3.42 0.87 0.07 Mechanical dispersion (ms) 63.89 ± 26.22 57.35 ± 27.33 <0.01* 53.30 ± 21.68 50.00 ± 22.40 0.05 0.06 Δ- percentage changes between baseline and at 6 month follow up
P279 Subclinical left ventricular dysfunction in patients with insulin resistence and hypovitaminosis D
Authors: Stevanovic A , Dekleva M , Ilic Pasquali N
Published: January 2020

Introduction

Patients with subclinical left ventricular diastolic and systolic dysfunction are at risc of future cardiac events.

Insulin resistance (IR) has been reported to be a strong risk factor for cardiovascular disease (CVD). Hypovitaminosis D is associated with insulin resistance and beta cell dysfunction and vitamin D deficiency is also associated with increased risk of CVD, including hypertension, heart failure, and ischemic heart disease.

Aim

The aim has been to explore association of IR and vitamin D deficiency with subclinical left ventricular disfunction.

Method

The study consisted of 79 patients divided into two groups according IR, evaluated at baseline by the homeostasis model assessment method (HOMA-IR). v The HOMA1-IR index was calculated by the formula: HOMA1-IR = fasting plasma insulin (µU/ml) x fasting plasma glucose (mmol/L). The HOMA2-IR index was obtained by the program HOMA Calculator (free) download Windows version.

The cut-off values for IR were: HOMA1-IR > 2.7 and HOMA2-IR > 1.8; group of 41 patients, and group od 38 patients without of IR.

Parameters of left atrial and ventricular geometry were estimated by echocardiography. Tissue Doppler velocities were measured from medial and lateral annulus (e, a, s) including isovolumic contraction velocity (IVCv) and E/e Global longitudinal strain (GLS) was derived from two-dimensional speckle-tracking.

Results

In IR group level of 25-OH-D was deficient in 25 (61.2%), insufficient in 10 (25%) and sufficient in 6 (13.8%) patients and significantly lower compared to control group (46.8 ± 25.5 vs 61.5 ± 33.8, p < 0.001).

Importantly, 25-OH-D was associated with global longitudinal strain (r= −0.21, <0.05). Values of GLS (-19.9 ± 2.8 vs -26.6 ± 2.9; p < 0.001) and IVCv (0.07 ± 0.02m/s vs 0.09 ± 0.03m/s; p < 0.05) were significantly lower and E/e (9.11 ± 2.24 vs 7.18 ± 1.65; p < 0.001) significantly higher in group of patients with IR.

Conclusion

The results showed that insulin resistence is asociated with subclinical LV diastolic and systolic dysfunction. Level of 25-OH-D was significantly lower in patients with insulin resistence suggests that vitamin D deficiency may have a certain contribution to the development of myocardial dysfunction in these patients.

Fortunately insulin resistance and vitamin D deficiency are a modifiable risk factors; the reduction of insulin resistance and increase the level of 25-OH-D may reduce CV risk in this group of patients.
P309 The use of echocardiographic parameters to predict clinical outcomes in AL-amyloidosis cardiomyopathy
Authors: Geenty P , Sivapathan S , Deshmukh T , Brown P , Boyd A , Kwok F , Richards D , Altman M , Stewart G , Thomas L
Published: January 2020

Background

AL-amyloidosis has a rapid clinical progression, with cardiac involvement associated with a particularly poor prognosis. Cardiac amyloidosis is diagnosed by either invasive biopsy or conventional echocardiographic parameters such as increased wall thickness, in the absence of other causes. More recently, novel parameters including 2D longitudinal strain have demonstrated diagnostic utility in a range of infiltrative cardiomyopathies including cardiac amyloidosis.

Aim/Method: We sought to evaluate traditional and novel echocardiographic parameters in their ability to predict adverse outcomes in a cohort of AL-amyloid patients. 80 patients who had transthoracic echocardiograms at a single centre were included. Comprehensive echocardiographic assessment was performed, including left ventricular ejection fraction (LVEF), LV Global Longitudinal Strain (GLS), LV mass (indexed to BSA). The primary endpoint was a composite of of major adverse cardiac events (MACE) and all-cause mortality, that was assessed by interrogation of the medical records on a specified censor date.

Results

At a mean follow-up (time from echo to censor date) of 5.4 ± 2.6years, 38/80 (47.5%) of patients experienced the primary endpoint of MACE or death, of which 25/80 (31%) were deaths. LVEF (59 ± 5.6%vs56 ± 6.4%, p = 0.04), GLS (17.4 ± 3.9%vs14.8 ± 4.9%, p = 0.01) basal longitudinal strain (12.3 ± 3.2%vs9.6 ± 3.9%, p = 0.002), indexed LV mass (107 ± 36g/m2vs130 ± 34g/m2, p = 0.06) and E/E’ (13.7 ± 4.9vs20.6 ± 9.6, p < 0.001) were all significantly different between patients who experienced the primary endpoint and those that didn’t. The strongest predictors of outcome were E/E’ (AUC 0.74), LV mass (AUC 0.73) and the ratio GLS:LV mass (AUC 0.73). An E/E’ of 15 had a sensitivity of 71% and specificity of 69%, while an indexed LV mass of 108 had a sensitivity and specificity of 74% and 67% respectively. GLS to LV mass as a cutoff of 0.16 had a sensitivity and specificity of 70% and 69% respectively.

Conclusion

In a cohort of 80 patients with AL-amyloid cardiomyopathy, almost half (47.5%) reached the primary composite endpoint. Diastolic dysfunction as expressed as E/E’, and LV mass were the most powerful predictors of outcome, while global longitudinal strain and LV basal strain were also reduced, and showed superiority over LV ejection fraction in predicting prognosis.
P316 A feasible and accurate method for the assessment of early ventricular dysfunction in children with kawasaki disease: result from the MyoWoRK (myocardial work related to kawasaki disease) study
Authors: Borrelli N S , Di Salvo G , Sabatino J , Avesani M , Filippini E , Karagodova E , Spada M , Josen M , Fraisse A
Published: January 2020

Funding Acknowledgements

EACVI Training Grant

Introduction

Kawasaki disease (KD) is an acute vasculitis of unknown etiology. It is associated with high morbidity and mortality due to the development of coronary artery aneurysms and myocardial dysfunction.

Purpose

The aim of this study was to evaluate sensitivity and specificity of left ventricular (LV) pressure–strain loop (PSL) area, which reflects regional myocardial work and metabolic demand, in predicting subtle myocardial abnormalities in KD patients with coronaries aneurisms.

Methods

A total of 88 patients (59 male, age 8.95 ± 4.95 years) were included in our study. Among the children admitted in our institution with a diagnosis of KD during the study time frame, 42 patients (KDg) (29 male) with coronary artery dilatation (Z-score >2.5) were selected. These cases were compared with 46 (30 male) age-matched controls (CTRg). Classical echocardiographic parameters of LV systolic function were normal in both groups, while global longitudinal strain (GLS) was decreased in 6 KD patients. Global work index (GWI) was calculated as the area of the LV PSL. From GWI, it was estimated also Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE). We also made a subgroup analysis between KD patients with normal GLS (> -19 %) and control patients.

Results

Despite normal LV systolic function by routine echocardiography, compared to controls, KD patients had lower GWI (1448 ± 382 mmHg% in KDg vs 1751 ± 263] mmHg% in CTRg, p = 0.00003), GCW (1904 ± 390 mmHg% in KDg vs 2174 ± 292 mmHg% in CTRg, p= 0.0004) and GWE (94 ± 5 % in KDg vs 96 ± 2 % in CTRg, p= 0.01). There was not significant difference in GWW between the KDg and CTRg. When KD patients with normal GLS were analysed separately, they preserved a significant difference in GWI, GCW and GWE in comparison with controls (GWI: 1490 ± 347 mmHg% in KDg vs 1751 ± 263 mmHg% in CTRg, p = 0.0002; GCW: 1972 ± 321 mmHg% in KDg vs 2174 ± 292 mmHg% in CTRg, p = 0.004; GWE: 95 ± 3 in KDg vs 96 ± 2 % in CTRg, p= 0.04). No association was found between GWI, GCW, GWW, GWE and number or dimension of the involved aneurysmatic coronaries.

Conclusions

The estimation of myocardial work by PSL is a novel tool for the evaluation of patients with KD. GWI, GCW and GWE were significantly reduced in KD patients with dilated coronaries. In KD patients with normal GLS, estimation of GWI, GCW and GWE may be a sensitive indicator of myocardial dysfunction and an adjuvant criterion to avoid delayed diagnosis of KD.

Abstract P316 Figure. Myocardial work in KD and CTR.