bluuebunny/crossref_metadata_2025 huggingface dataset:
Layer-specific strain and the degree of left ventricular thickness in patients with hypertrophic cardiomyopathy
Authors: Tsugu T , Nagatomo Y , Dulgheru R , Marchetta S , Postolache A , Tridetti J , Nguyen M.L , Piette C , Lancellotti P
Published: November 2020

Background

Left ventricular (LV) wall thickness is an important parameter for the diagnosis of hypertrophic cardiomyopathy (HCM) and is also associated with long-term clinical outcome in HCM patients. However, conventional tools have failed to analyze the mechanisms of structural and functional abnormalities that occur at the cellular level in hypertrophied myocardial tissue. Recently, technological progression of 2D-speckle tracking echocardiography (2D-STE) has enabled the estimation of layer-specific strain (LSS), such as epicardial, mid-myocardial, and endocardial longitudinal strain, respectively. LSS may have the potential to elucidate the detailed mechanisms of myocardial dysfunction.

Purpose

The aim of this study was (i) to clarify the detailed mechanisms of structural and functional abnormalities of myocardial tissue in HCM using LSS (ii) to investigate the diagnostic accuracy of LSS for HCM.

Methods

Forty-one patients with HCM and preserved LV ejection fraction (LVEF) (66% male, 52±18 years, LVEF 62.9±3.7%) and 41 controls matched for age and sex (66% male, 52±20 years, LVEF 63.5±8.2%) underwent 2D-STE (GE-Healthcare, Vivid-E9). Quantitative strain values of epicardial, mid-myocardial, and endocardial layers were measured.

Results

LV wall thickness including interventricular septum thickness (HCM vs. Controls; 18.9±5.0 vs. 9.1±1.8, p<0.001), posterior wall thickness (11.5±2.5 vs. 8.8±1.9, p<0.001), and maximum wall thickness (20.1±4.3 vs. 9.4±0.4, p<0.001) were significantly lower in HCM than in Controls. Absolute values of LSS for all layers were lower in HCM than in Controls (HCM vs. Controls; epicardial; −13.1±3.3 vs. −19.5±1.6, p<0.001; mid-myocardial; −15.8±3.3 vs. −21.4±1.7, p<0.001; endocardial; −18.9±3.9 vs. −23.6±1.9, p<0.001). End/Epi ratio was higher in HCM than in Controls (HCM vs. Controls; 1.5±0.2 vs. 1.2±0.0, p<0.001). Next, we investigated the echocardiographic parameters that correlated with LV maximal wall thickness (MWT). End/Epi ratio was an independent predictor of LV MWT (β=0.96, p<0.001). Receiver operating characteristic analysis revealed that a higher End/Epi ratio (≥1.3) was the strongest predictor of diagnostic criteria for HCM (LV wall thickness ≥15 mm) (area under the curve 0.99, p<0.001, sensitivity 98%, specificity 97%).

Conclusions

In HCM patients with preserved LVEF, (i) LSS was lower and End/Epi ratio was higher than in controls. (ii) End/Epi ratio (≥1.3) was the strongest predictor of abnormal wall thickness of HCM. The mechanism of higher End/Epi ratio in HCM might be attributable to the more common myofibrillar disarray in mid- and epicardial layers. Variations of LSS represented by End/Epi ratio might have the potential to accurately detect HCM and to elucidate the pathophysiology of impaired LV wall motion at cellular level in HCM.

Funding Acknowledgement

Type of funding source: None
Prognostic value of reduced heart rate reserve during exercise stress-echocardiography in hypertrophic cardiomyopathy
Authors: Ciampi Q , Olivotto I , D'Alfonso M.A , Tassetti L , Milazzo A , Peteiro J , Monserrat L , Palinkas A , Palinkas E , Tesic M , Djordjevic-Dikic A , Losi M.A , Canciello G , Re F , Picano E
Published: November 2020

Background

Heart rate reserve (HRR) during exercise evaluates chronotropic incompetence and is a prognostically important marker of cardiac autonomic dysfunction, additive to regional wall motion abnormalities (RWMA) in patients with coronary artery disease.

Objectives

To assess determinants and prognostic value of HRR in patients with hypertrophic cardiomyopathy (HCM).

Methods

From 1998 to 2019, we enrolled 774 HCM patients (age = 48.8±15.9 years, 410 men) with exercise stress echocardiography (ESE) in 10 certified centres of the international stress echo network. During ESE we assessed: left ventricular outflow tract obstruction (LVOTO, significant when >50 mmHg); RWMA; HRR (peak/ rest heart rate), 344 in beta-blockers therapy (44.4%). Patients were followed for a median 49 months (IQ range, 25–78 months). The study end-point was all-cause mortality.

Results

During ESE, we observed stress-induced RWMA in 42 (5.4%) and LVOTO in 248 (33%); HRR was 1.92.±0.41. There were no difference in patients with normal and abnormal HRR with and without beta-blockers therapy (147, 41.1% vs 211, 58.9%, p=0.079). During follow-up, 43 deaths occurred. Beta blockers therapy in univariate analysis did not have prognostic role (HR 1.105, 95% CI 0.602–2.028, p=0.768). The lowest HRR quartile (≤1.62) had a 10-fold higher 6-year death rate (10.9%) than the highest quartile (>2.16, 1.04%): see figure. At multivariable analysis, lowest HRR quartile (HR 2.074, 95% CI 1.082–6.773, p=0.034), age (HR 1.045, 95% CI 1.014–1.077, p=0.004), maximal wall thickness (HR 1.137, 95% CI 1.054–1.226, p=0.001), stress-induced RWMA s(HR 4.289, 95% CI 1.733–10.615, p=0.002) and ≥ moderate mitral regurgitation at rest (HR 3.127, 95% CI 1.507–6.488, p=0.002) predicted death.

Conclusions

A blunted HRR during ESE predicts adverse outcome independent of inducible RWMA in HCM patients. Autonomic dysfunction deserves consideration as a potential therapeutic target in this disease.

Figure 1

Funding Acknowledgement

Type of funding source: None
Hyperventilation echocardiography in INOCA: the HEROIC study
Authors: Boskovic N , Djordjevic-Dikic A , Dedic S , Giga V , Nedeljkovic I , Tesic M , Jovanovic I , Aleksandric S , Beleslin B , Picano E
Published: November 2020

Background

Patients with ischemia and no obstructive coronary artery disease (INOCA) are a heterogeneous group and an unmet diagnostic challenge. Noninvasive Doppler is a feasible tool to assess coronary flow velocity (CFV) in left anterior descending coronary artery (LAD) during stress echocardiography (SE).

Aim

To assess CFV response during coronary vasoconstrictor and vasodilator stimuli in INOCA patients.

Methods

In a prospective single center study, we enrolled 16 INOCA patients (age 60±12 years, 15 females) with previously normal angiograms. All underwent SE testing with hyperventilation (HYP, respiratory rate of 30 per min for 5') followed by supine bicycle exercise (HYP+EXE); and adenosine CFV evaluation (ADO, 0.84 mg/kg in 1 min) on the other day. The ratio of peak/rest changes of CFV during HYP in LAD was taken as an index of vasoconstriction, and CFV reserve was evaluated after EXE. An abnormal response to HYP was a CFV ratio <1.0 (vasoconstrictor response). An abnormal response to ADO was a CFV reserve <2.0 (blunted vasodilatory response). CFVR at peak HYP+ EXE was an indicator of endothelial dependent vasodilatation.

Results

The double product increased during HYP, in comparison to rest (13 337 vs 9858, p<0.001), and further increase with EXE (21 118 vs HYP, p<0.001). Chest pain or dyspnea were present in 2/16 pts during HYP, and in 5/16 patients during HYP+EXE (12.5% vs 31.25%, p=0.083). ST segment depression (≥1mm) was present in 1/16 patients during HYP, and 3/16 during HYP+EXE. Two patients showed regional wall motion abnormalities with HYP+EXE. CFVR response was blunted in 9/16 patients during HYP+EXE, and abnormal for vasoconstriction during HYP in 6. Vasodilation during ADO was preserved in all patients. There was significant difference between CFVR response during HYP+EXE and ADO (1.9±0.5 vs 2.4±0.4 respectively, p=0.039), and between CFVR HYP and ADO (1.2±0.3 vs 2.4±0.4, p<0.001).

Conclusion

In INOCA patients, HYP+EXE is a more powerful ischemic stress than HYP alone and unmasks abnormalities in regional wall motion and/or CFV response in over one- half of patients, likely unmasking the underlying abnormal coronary vasomotor response of large epicardial and/ or small coronary vessels. INOCA patients show profound heterogeneity of coronary vasomotor responses which can be detected with a combined vasodilator - vasoconstrictor SE approach with CFV assessment. The clarification of underlying coronary microcirculatory heterogeneity is the prerequisite for a personalized treatment, and can be easily extracted from CFV-SE. Normal INOCA hearts are all alike, every abnormal heart is abnormal in its own way.

Funding Acknowledgement

Type of funding source: None
The prognostic value of coronary flow reserve of left anterior descending artery in non-diagnostic or inconclusive stress echocardiography tests
Authors: Kotevska Angjushev M , Dedic S , Boskovic N , Giga V , Tesic M , Jovanovic I , Aleksandric S , Beleslin B , Djordjevic Dikic A
Published: November 2020

Background

Relevant number of all stress echocardiography results are non-diagnostic or inconclusive. Such importance cannot be ignored as previous studies have shown that these patients have higher risk for adverse events. Non-invasive transthoracic Doppler derived coronary flow reserve (CFR) of left anterior descending (LAD) artery, as additional test, is an effective tool to predict adverse cardiac events in various clinical settings.

Purpose

The aim of this study was to investigate the value of CFR of LAD in predicting outcome.

Methods

122 patients, (35,8% with previous MI) with nondiagnostic stress echocardiography results (target heart rate not reached, chest pain without ECG and echo changes) and with inconclusive stress echocardiography results (target heart rate reached, chest pain with ECG changes and without echo changes) were referred for transthoracic

Doppler echocardiographic CFR assessment of LAD. CFR was calculated as the ratio between maximal hyperemic and baseline coronary flow velocity. CFR ≤2 was considered abnormal. All patients were followed for major adverse cardiac events (MACE): nonfatal myocardial infarction, hospitalization, revascularization (CABG or PCI) and death.

Results

Measured values of CFR LAD were in the range 1,52- 4,00 (mean: 2,4±0.44). CFR LAD was abnormal in 22 (18%), and preserved in 100 patients (82%). During median follow-up of 23 months (interquartile range 9–35), 14 patients underwent revascularization (2 had CABG, 12 had PCI). There were no myocardial infarctions, hospitalizations or cardiovascular deaths in the follow-up period. Patients with lower CFR values (CFR≤2) had a higher event rate and shorter event free survival time compared to those with CFR>2, event rate (9/22, 40,9% vs 5/98 5,1%; p<0.0001) and event free time (22±3 vs 33±1 months; p<0.0001) by Kaplan Maier analyses, (Log Rank 24.42; p<0.001).

Conclusions

Preserved CFR of LAD (>2.0) predicts excellent survival in patients with non-diagnostic and inconclusive stress echocardiography.

Funding Acknowledgement

Type of funding source: None
Prognostic relevance of exercise pulmonary hypertension for new-onset atrial fibrillation in primary mitral regurgitation
Authors: Teramoto K , Izumo M , Kuwata S , Kamijima R , Suzuki T , Nishikawa H , Mizukoshi K , Takai M , Ohara H , Harada T , Akashi Y.J
Published: November 2020

Background/Introduction

New-onset of atrial fibrillation (AF) portends poor prognosis in patients with primary mitral regurgitation (MR). However less is known about prognostic indicator for new-onset AF.

Purpose

The purpose of this study was to identify the prognostic relevance of exercise pulmonary hypertension for the new-onset AF in patients with primary MR.

Methods

Total of 114 consecutive patients with primary MR who underwent symptom-limited exercise echocardiography using supine-cycle ergometer were followed for new-onset AF over mean follow-up time of 3.6±2.6 years. Those with prevalent AF and pulmonary hypertension (estimated systolic pulmonary artery pressure ≥50mmHg) prior to exercise echocardiography were excluded from our analysis. We defined exercise-induced pulmonary hypertension (ExPHT) as those with peak estimated systolic pulmonary artery pressure (SPAP) ≥60mmHg or delta SPAP defined as differences between rest and peak SPAP ≥20mmHg.

Results

The mean age was 61±15 years old and 70 (61%) were male. Of those, 8 (7.8%) had mild MR, 32 (31.1%) had moderate MR, and 63 (61.2%) had severe MR. 60 (52.2%) patients had ExPHT. A total of 27 cases of new-onset AF were found during follow-up where the ExPHT group had higher prevalence of new-onset AF than the non-ExPHT group (35% vs. 11%, p=0.002). Those with ExPHT had significantly stronger association with shorter event-free survival time of new-onset AF (log-rank p<0.001, Figure). When adjusted for age, sex, body surface area, the American Society of Echocardiography MR grade, left atrial dimension, peak systolic blood pressure and heart rate, the multivariable Cox regression analysis showed that those with ExPHT had a hazard risk of 3.1 ([95% CI 1.1–9.1], p=0.039) for new-onset of AF.

Conclusions

Exercise-induced pulmonary hypertension predicted incident of new-onset AF in those with primary MR. Exercise echocardiography is expected to play an important role in decision making with regards to the optimal timing for surgical intervention in primary MR.

Figure 1

Funding Acknowledgement

Type of funding source: None
The value of 3D-speckle tracking longitudinal strain for the assessment of left ventricular function recovery in ischemic heart failure patients undergoing surgical remodeling:the RECOVERY-IN study
Authors: Castelvecchio S , Frigelli M , Sturla F , Citarella M , Pappalardo O.A , Milani V , Guastafierro F , Menicanti L , Votta E
Published: November 2020

Background

Three-dimensional (3D) speckle-tracking echocardiography is largely employed to evaluate left ventricle (LV) morphology and function.

Purpose

To investigate LV function before and after surgical ventricular reconstruction (SVR) through the analysis of global (GLS) and segmental (SLS) longitudinal strain, and the derived mechanical dispersion (MD).

Methods

Twenty patients eligible for SVR, with previous LV remodelling and ischemic heart failure (HF), received 3D echocardiographic evaluation before SVR and at 6-months follow-up; 15 normal controls, matched by age and BSA, were enrolled. Standard off-line GLS analysis was performed with 4D LV-ANALYSIS©; advanced segmental analysis was accomplished automatically through in-house numerical post-processing.

Results

Before SVR, GLS deteriorated compared to normal subjects (−6.7% vs. −19.6%, P<0.0001) as confirmed by SLS at each LV segment basal, mid and apical level (P<0.0001); MD was higher than in controls (P<0.001) and markedly increased from basal to apical LV segment. After SVR, GLS significantly improved from −6.7% to −11.3% (P<0.0001). Analysis of variance showed that SLS recovery was higher in the basal region (7.25%) than in both mid (4.06%, P=0.001) and apical (1.92%, P<0.0001) segments, respectively, with adjustment for baseline values.

Conclusions

After SVR, LV longitudinal strain mostly improves in the basal segments, outlining the role of the remote myocardium in enhancing LV function through an extensive volume reduction; post-surgical MD reduction indicates a more homogeneous myocardial contraction.

Heath map of longitudinal strain (%)

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): IRCCS Policlinico San Donato is a clinical research hospital partially funded by the Italian Ministry of Health.
Model-based analysis of myocardial strain in left bundle branch block patients
Authors: Owashi K.P , Galli E , Hubert A , Donal E , Hernandez A.I , Le Rolle V
Published: November 2020

Background

Although patients with typical left bundle branch block (LBBB) show greater efficacy of cardiac resynchronization therapy (CRT), there is a wide range of responses to CRT with a subset of patients showing little or no improvement. Recently, it has been shown that combination of echo-based parameters of LV dyssynchrony and QRS duration helped to improve the prediction of the response to CRT. However, the interpretation of features extracted from echocardiography could be difficult due the complexity of mechanisms involved in cardiac contraction. Computational modelling could help to improve the interpretation of myocardial strains in LBBB patients before implantation.

Purpose

Purpose of the study is to propose a patient-specific model-based approach in order to assist the analysis of myocardial strains and to improve the interpretability of echo-based parameters.

Methods

The proposed model of the cardiovascular system integrates four main sub-models: 1) cardiac electrical system, 2) right and left atrium, 3) multi-segment right and left ventricles and 4) systemic and pulmonary circulations. Patient-specific simulations of myocardial strains were obtained by coupling the computational model and the clinical data to a parameter identification algorithm (Figure 1, upper panel). The proposed approach was evaluated on data obtained from 10 LBBB patients, including ischaemic (n=5) and non-ischaemic (n=5) cardiomyopathy. The localisation of scar was determined by cardiac MRI. Bull's-eye representations of the electrical activation time and contractility levels were analysed.

Results

The comparison between simulated and experimental strains for the 10 subjects reflects a satisfying adaptation of the model to different strain morphologies. The mean errors between real and synthesized signals are equal to 3.72±0.91. The lower panel of Figure 1 presents simulated (black line) and experimental (red line) myocardial strain signals for selected LBBB patients with a lateral ischaemia, anterior ischaemia and non-ischaemia. The bull's-eye representations of electrical activation delay and contractility levels, estimated from the model-based approach, for ischemic and non-ischemic LBBB is included in the figure. Contractility bull's-eye results allow ischaemic and non-ischaemic cases distinction, where low levels of contractility could be associated with damaged tissues.

Conclusion

Identified parameters show significant electrical conduction, mechanical activation delays for the LBBB patient. Hypocontractile myocardial segments were successfully localized from the model-based approach in both ischemic and non-ischemic patients.

Funding Acknowledgement

Type of funding source: None
Effects of aging on coronary flow reserve in patients with no evidence of myocardial perfusion abnormality
Authors: Ramandika E , Kurisu S , Nitta K , Hidaka T , Utsunomiya H , Ishibashi K , Ikenaga H , Fukuda Y , Kihara Y
Published: November 2020

Background

Coronary flow reserve (CFR) reflects the functional capacity of microcirculation to adapt to blood demand during increased cardiac work.

Purpose

We tested the hypothesis that aging had impacts on coronary flow velocities and CFR in patients with no evidence of myocardial perfusion abnormality on single photon emission computed tomography (SPECT).

Methods and results

Seventy-six patients with no evidence of myocardial perfusion abnormality on SPECT undergoing transthoracic Doppler echocardiography were enrolled in this study. Patients were divided into three age groups: 17 patients aged <70 years (Group I), 38 patients aged 70–79 years (Group II), and 21 patients aged ≥80 years (Group III). Compared with Group I, CFR was significantly lower in Group II (P<0.01) and Group III (P<0.01). Multivariate analysis showed that female (P=0.03), cigarette smoking (P=0.004), hemoglobin level (P=0.001) and LV mass index (P=0.03) were determinants for resting coronary flow velocity. On the other hand, age (P=0.008), hemoglobin level (P<0.001) and LV mass index (P=0.04) were determinants for hyperemic coronary flow velocity. Age was only independent determinant for CFR (β=−0.48 P<0.001).

Conclusions

Our data suggested that aging impaired CFR in patients with no evidence of myocardial perfusion abnormality primarily due to the decrease in hyperemic coronary flow velocity.

Comparison of coronary flow reserve amon

Funding Acknowledgement

Type of funding source: None
Incidence and predictors of left atrium thrombus in acute ischemic stroke patients without atrial fibrillation: a single center cohort study
Authors: Cinar T , Hayiroglu M.I , Cicek V , Asal S , Atmaca M.M , Keser N , Orhan A.L
Published: November 2020

Introduction

The present study aimed to determine independent predictors of left atrial thrombus (LAT) in acute ischemic stroke patients without atrial fibrillation (AF) using transesophageal echocardiography (TEE).

Material and methods

In this single center, retrospective cohort study, we enrolled 149 consecutive acute ischemic stroke patients. All of the patients underwent TEE examination to detect LAT within 10 days following admission. Multivariate logistic regression analysis was performed to assess independent predictors of LAT.

Results

Among all cases, 14 patients (9.3%) had a diagnosis of LAT on TEE examination. In a multivariate analysis; a previous diagnosis of cerebrovascular accident, elevated mean platelet volume (MPV), low left ventricle ejection fraction (EF) and a reduced left atrium appendix (LAA) peak emptying velocity were independent predictors of LAT. The area of MPV under the receiver operating characteristic curve analysis was 0.70 (95% CI: 0.57–0.83; p=0.011). With the optimal cut-off value of 9.45, MPV had a sensitivity of 71.4% and a specificity of 63% to predict LAT.

Conclusion

Patients with low ventricle EF and elevated MPV should undergo further TEE examination for the possibility of cardio-embolic source. In addition, this research may provide novel information with respect to the applicability of MPV to predict LAT in acute ischemic stroke patients without AF.

Figure 1

Funding Acknowledgement

Type of funding source: None
Baseline left atrial strain is associated with clinical outcomes following cardiac resynchronization therapy in patients with intermediate electrocardiographic criteria
Authors: Huntjens P , Sugahara M , Soyama Y , Faddis M , Gorcsan J
Published: November 2020

Background

Guidelines favor patient selection by left bundle branch block (LBBB) with QRS width ≥150 ms for cardiac resynchronization therapy (CRT). However, predicting response to CRT patients with QRS width 120 to 149 ms or non-LBBB remains difficult. Speckle tracking left atrial (LA) strain is a novel means to assess cardiac function, however its applications to CRT patients remains unclear.

Purpose

To test the hypothesis that baseline LA strain has prognostic value in CRT patients with intermediate ECG criteria.

Methods

We studied 195 patients with heart failure (HF) who underwent CRT based on routine indications: ejection fraction ≤35% and QRS width ≥120 ms. GLS was assessed using the 3 standard apical views. LA longitudinal strain was based on 12 segments from the 2 and 4-chamber apical view. Peak LA strain, a measure associated with the reservoir function of the LA, was defined as the average of peak longitudinal strain from all segments. The predefined combined clinical endpoint was death, heart transplant or left ventricular assist device (LVAD) over 4 years after CRT.

Results

LA strain was feasible in 162 (83%) of the candidates for CRT: age 64±11 years, 72% male, QRS duration 156±26 ms, 39.5% had LBBB with QRS ≥150ms, 60.5% had intermediate ECG criteria. Median LA strain was 11.0% [1.3% - 36.8%]. High LA peak strain was associated with more favorable event-free survival and Low LA Peak strain was associated with worse clinical outcome following CRT (FIGURE, p<0.001). Patients with intermediate ECG criteria for CRT (non-LBBB or QRS width 120 to 149 ms) and high peak LA strain had similar outcome to those with Class I indications for CRT (LBBB and QRS≥150 ms). Multivariable analysis revealed that LA strain had independent prognostic value (hazard ratio 0.98 per LA strain %, p<0.01) even after adjusted for other clinical, electrophysiological and echocardiographic covariates including QRS morphology and duration, ischemic cardiomyopathy, LVEF and global longitudinal strain.

Conclusions

Baseline peak LA strain had important prognostic value in HF patients who are candidates for CRT. Prognostic value of LA strain was most significant in CRT patients with intermediate ECG criteria (QRS 120 to 149ms or non-LBBB) and has promise for clinical applications.

LA strain and clinical outcome after CRT

Funding Acknowledgement

Type of funding source: None
Unsupervised machine learning generated clusters of left ventricular strain curves identifies patients in risk of heart failure and cardiovascular death following acute myocardial infarction
Authors: Simonsen J.O , Skaarup K.G , Djernaes K , Modin D , Lassen M.C.H , Grove G.L , Pedersen S , Estepar R.S.J , Martinez S.S , Gislason G , Biering-Soernsen T
Published: November 2020

Background

Today myocardial deformation, also known as strain, is assessed by the global longitudinal strain (GLS) which only provides information about the maximal deformation during systole. Hence, a lot of information obtained from different patterns of deformation curves might be undiscovered. Unsupervised Machine leaning (uML) is capable of identifying similar patterns of deformation curves. Identifying different phenotypical patterns from myocardial deformation curves might provide insights into the pathophysiological development of cardiac disease and entail useful prognostic information.

Purpose

To investigate whether uML can group specific patterns of myocardial deformation curves which provide prognostic information on heart failure and/or cardiovascular death (HF/CVD) following ST-segment elevation myocardial infarction (STEMI).

Methods

A total of 319 STEMI patients had an echocardiogram performed at median 2 days after primary percutaneous coronary intervention (pPCI). Speckle tracking echocardiography analysis divided the left ventricle into 18 segments. Standardisation of the cardiac cycle was done using linear interpolation and complete strain data (mean of all segments) as function of time throughout the cardiac cycle was used as input for the uML algorithm. Clusters were identified using a K-means cluster analysis algorithm. Primary endpoint was the composite of heart failure (HF) and/or cardiovascular death (CVD). Median follow-up time was 1423 days (IQR: 91; 1660).

Results

Mean age was 62 years, 75% were male and 130 (41%) suffered incident HF/CVD during follow-up. The uML algorithm grouped patients into three clusters containing 97, 104, and 118 patients respectively. GLS curves of the three clusters are illustrated in the Figure 1. Incidence of HF/CVD increased significantly from cluster 1 through 3 (24% vs. 39% vs. 60%, P<0.001). In multivariable Cox regressions adjusting for the variables in the score risk chart model all three clusters were significantly associated with future HF/CVD (Figure 1). Cluster models provided significant incremental prognostic information when comparing C-statistics (0.64 vs. 0.62, p=0.029)

Conclusion

Unsupervised Machine Learning clusters of left ventricular deformation curves identifies patients in risk of HF/CVD following STEMI treated with pPCI, and provides incremental prognostic information to the score risk chart model.

Figure 1. GLS curves of the three clusters

Funding Acknowledgement

Type of funding source: None
Left ventricular longitudinal strain in professional athletes, a useful tool to detect an athletes hearts?
Authors: Bewarder Y , Kulenthiran S , Schaefer O , Lauder L , Ukena C , Marshall R , Hepp P , Laufs U , Stoebe S , Hagendorff A , Boehm M , Mahfoud F , Ewen S
Published: November 2020

Background

Professional cyclists frequently present with physiological adaptations to endurance exercise with an increase in left ventricular wall thickness and mass. Global longitudinal strain (GLS) is an early and sensitive echocardiographic method to detect left ventricular dysfunction. However, it is unclear whether GLS is able to differentiate between athlete's hearts or different pathological conditions of left ventricular hypertrophy.

Methods

A total of 87 professional athletes (37 professional cyclists, 29 professional soccer players, and 21 professional handball players) were compared to 125 patients with different forms of left ventricular hypertrophy (17 hypertrophic obstructive cardiomyopathy (HOCM), 36 hypertensive heart disease (HHD), 35 severe aortic valve stenosis (AVS); 37 untrained individuals served as controls. Examinations were performed between October 2018 to October 2019. All subjects underwent echocardiographic examination, including GLS.

Results

In all 212 participants/patients included a preserved ejection fraction >50% (mean 61±7%) was detected. Left ventricular mass index (LVMI) in professional cyclists (165.5±37.1 g/m2) was increased when compared to professional soccer players (97.3±12.4 g/m2, p<0.001), professional handball players (92.2±15.8 g/m2, p<0.001) and healthy controls (94.3±20.7 g/m2, p<0.001), as well as to patients with HHD (129.2±30.0 g/m2, p<0.001), or AVS (140.1±35.4 g/m2, p=0.064), but not to patients with HOCM (159.7±39.4 g/m2, p=0.64). Professional cyclists (−21.0±3.5%) achieved higher average GLS values than professional soccer (−18.4 ± %, p=0.004) or handball players (−18.4 ± %, p=0.021), healthy controls (−19.0±3.0%, p=0.008), HOCM (−15.0±6.5%, p<0.001), HHD (−13.8±5.9%, p<0.001), and AVS (−16.0±7.0%, p<0.001) (Figure 1).

Conclusion

In professional cyclists, higher LVMI and average GLS values were detected compared to professional soccer and handball players with lower excessive endurance exercise, as well as untrained healthy controls. Average GLS can help to differentiate between athletes' hearts in professional cyclists compared to pathologic patterns in different diseases characterized by left ventricular hypertrophy with elevated LVMI.

Figure 1

Funding Acknowledgement

Type of funding source: None
The prognostic value of myocardial deformational patterns is reduced in patients with heart failure
Authors: Holm A , Brainin P , Sengeloev M , Joergensen P.G , Bruun N.E , Schou M , Pedersen S , Fritz-Hansen T , Biering-Soerensen T
Published: November 2020

Background

Early systolic lengthening (ESL) and postsystolic shortening are considered highly specific for myocardial ischemia. We aimed to investigate the prognostic potential of both deformational patterns in patients with heart failure (HF) and to determine if a history of ischemic heart disease modified this relationship.

Method

A total of 884 patients with systolic HF (66±12 years, male 73%, mean ejection fraction 28±9%) underwent speckle tracking echocardiography. Of these, 61% suffered from ischemic cardiomyopathy (ICM). Patients were followed for all-cause mortality. We assessed the ESL index: [−100x (peak positive strain/maximal strain)] and the postsystolic index (PSI): [100x (postsystolic strain/maximal strain)]. Both parameters were averaged across 18 myocardial segments.

Results

During a median follow-up of 3.4 years [interquartile range 1.9 to 4.8], 132 patients (15%) died. In multivariable survival analyses adjusted for potential confounders (age, sex, BMI, mean arterial pressure, cholesterol, heart rate, CABG/PCI, left ventricular ejection fraction and mass index, left atrial volume index, tricuspid annular plane systolic excursion, E-wave, E/e', deceleration time, and global longitudinal strain) neither the ESL index (HR 1.02 per 1% increase [0.97 to 1.08], P=0.40) nor PSI (HR 1.00 per 1% increase [0.98 to 1.01], P=0.69) were associated with all-cause mortality. ICM modified the relationship (P interaction unadjusted/adjusted=0.001/0.008; Figure) such that per 1% increase in ESL index in patients with ICM was significantly associated with all-cause mortality (unadjusted: HR 1.09 [1.04 to 1.15], P<0.001 and adjusted: HR 1.06 [1.00 to 1.13], P=0.045) but not in those without (unadjusted: HR 1.02 [1.01 to 1.03], P=0.002 and adjusted: HR 0.99 [0.90 to 1.09], P=0.086). ICM did not modify the relationship between PSI and all-cause mortality (P interaction unadjusted/adjusted=0.15/0.13).

Conclusion

Our results indicate that in this cohort of undifferentiated HF patients with reduced ejection fraction the prognostic value of deformational patterns was reduced. However, the ESL index may provide some information on prognosis in patients with ICM.

ESL and interaction with ICM

Funding Acknowledgement

Type of funding source: None
Left atrial deformation in estimating left atrial pressure
Authors: Lindqvist P , Tossavainen E , Henein M.Y
Published: November 2020

Background

In the absence of mitral valve disease, elevated left atrial (LA) pressure reflects reduced left ventricular (LV) compliance and raised diastolic pressures, hence an important explanation for exertional breathlessness.

Methods

We studied 145 symptomatic patients, age 63±14 years, 55 males, using conventional transthoracic echocardiography guidelines protocol, including LA and LV myocardial deformation investigations along with simultaneous right heart catheterization using conventional techniques. From invasive measurements, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP) were measured and pulmonary vascular resistance (PVR) calculated. No patient had more than mild mitral or aortic valve disease.

Results

LA strain rate during atrial systole (LASRa) was the strongest correlate with PCWP (r2=−0.39, p<0.001), over and above LASR during LV systole (LASRs) and peak LA longitudinal strain (PALS) (r2=−0.21 and −0.19, respectively, p<0.001 for both). Both LASRa and PALS predicted elevated PCWP >15 mmHg but only modestly (AUC= 0.55 and 0.52). The relationship between LASRa and PCWP was stronger in patients with post-capillary pulmonary hypertension compared to those with pre-capillary pulmonary hypertension (r2=0.21 vs. r2=0.02). However, the strongest relationship between LASRa and PCWP was in patients with LA volume >34 ml/m2 (r2=0.59, p<0.001, see figure) but other strain relationships did not improve after only including patients with increased LA volume. Finally, LASRa correlated modestly with the respective LVSRa (r=0.53, P<0.01), and to lesser extent with other cavity interaction correlations (r=0.26–0.48, p<0.01).

Conclusion

Despite being somehow related to ventricular function, left atrial strain rate during atrial contraction is the closest correlate to PCWP, particularly in patients with dilated LA cavity. These data should be of significant clinical value in daily management of symptomatic patients.

LASRaecho and PCWPrhc in patients with d

Funding Acknowledgement

Type of funding source: None
Non-invasive myocardial work: characterising the normal and ischaemic response to exercise
Authors: Borrie A , Goggin C , Ershad S , Robinson W , Sasse A
Published: November 2020

Background/Introduction

Myocardial work and work efficiency are new parameters for assessing left ventricular function. They have been shown to have value in a range of clinical settings but have not previously been applied to exercise stress echocardiography.

Purpose

We aim to characterize the normal myocardial work and work efficiency response to exercise in a mixed population and determine if myocardial work could be used to identify patients with inducible ischaemia.

Methods

Patients were retrospectively enrolled from an existing database of exercise stress echocardiography. Inclusion criteria were a clinical indication of possible ischemia and technical suitability to calculate myocardial work. Exclusion criteria were abnormal baseline left ventricular function or inadequate image quality. Echocardiograms positive for ischaemia were defined by independent visual assessment and compared with angiographic findings where available. Myocardial work and work efficiency were calculated using a proprietary algorithm.

Results

A total of 177 patients met inclusion criteria, 117 were excluded leaving 40 normal and 20 positive tests for analysis. During normal exercise global work increased 54% and efficiency remained at 96%. Segmental work showed a basal to apical gradient which became more prominent at peak exercise. In patients with inducible ischaemia during exercise there was a significant difference in response; work decreased by 1.9% and efficiency dropped to 87%. Receiver operating characteristic curve for myocardial work had an area under the curve of 0.94. Youden's J statistic suggested an optimum cut point of a 25% increase in work to define a normal test.

Conclusion

During normal exercise myocardial work increased and efficiency remained unchanged, however during exercise induced ischaemia both myocardial work and efficiency decreased. We have demonstrated that myocardial work can be applied to stress echocardiography to identify ischemia but the utility of this remains uncertain. Further research compared to an objective measure of functional ischemia is needed.

Response to exercise

Funding Acknowledgement

Type of funding source: None
The impact of maternal diabetes on fetal left atrial size and function
Authors: Pathan F , Lam P , Sivapathan S , Orde S , Nanan R , Negishi K
Published: November 2020

Introduction

The developmental impact of maternal diabetes on the fetal left atrium (LA) is unclear.

Purpose

To determine if maternal diabetes mellitus (DM) impacts fetal LA size and function (fetal LA strain (LAS)).

Methods

We evaluated LA area (LAA) and LAS on fetuses of diabetic and control mothers who attended a mandated 24 week fetal morphology scan. Participants were excluded from the study if: there was a history of pre-eclampsia or if the fetus did not have adequate images for LAS analysis

We used fetal cardiac 4-chamber view for analysis. A region of interest was drawn along the LA endocardial border for tracking and was used for assessment of maximum LAA.

Baseline variables were compared using Student t test or Mann-Whitney U test and are presented as Mean ± Standard Deviation or Median (Interquartile range (IQR)). Body mass index (BMI), maternal age, gestational age, fetal heart rate (FHR), smoking status, estimated fetal weight (EFW) and Maternal DM were analysed in univariate and multivariate models with respect to LAA and LAS.

Results

160 pregnant women (50 controls, 110 diabetics) were scanned. 9 were excluded due to poor image quality, resulting in 104 mothers with diabetes (T1DM 9, T2DM 8, and gestational DM 87) and 47 controls without diabetes.

The mothers were well matched for age, blood pressure, smoking prevalence and gestational age. The diabetic mothers had a significantly higher BMI: Median (IQR) ((30.4 kg/m2 (25.1–34.8) vs 20.8 kg/m2 (21.4–27.4), p<0.001) and had higher weight (77 kg (65–93) vs 64 kg (62–68), p<0.001).

FHR was higher in fetuses of diabetic mothers (147±10 vs 144±8, p 0.04). Maternal DM resulted in larger LAA 1.68 cm2±0.39 cm2 vs 1.56 cm2±0.36 cm2; p=0. 08, however the result was not significant. The LAS was significantly lower in fetuses with maternal DM compared to fetuses of controls: 28.8% ± 8.8% vs 32.3% ± 9.2%; p 0.033.

On multivariate analysis (Table 1), the predictors of LAS were Maternal DM and FHR and predictors of LAA were EFW and Maternal DM.

Conclusions

Maternal diabetes modulates both LA size and LA function. The association between LA function and FHR may provide an explanation for fetal tachycardia in Maternal DM.

Fetal left atrial strain

Funding Acknowledgement

Type of funding source: None
The impact of chemotheraphy and supervised high-intensity interval physical activity on left ventricle strain and myocardial work parameters – SPORT NATHY TRIAL pilot study results
Authors: Nowak A , Bartczak-Rutkowska A , Litwiniuk M , Kufel-Grabowska J , Marszalek S , Gorecki M , Malinowska M , Suchorska W , Dos J , Nowaczyk P , Dudek M , Marszalek A , Lesiak M , Straburzynska-Migaj E
Published: November 2020

Introduction

Cardiotoxic effect of chemotheraphy represents known and challenging problem, thus search for potentially cardioprotective factors plays a key role in the contemporary cardio-oncology. Physical activity may allievate side effects of chemotheraphy and improve quality of live. Myocardial Work is a novel echocardiographic technique and promising tool for cancer patients assesement.

Purpose

The aim of this randomised pilot study was to assess left ventricle function using speckle tracking myocardial strain (2D STE) with Myocardial Work (MW) module in young women undergoing neoadjuvant chemotheraphy due to breast cancer and the impact of supervised high-intensity interval physical activity on these echocardiographic parameters.

Material and methods

We evaluated 24 women aged 27–41 (mean 34±4 yrs) with invasive breast cancer undergoing standard neoadjuvant chemotheraphy and randomized them into two groups: control - (CG, 15 pts) and experimental - with 6 months of supervised high-intensity interval exercise (SHIIEG, 9 pts). Every patient underwent echocardiographic examination 2D STE and MW before chemotheraphy and at 6 months follow-up. The following parameters were evaluated: Global Longitudinal Strain (GLS), Global Work Index (GWI), Global Constructive Work (GCW), Global Work Efficiency (GWE), Global Waste Work (GWW).

Results

Following parameters significantly decreased after chemotherapy: EF (65.4±5.7 vs 60.5±7.0%; p=0.003), GLS (20.4±2.5 vs 18.4±2.0%; p=0.001), GWI (1835.4±206.9 vs 1594.1±228.3 mmHg%; p=0.0004), GCW (2240.5±270.8 vs 1884.9±241.3 mmHg%; p=0.0001), GWE (95.9±1.5 vs 94.9±1.7%; p=0.02). No signifficant changes in GWW (78.6±36.4 vs 80.5±32.2 mmHg%; p=0.7) were found.

The comparison of control (CG) and experimental group (SHIIEG) at 6 months follow-up revealed no signifficant differences in the following parameters: GLS (p=0.9), GWI (p=0.3), GCW (p=0.2), GWE (p=0.3) and GWW (p=0.5). However analysis of relative percentage change from baseline in GLS and GWW (Δ%GLS, Δ%GWW) almost reached statistical significance [for CG and SHIIEG respectively: Δ%GLS (−15.6 vs −4.4; p=0.07), Δ%GWW (+39.4 vs −7.3; p=0.06)].

Conclusions

Neoadjuvant chemotherapy administered in young women with invasive breast cancer impaires the function of left ventricle after 6 month of theraphy, resulting in decrease of GLS, GWI, GCW and GWE. The supervised high-intensity interval physical activity impacts the relative change of GLS (Δ%GLS) and GWW (Δ%GWW), therefore may have cardioprotective effect on left ventricle function.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Greater Poland Cancer Centre, Poznan, Poland
Usefulness of strain imaging to determine prognosis in pulmonary hypertension
Authors: Monivas Palomero V , Remior P , Garcia-Rodriguez D , Garcia-Gomez S , Garcia-Izquierdo E , Borrego A , Navarro S , Martinez Mingo A , Arellano-Serrano C , Oteo J.F , Garcia-Touchard A , Goicolea J.F , Hernandez Perez F , Mingo S
Published: November 2020

Introduction

Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterization (RHC).

Purpose

To describe classical and myocardial deformation echocardiographic parameters in patients with established PH and to identify prognostic variables

Methods

We prospectively enrolled 76 patients with mPAP ≥25 mmHg undergoing RHC between 2017 and 2018. All subjects underwent transthoracic echocardiography (TTE) according to the latest ASE/EACVI guidelines the same day of the RHC. Strain analysis was carried out by speckle-tracking echocardiography (QLAB 10.7, Philips). Clinical events during the follow-up were: acute heart failure hospitalization, cardiac transplant and all-cause mortality.

Results

Mean age was 59±12, 43.4% were women and 49 patients (64.5%) belonged to group 2 of PH. The median follow-up was 288 (ICR 92–534) days. Total number of events was 42 (55.3%, 9 deaths). Variables associated to events are shown in Table 1. All classic LV and RV systolic function and strain parameters were associated with a worse prognosis, being free-wall RV longitudinal strain (RVLS) the only one that remained as a prognostic factor in mutivariate analysis. Other variables associated with a worse prognosis were PCP>15 mmHg and NT-proBNP>1800, the latter being independent predictor of events. The attached figure shows event-free survival curves for the global population divided according to whether or not they belong to group II PH.

Conclusions

Our data highlight the prognostic value of free-wall RVLS and NT-proBNP in patients with established PH. NT-ProBNP was only useful in group II PH while free-wall RVLS identified patients with a higher risk of events in both groups, mainly in patients with heart disease

Free event survival Curves

Funding Acknowledgement

Type of funding source: None
Global Constructive Work predicts left ventricular reverse remodeling one year after MitraClip implantation in patients with functional mitral regurgitation
Authors: Papadopoulos K , Ikonomidis I , Chrissoheris M , Chalapas A , Kourkoveli P , Spargias K
Published: November 2020

Background

Percutaneous edge-to-edge mitral valve repair (PMVr) has recently been identified as an effective method for treating patients with functional mitral regurgitation. However, it is still unknown which patients will benefit by showing clinical improvement and left ventricular reverse remodeling.

Purpose

The purpose of this study is to analyze novel echocardiographic markers and identify markers of LV reverse remodeling after MitraClip implantation.

Methods

We retrospectively analyzed 58 high surgical risk (logistic EuroSCORE 23±15%) consecutive patients (aged 72±10yrs) with functional moderate-to-severe and severe mitral regurgitation (EROA 29±14mm2) and reduced LV contractility (EF 32±8%, GLS −8.6±3.7%). At baseline and 1-year after PMVr we assessed echocardiographic parameters such as MR severity, EF, Global Longitudinal Strain (GLS), Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE).

Results

In patients with MitraClip implantation there was a significant reduction of MR (3.7±0.4 vs 1.7±0.8, p<0.001) one year after the intervention. The EF and GLS did not improve after the implantation (32±8 vs 33±10%, p=0.178 & −8.6±3.7 vs −8.6±3.7%, p=0.922 respectively) but Global Work Index (GWI) and Global Constructive Work (GCW) demonstrated significant improvement (607±282 vs 650±260mmHg%, p=0.04 & 854±288 vs 949±325mmHg%, p<0.001 respectively). The baseline EF, GLS, GWI, GCW and EROA were the factors that were significantly associated with more than 20% reduction of LVEDV one year after intervention (p<0.02 for all). To be more specific, left ventricles with better performance and contractility combined with worse mitral regurgitation were the ones that responded better. Further, baseline GCW was the only factor that was significantly associated with reduction of the LVESV. A ROC curve analysis identified a cut-off value of 846mmHg% (AUC 0.759, 95% CI: 0.588–0.930; p=0.007) to be associated with 10% reduction of LVESV, with a sensitivity and specificity of 79% and 74% respectively.

Conclusions

Transcatheter edge-to-edge repair is an effective method for treating patients with FMR and improves LV performance one year after intervention. A preserved baseline GCW seems to be a good predictor of LV reverse remodeling after MitraClip implantation.

Funding Acknowledgement

Type of funding source: None