bluuebunny/crossref_metadata_2025 huggingface dataset:
P318 Left atrial dysfunction assessed by echocardiography in relation to left atrial fibrosis in patients undergoing ablation for atrial fibrillation
Authors: Pilichowska E , Baran J , Kulakowski P , Zaborska B
Published: January 2020

PURPOSE

Left atrial (LA) fibrosis is the hallmark of LA remodeling in atrial fibrillation (AF), alters LA function and may predict poor catheter ablation (CA) outcome. LA fibrosis may be assessed invasively using electroanatomical mapping (EAM) during electrophysiological study.

The aim was to assess LA function parameters in relation to degree of LA fibrosis derived from EAM in patients with AF.

METHODS

Patients (pts) n = 39 (79% males, mean age 56+/-10) with non-valvular AF were studied with TTE and TEE before first CA during sinus rhythm. LA strain (LAS) and strain rate (LASR) were analyzed in reservoir (r), conduit (cd) and contractile (ct) phases. The velocities of mitral A, E" and A" were measured with Doppler. E/E" and LA stiffness index - the ratio of E/E" to LASr were assessed. LA appendage flow velocity (LAAv) was measured in TEE. LA volume using biplane area-length method was calculated.

The EAM of LA was build using Carto System before CA. Low amplitude potentials area (LAPA) was quantitatively analyzed and expressed as a percentage of LA surface using the cut-off <0.5 mV to detect sites of fibrosis. LA parameters were compared between mild (LAPA <10%) moderate (LAPA 10-40%) and extensive degree of LA fibrosis (LAPA >40%) (table).

RESULTS

The mean LA volume was 35 ± 11 mL/m². The LAPA ranged from 2 to 78 % of LA surface. Reduced LA function was observed in the LAPA >40% group. Extensive LAPA altered mainly LA compliance parameters. Traditional LA systolic function parameters did not differ in relation to degree of LAPA.

CONCLUSION

LA compliance is mostly affected by LA fibrosis, thus LA diastolic parameters may be useful in the noninvasive assessment of LA fibrosis. Whether these parameters should be a part of the proper selection of candidates for CA requires further studies.

LA function parameters LA parameters Group 1 LAPA <10% n = 13 Group 2 LAPA >10% <40% n = 13 Group 3 LAPA >40% n = 13 P-value Group 1 + 2 vs 3 Mitral A 0.55 ± 0.10 0.55 ± 0.24 0.73 ± 0.32 0.077 A" 9.19 ± 1.74 7.85 ± 1.43 7.92 ± 2.40 0.376 LASr 31.48 ± 4.52 26.48 ± 8.79 19.63 ± 6.76 <0.001 LAScd 17.30 ± 3.05 15.44 ± 6.93 10.91 ± 4.04 0.003 LASct 14.18 ± 5.36 11.05 ± 3.67 8.72 ± 4.78 0.024 LASRr 1.22 ± 0.19 1.24 ± 0.21 0.92 ± 0.20 <0.001 LASRct -1.71 ± 0.46 -1.37 ± 0.34 -1.04 ± 0.33 <0.001 LA stiffness 0.20 ± 0.07 0.34 ± 0.17 0.63 ± 0.29 <0.001 LAAv 0.83 ± 0.18 0.55 ± 0.17 0.60 ± 0.16 0.178
P327 Concordance between regadenoson stress echocardiography and spect-MIBI (99mTc) in patients with suspected myocardial ischemia
Authors: Echarte J C E M , Menendez P M S , Iglesias I I G , Vara J V M , Borrego J B R , Sevilla A I S M , Rodriguez E R P , Garrote C G C , Fernandez F F V
Published: January 2020

Background

Regadenoson is a selective A2A adenosine receptor agonist approved for the detection of myocardial with SPECT-MIBI. To date, few studies have appraised the utility of this drug using transthoracic echocardiography with the same purpose. We designed this prospective study to evaluate the diagnostic agreement between these two techniques used simultaneously to detect myocardial ischemia. We report our first results evaluating the concordance between both techniques.

Methods

Patients enrolled were referred to our clinic for the evaluation of chest pain. Myocardial perfusion imaging was performed with regadenoson (400 µg ) which was injected before 99mTc-MIBI. Stress and rest sets of images were evaluated for relative uptake of the radiotracer in order to detect and characterize perfusion defects. The echocardiogram was acquired 60-90 seconds after the administration of the drug using a standardized technique. Two independent observers (one cardiologist and one specialist in nuclear medicine) interpreted the images, both unaware of the result of the complementary technique.

Results

One hundred twenty five patients were included, 69 (55%) of them males. Median age was 73 years (IQR 65-79). One hundred seventeen patients had both studies interpretable. Thirty-nine (32.5%) patients had had a diagnosis of ischemic heart disease before the study (either a myocardial infarction or a coronary revascularization). The median pre-test probability of coronary artery disease in those without a true previous diagnosis was 30.5% (16.0-50.8), being 50% in the intermediate risk (15-85%) and 49% in the low risk stratum (less than 15%). Significant reductions is systolic and diastolic blood pressure were detected with regadenoson [systolic 134 (21) mmHg Vs 131 (23) mmHg, p < 0.001; diastolic: 78 (12) mmHg Vs 73 (13) mmHg, p < 0.001], with a striking increase in heart rate: 67 (13) bpm Vs 91 (17) bpm, p < 0.001. More patients had a SPECT test showing myocardial ischemia (28% Vs 16%; p < 0.001). Agreement between both tests were 84%. The kappa index obtained from this sample was 0.34 (CI95% 0.15-0.53). Segregating those patients without a history of coronary artery disease (n = 81), the positive test rate were 14% for echo and 20% for SPECT-MIBI (p = 0.019). Kappa index was even lower: 0.29 (CI95% 0.02-0.56). Conclusions. SPECT-MIBI provides more positive tests than stress echocardiography when regadenoson is used as the stressor agent. The concordance between tests is low.
P330 Blunted heart rate reserve during vasodilator stress echocardiography in diabetic and renal failure patients
Authors: Bellino M , Ferraro D , Silverio A , Peluso A P , Soriente L , Provenza G , Ascoli R , Iuliano G , Prota C , Polito M V , Cogliani F , Maiellaro F , D"auria F , Picano E , Citro R
Published: January 2020

Funding Acknowledgements

None

Background

A blunted heart rate reserve (HRR) during dipyridamole stress echo (SE) is a marker of cardiac autonomic dysfunction associated with poor outcome, independently of inducible ischemia, underlying coronary artery disease (CAD) and beta-blocker therapy. Patients with diabetes and/or renal failure have higher prevalence of underlying autonomic dysfunction.

Aim. To assess the value of HRR in patients undergoing dipyridamole SE.

Methods

We prospectively recruited a sample of 61 patients with known or suspected CAD (mean age 75 ± 10 years; 34 males, 55,7%; 50% on beta-blockers at the time of testing). Coexistent atrial fibrillation or previous pacemaker implantation were considered as exclusion criteria. Three groups were identified a priori: non-diabetic with normal renal function (n = 43, Group 1); diabetics, with normal renal function (n = 14, Group 2); severely impaired renal function on dialysis (n = 4, Group 3). All patients underwent dipyridamole SE (0.84 mg/kg in 10"). Wall motion score Index (WMSI) was calculated with a 17-segment score of left ventricle, each segment scored from 1= normal to 4= dyskinetic. HRR was measured by ECG as the peak/rest HR ratio.

Results

A positive SE (stress WMSI> rest WMSI) was present in 2 patients of Group 1 (4.7%), 4 of Group 2 (28.6%) and no patient in Group 3. Heart rate was different, although not significant, among the 3 groups both at rest (66.1 ± 11.1 vs 64.6 ± 8.5 vs 79.0 ± 8.0, p = 0.050) and at peak stress (83.8 ± 12.6 vs 75.3 ± 10.3 vs 86.5 ± 11.1, p = 0.059). Of note, HRR was statistically different among groups (1.29 ± 0.20 vs 1.19 ± 0.14 vs 1.09 ± 0.06, p < 0.047; see figure). There was no difference in HRR between patients off and on-beta-blockers (1.19 ± 0.16 vs 1.24 ± 0.24, p = 0.421) and with or without positive SE (1.20 ± 0.14 vs 1.25 ± 0.20, p = 0.530). Overall, HRR ≤ 1.17 (median value) was reported in 39.5% of Group 1, 71.4% of Group 2, and 100% of Group 3 pts (p = 0.024). No significant correlations between HRR and peak WMSI (p = 0.183) or age (0.062) were reported.

Conclusion

HRR is frequently abnormal in patients referred for SE testing, especially in presence of concomitant diabetes and advanced renal failure. The blunted chronotropic response is a simple, imaging independent marker of cardiac autonomic dysfunction and may usefully complement the conventional evaluation with regional wall motion abnormalities during vasodilator SE.

Abstract P330 Figure title: HRR box plots
P335 Evaluation of systolic right ventricular function with 3D echocardiography in patients with isolated right ventricular pacing induced left ventricle dysfunction
Authors: Jenei C , Kadar R , Clemens M , Csanadi Z
Published: January 2020

Background

Right ventricular (RV) pacing may worsen left ventricular (LV) systolic function causing heart failure, but the exact mechanism of the LV dysfunction is unknown. The purpose of this study was to examine the right ventricle by three-dimensional echocardiography in patients with LV dysfunction accompanied by long-term RV pacing.

Methods

We analysed consecutive patients receiving permanent pacemaker (PPM) due to atrioventricular block from 2015 January to 2017 March (n = 335). During the mean follow-up period (27 months) 4 patients were selected with at least 5% decrease in the LV ejection fraction measured by two-dimensional echocardiography (B group). Control (K) group contains 4 age-, sex-, concomitant disease matched patients without the sign of LV dysfunction from the same time interval. Right ventricle function was assessed by 3D echocardiography.

Results

In both groups, there were 3 men, and the mean age was similar (B: 68 ± 6 y vs. K: 66 ± 10 y; p = 0.65). Right ventricular ejection fraction (EF) was significantly higher in controls compared to patients (K: 49 ± 7.8% vs. B: 36 ± 3.1%; p = 0.02), while the right ventricular volumes [end-systolic (K: 79 ± 47 ml vs. B: 71 ± 7 ml; p = 0.77), end-diastolic (K: 151 ± 73 ml vs. B: 111 ± 11 ml; p = 0.36) and stroke volumes (K: 58 ± 44 ml vs. B: 40 ± 6 ml; p = 0.5)] did not differ significantly. We did not find any important differences between the groups regarding the permanent right ventricle pace rate (K: 93 ± 5.6% vs. B: 84 ± 19.5%; p = 0.5), systolic pulmonary pressure (K: 34 ± 6 mmHg vs. B: 35 ± 18 mmHg; p = 0.92), or the severity of tricuspid regurgitation.

Conclusion

The left ventricular dysfunction after permanent right ventricular pacing results in right ventricular systolic dysfunction. The decrease of RV ejection fraction is not associated with RV enlargement or increase of pulmonary pressure.
P357 Remote ischemic post-conditioning may prevent cardiac remodeling within two years of STEMI by cardioprotective microRNA upregulation
Authors: Ikonomidis I , Vlastos D , Katsanos S , Gazouli M , Thymis J , Triantafyllou C , Varoudi M , Andreadou I , Triantafyllidi H , Makavos G , Kapelouzou A , Vrettou A R , Frogoudaki A , Cokkinos D , Iliodromitis E K
Published: January 2020

Background

Remote ischemic post-conditioning attenuates ischemia-reperfusion injury in patients with STEMI. However, its biochemical mechanisms, including micro-RNA expression, and effects on cardiac remodeling have not been deﬁned.

Methods

We examined 80 patients with STEMI and 20 healthy controls. All patients had been evaluated by cardiac echocardiography. The conditioning protocol utilised a single ischemic stimulus by brachial cuff inﬂation of both arms at 200mmHg for 5 minutes, while 20 patients underwent a sham conditioning procedure by way of cuff inﬂation omission after its placement. Blood samples were taken before and after the conditioning protocol; thus, the expression of microRNA-144,-150,-499 (cardioprotective action), -21, and -208 (remodeling stimuli) was quantiﬁed at baseline and after the ischemic conditioning procedure, by polymerase chain reaction. Additionally, cardiac remodeling was evaluated by repeat echocardiography after a 2-year follow-up period, in 40 patients.

Results

Our conditioning protocol resulted in a statistically signiﬁcant increase in miR-144,-150, -499, -21, and -208 expression (55.9 vs 7.4/U6sn, p < 0.001; 3.4 vs 1.8/U6sn, p < 0.05, p = 0.01; 3.5 vs 1.6/U6sn, p < 0.001; 2.1 vs 1.2/U6sn; 2.4 vs 1.9/U6sn) compared to baseline; none of the aforementioned measurements was affected by the sham procedure. Furthermore, both left-ventricular end-diastolic (LVEDV) and end-systolic volume (LVESV) were decreased after the 2-year follow-up period (from 99.3 ± 6.7 to 85.9 ± 5.7, p= 0.004, and from 55.3± 6.1 to 48.6± 5.2, p= 0.04, respectively). In addition, the increase in mir-144 and mir-499 was signiﬁcantly correlated with a decrease in LVESV (r=-0.355, p < 0.05; r=-0.368, p < 0.05, respectively), while the increase in mir-499 was also signiﬁcantly correlated with a decrease in LVEDV (r=-0.374, p < 0.05) at follow-up.

Conclusion

Remote ischemic conditioning may prevent adverse myocardial remodelling within 2 years of the index ischemic event, likely by up-regulation of cardio-protective microRNAs expression.
P361 Assessment of accuracy and reproducibility of coronary flow reserve measured by SPECT in patients with known or suspected coronary artery disease
Authors: Do Amaral Henrique De Souza A , Harms H , Campbell L , Bibbo C , Harrington M , Hainer J , Dorbala S , Blankstein R , Taqueti V , Kijewski M , Barbagelata A , Breault C , Park M , Di Carli M
Published: January 2020

Funding Acknowledgements

Spectrum Dynamics

Background

Traditional relative assessment of regional myocardial perfusion by single photon emission computed tomography (SPECT) has limited ability to identify multivessel coronary artery disease, as well as diffuse atherosclerosis and coronary microvascular dysfunction. Current gamma cameras with cadmium-zinc-telluride (CZT) detectors have higher temporal resolution and sensitivity and allow the acquisition of multi-frame images and quantification of absolute myocardial blood flow (MBF) and coronary flow reserve (CFR

Purpose

The aim of this study was to assess the accuracy and reproducibility of quantitative measurements of MBF and CFR obtained with a CZT SPECT system compared to PET in a cohort of patients with known or suspected coronary artery disease.

Methods

Accuracy was assessed in 22 patients who underwent dynamic rest/stress 99mTc-sestamibi-SPECT and 13N-ammonia PET myocardial perfusion imaging within two weeks of each other. Fourteen patients comprised the reproducibility cohort and underwent two dynamic 99mTc-sestamibi SPECT scans within two weeks. A rest/pharmacological stress single-day SPECT protocol was performed, using a 1:3 dose ratio. SPECT image reconstruction was performed using a spline-fitting method and SPECT MBF was quantified using a net retention kinetic model in commercially available software. Rest MBF and CFR were adjusted for heart-rate pressure product.

Results

Global MBF at rest and stress showed a good correlation between SPECT and PET (r = 0.814, p < 0.001). For global rest MBF the mean difference between the two techniques was -0.25 ± 0.24 ml/min/g, while for stress MBF mean difference was -0.21 ± 0.40 ml/min/g. We also observed a significant correlation between global SPECT and PET CFR measurements (r = 0.745, p < 0.001), with no significant difference between the two (mean difference: 0.16 ± 0.50). Regarding the reproducibility cohort, the correlation between global CFR measured by two SPECT scans was also significant (r = 0.616, p = 0.019), with a mean difference of 0.14 ±0.51. The mean difference between scans for rest MBF (-0.05 ± 0.19) and stress MBF (0.01 ± 0.42) were also not significant.

Conclusion

MBF and CFR quantification is feasible using a CZT gamma camera and provides accurate and reproducible results that correlate with 13N-ammonia PET. This may be of special relevance in sites where PET is not available, enabling MBF and CFR quantification with CZT SPECT cameras.

Abstract P361 Figure.
P371 Right ventricle end-systolic remodeling index in patients with atrial septal defect and severe pulmonary arterial hypertension
Authors: Selegny M , Fournier E , Amsallem M , Tortigue M , Kara M , Benmoussa N , Cohen S , Isorni M A , Jais X , Humbert M , Hascoet S
Published: January 2020

Background Outcome of patients with atrial septal defect (ASD) and severe pulmonary arterial hypertension (PAH) relates to right ventricular (RV) function.

Magnetic resonance imaging (MRI) remains the gold standard for evaluating the RV function but it is not used routinely. We investigated the relationship between MRI and multiple echocardiography parameters, including the Right Ventricle End-Systolic Remodeling Index (RVESRI), a new prognostic marker in patients with PAH.

Methods 23 patients with ASD and severe PAH (median age 49y.o.[39-59], Sp0 2 92% [90-95], WHO functional class II or III, mean pulmonary artery pressure 51mmHg [40-59]) were included between 2014 and 2018. All patients underwent MRI and echocardiography assessment. Echocardiographic measurements of RV remodeling and function included TAPSE, RV fractional area change (RVFAC), peak systolic velocity of the tricuspid valve (S’TV), right atrial (RA) area, RV strain, Systolic to diastolic ratio, eccentricity index and RVESRI, defined by septum length divided by lateral wall length (Figure 1). Pericardial effusion was noted.

Results Median RV ejection fraction (EF) evaluated with MRI was 46 % [34-59]. RV dysfunction (RVEF < 45%) was observed in 43% of patients. Median RVFAC and

RVESRI were 29.6%[23-34] and 1.6[1.4-1.7] respectively. By spearman correlation, RVFAC and RVESRI were significantly correlated to RVEF (Rho 0.62, p < 0.007 and

Rho -0.51,p < 0.02 respectively). By linear regression, RVFAC and RVESRI were also correlated to RVEF (R 2 =0.36, p < 0.003 and R 2 =0.34, p < 0.08). Pericardial effusion was associated with RV dysfunction (p< 0.008) and a lower RVFAC (p < 0.01). TAPSE, S’TV and RV strain were not correlated with RVEF.

Conclusion RVFAC, RVESRI and pericardial effusion were markers of RV dysfunction in patients with ASD and severe PAH. RVESRI appears as a simple and reliable parameter for follow-up. Its prognostic value in patients with CHD remains to be demonstrated.
414 Ventricular-arterial interaction predicts response to cardiac resynchronization therapy: a link with improvement of endothelial function and arterial elastic properties
Authors: Karamichalakis N , Ikonomidis I , Parissis J , Simitsis P , Xydonas S , Letsas K , Manolatos D , Vlachos K , Georgopoulos S , Efremidis M , Sideris A , Filippatos G
Published: January 2020

Background

Endothelial dysfunction (ED) is a hall mark of chronic heart failure and has been linked to disease progression, hospitalizations and mortality.

Purpose

to evaluate the impact of cardiac resynchronization therapy (CRT) in ED and to determine predictors of response to CRT

Methods

CRT recipients from 19/07/2016 until 19/10/2018 were studied at baseline and 3 months after. In each visit we evaluated a 12 lead ECG, carotid to femoral pulse wave velocity (cfPWV), flow-mediated dilatation of the brachial artery (FMD), left ventricle ejection fraction (LVEF) and left ventricle (LV) global longitudinal strain (GLS). We evaluated arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography and the ratio of cfPWV to GLS, as valid markers of ventricular-arterial interaction. We also assessed the layer of endothelial glycocalyx by measurement of Perfused Boundary Region (PBR) of the sublingual microvessel range:5-25 microns.

Results

32 patients with a mean age 65.5 (±10.9) years and severe LV systolic dysfunction were enrolled. During follow-up, LVEF, GLS, LVESV and all ED markers exhibited significant improvement (table 1). 23 patients were responders. Among the baseline vascular function markers, only the ratio cfPWV/GLS predicted response to CRT (OR: 0.245, 95%CI: 0.042-0.759, p = 0.044).Threshold analysis showed that the best threshold of cfPWV/GLS for response to CRT was 2.75 (specificity: 0.67%, sensitivity: 0.94%).

Conclusions

After 3 months of CRT, endothelial function, arterial elasticity and ventricular arterial interaction are improved. The baseline ratio cfPWV/GLS, a novel marker of ventricular arterial interaction, can be applied to predict response to CRT.

table 1 Baseline Follow-up Change Measurement mean (sd) mean (sd) mean (sd) p-value SBP (mmHg) 126 (19) 128 (16) 2.18 (11.98) 0,465 DBP (mmHg) 79 (9) 80 (9) 1.06 (8.58) 0,618 LVEF (%) 27 (7) 35 (9) 7.50 (4.77) <0.001 LVESV (mL) 151 (42) 120 (46) -26.91 (17.20) <0.001 GLS (%) 6.47 (2.89) 9.33 (4.18) 2.85 (2.28) <0.001 FMD (%) 5.88 (2.79) 10.25 (3.67) 4.37 (3.34) <0.001 Ea/Ees 2.81 (1.10) 2.04 (0.99) -0.77 (0.47) <0.001 cfPWV 11.11 (2.61) 10.01 (2.45) -1.10 (1.56) 0,003 PBR 5-25(microns) 2.26 (0.20) 2.14 (0.24) -0.13 (0.25) 0,028 cfPWV/GLS 2.18 (1.46) 1.45 (1.11) -0.73 (0.55) <0.001 Measurements at baseline, follow-up and their change during study

Abstract 414 Figure. picture 1
419 Revisiting cardiac Doppler index with single heart beat 4D ultrafast echocardiography
Authors: Papadacci C , Finel V , Villemain O , Goudot G , Provost J , Messas E , Tanter M , Pernot M
Published: January 2020

Funding Acknowledgements

European Research Council under the European Union’s Seventh Framework Programme (FP/2007-2013) / ERC Grant Agreement n° 311025 and the ANR-10-IDEX-00

Background

4D echocardiography has the strong potential to improve cardiac index quantification by providing reproducible and user independent measurements. Quantification of left ventricle volume and ejection fraction, for instance, have been shown to be more reliable using 4D echocardiography. However, Doppler index evaluation has not yet benefited from it, due to limited volume rates and single location estimation when assessing spectral Doppler.

Purpose

In this study, we propose to demonstrate the feasibility of performing semi-automatic evaluation of cardiac Doppler indices within a single heartbeat on three human hearts by performing 4D ultrafast echocardiography, a new technique allowing a drastic volume rate increase.

Methods

A 4D ultrafast echocardiography scanner prototype connected to a matrix probe was developed to image the human heart. The probe was positioned on the apical 4-chamber view of N = 3 volunteers. High volume rate (5200 volume/s) acquisitions were performed three times by two different trained cardiologists. 4D color flow and tissue Doppler imaging were computed from the each single heartbeat acquisition. Spectral Doppler were derived at each voxel of the volumes. Region of interest such as LV outflow tract, mitral inflow or basal inferoseptal locations were automatically detected. Doppler index were derived from Doppler spectra and tissue velocity curves at these locations, and were compared against indices obtained using a clinical procedure based on 2D echocardiography.

Results

For each acquisition and the three volunteers, major Doppler indices: E, A, E/A, S, e’, a’, e’/a’, s’, E/e’, cardiac output were successfully assessed during a single heartbeat. A high degree of similarity between the indices assessed by 4D ultrafast echocardiography and clinical 2D measurements were found.(p > 0.05 for each index).

Conclusions

4D ultrafast echocardiography can quantify the major cardiac Doppler indices in a single heart beat acquisition. It promises to improve patient care by accelerating examination time and to improve results reproducibility by removing most of the operator dependency. It also offers a unique feature by enabling E/e’ index assessment in the same heart beat which could be of a great interest for atrial fibrillation patients.

Abstract 419 Figure.
430 Relation of blood pressure to coronary artery calcium and mortality
Authors: Cho I J , Lee J H , Choi S Y , Chun E J , Park S H , Han H W , Sung J D , Jung H O , Chang H J
Published: January 2020

Background

Diastolic blood pressure has a J-curve relation with coronary heart disease and death, but it is debating whether a J-curve association exists in general population. We aimed to assess the relation of blood pressure to mortality, and whether their association is interacted with presence of high coronary artery calcium (CAC).

Methods

The KOICA registry is a retrospective, multicenter observational study designed to investigate the effectiveness and prognostic value of CAC score for primary prevention of cardiovascular disease in asymptomatic Korean adults. The association between CAC score and blood pressure was assessed. Patients were divided into 2 groups according to the baseline CACS (> 300 and ≤ 300), and all-cause mortality was assessed.

Results

The study population composed 48903 subjects with a mean age of 54 ± 9. There were 425 (0.9%) deaths during follow-up. At baseline, SBP (systolic blood pressure) more than 110 mmHg and DBP (diastolic blood pressure) more than 80 mmHg was associated with increased risk for CACS > 300. In patients with baseline CACS ≤ 300, all-cause mortality was increased in patients with SBP of 110-119 mmHg (HR 1.47, p = 0.023), 130-139 mmHg (HR 1.72, p = 0.002) and ≥ 140 mmHg (HR 1.47, p = 0.042) compared to SBP of 120-129 mmHg, whereas DBP did not predict all-cause mortality. In contrast, SBP was not associated to all-cause mortality in patients with CACS > 300, whereas DBP < 60 mmHg (HR 3.53, p =0.018) and 70-79 mmHg (HR 2.21, p = 0.042) was associated with increased risk for all-cause mortality compared to DBP of 80-89 mmHg.

Conclusion

Low DBP was associated with increased risk for all-cause mortality in subjects with high CAC score, suggesting high-risk for coronary artery disease. However, this J-curve relation was not shown in the population with low CAC score.
499 Delayed distal migration of a balloon expandable valve-in-valve transcatheter aortic valve: a clinical case and review of the literature
Authors: Andrikopoulou E , Kim A Y K , Shook D C S , Sobieszczyk P S S , Pelletier M P P , Kaneko T K , Shah P B S , Sun Y P S
Published: January 2020

Case Presentation

A 70 year old man presented with recurrent dyspnea and new decrease in his left ventricular ejection fraction 5 months following valve-in-valve (ViV) TAVR (26 mm). A TEE revealed migration of his ViV TAVR towards the left ventricular outflow tract (LVOT) with resultant severe paravalvular leak (Figure 1A, 1B, 1C; yellow arrow showing the TAVR, red arrow showing the previously implanted bioprosthetic surgical aortic valve). A 29 mm balloon expandable TAVR was placed and deployed higher to ensure anchoring of the device and adequate sealing of the area of paravalvular leak (Figure 1D, 1E, 1F). This resulted in resolution of regurgitation with an intraoperative transvalvular gradient of 10 mmHg. At his 3-month follow-up visit, a TTE showed a well-seated TAVR with mild paravalvular leak and a mean gradient of 17 mmHg. He successfully completed cardiac rehab and his dyspnea improved to mild.

Discussion

As the population ages and younger patients receive surgical aortic bioprostheses (SAVR), the rates of deteriorated SAVR’s is only expected to grow in the future. The use of TAVR is now established as an alternative to redo surgery in patients with deteriorated SAVR"s, therefore, it is crucial to be able to recognize and treat device-related complications in a timely manner. The occurrence of distal migration of TAVR, i.e. displacement of the device towards the LVOT, is rare. The vast majority of cases are noted intra-procedurally; few delayed cases have also been reported, the latest being 3 years after placement. Device migration can lead to various complications, namely obstruction of the coronary ostia and myocardial infarction, severe paravalvular regurgitation and depending on the geometry of the LVOT and the mitral valve, the displaced device may impinge on the anterior leaflet of the mitral valve and cause severe mitral regurgitation. Treatment options include either open surgical removal of the migrated valve and placement of a SAVR or implantation of a ViV TAVR. The decision should be personalized after accounting for patient and device-related characteristics: the patient’s overall STS score, the presence and severity of LVOT calcification, uniformity and extent of aortic leaflet calcifications, height of the coronary ostia, optimal valve sizing and expansion and coaxial positioning of the TAVR. Prompt recognition and management of TAVR migration is critical to ensure optimal short and long-term outcomes in TAVR patients, especially as the indication of use keeps expanding and as TAVR recipients keep getting younger.

Abstract 499 Figure. TAVR migration:pre and post-intervention
501 A common finding with an atypical (rare) presentation
Authors: Rigueira J , Cunha N , Ferreira R , Rodrigues M , Silva J , Junqueira N , Nobre A , Pinto F J , Almeida A G
Published: January 2020

Introduction

Hypereosinophilic syndrome (HES) is characterized by persistent eosinophilia and eosinophil-mediated organ damage. Cardiac thrombosis and thromboembolic complications are common causes of morbidity and mortality in these patients. The echocardiogram is the first method of image in the assessment of cardiac involvement by HES.

Clinical Case

An 81 year-old male, with previous history of hypereosinophilia under investigation without specific treatment, presented to the emergency department after several episodes of syncope and exertional dyspnea. The patient denied fever. He was hemodynamically stable and had a holosystolic murmur (III/VI) audible in the entire precordium.

The ECG was normal. The blood tests showed leukocytosis (26.69 x10^9/L) mainly related to hypereosinophilia (17.5 x10^9/L), thrombocytopenia (134.000/uL), elevation of troponin (hsTnT= 276 ng/L, normal range <14) and reactive C-protein (3.27mg/dL, normal range <0.5).

The transthoracic echocardiogram (limited for the acoustic window) showed a mass in the aortic valve with obstruction of the left ventricle outflow tract (LVOT) during systole (maximum velocity= 3.85m/s, maximum gradient = 59mmHg, mean gradient = 31mmHg), moderate mitral regurgitation, left ventricle hypertrophy with normal ejection fraction and mild pericardial effusion.

A transesophageal echo (TEE) was performed confirming the presence of a hyperechogenic sessile mass, with irregular contours, measuring 23x30 mm, attached to the aortic valve causing obstruction of the LVOT (Figure 1 A and B – TEE midesophageal long axis in diastole and systole, respectively; C and D - TEE midesophageal short axis in diastole and systole, respectively).

The patient was submitted to emergent cardiac surgery for excision of the mass and aortic valve replacement (Figure 1E and F- intraoperative and macroscopic views of the mass, respectively). The anatomopathological diagnosis confirmed an aortic valve thrombus.

Discussion/Conclusion: Native aortic valve thrombosis is a rare situation with severe complications like acute myocardial infarction, peripheral ischemia, stroke, cardiogenic shock and sudden death.

In HES, cardiac involvement is present in up to 40-50% of patients, mainly with endomyocardial fibrosis and mural thrombus formation. Native and prosthetic mitral valve thrombosis has also been described, but aortic valve involvement is very unusual.

Thrombi are one of the most common intracardiac masses, but here we present a rare case of native aortic valve thrombosis with high risk of sudden cardiac death, possibly related to HES. The echocardiogram, particularly the transesophageal echo was essential for the identification of the mass and surgical planning, but as usual in intracardiac masses, the final diagnosis was histological.

Abstract 501 Figure.
505 Car accident, an unusual cause of acute severe mitral regurgitation due to anterolateral papillary muscle rupture
Authors: El Jattari H , Snijders E , Laga S , Van Berendoncks A
Published: January 2020

A 52-year-old man was admitted to the emergency department of the University Hospital after being involved in a car crash. At first he was alert with stable vital parameters. There was bilateral rales on lung auscultation, without further prominent aberrant findings at the initial clinical examination. Shortly after, he became agitated with respiratory distress, resulting into respiratory insufficiency. Computed tomography (CT) scan of the thorax showed multiple rib fractures, a translated sternal fracture and pulmonary contusion. After intubation and stabilization he was transferred to the Intensive Care Unit (ICU), where his respiratory and cardiovascular parameters progressively worsened, leading to cardiogenic shock. An urgent chest X-ray revealed a tension pneumothorax with mediastinal shift to the right, for which a chest tube was inserted in the left hemithorax. No or little improvement was seen after this intervention. Therefore, an emergency transthoracic echocardiography (TTE) was performed. Subcostal view showed a severe mitral regurgitation with a mass in the left atrium. Because of a limited transthoracic window, we proceeded to a transoesophageal echocardiogram (TEE). A completely ruptured anterolateral papillary muscle of the mitral valve was seen, protruding in the left atrium and resulting in severe mitral regurgitation (Figure). Other echocardiographic findings were a hyperdynamic systolic function of the left ventricle, a hypo-contractile right ventricle with a mild-to-moderate quantity of pericardial effusion. Taking into account the increased cardiovascular risk profile of the patient, a coronary angiography was performed and showed normal coronary anatomy. Consequently, urgent surgical intervention was performed. Perioperative assessment confirmed the earlier described echocardiographic findings. Due to severe laceration of the left ventricular wall at the level of the attachment site of the anterolateral papillary muscle, reconstructive surgery was not possible. The anterolateral papillary muscle head with the attached mitral valve leaflet was fully excised with repair of the concealed myocardial rupture site. A mechanical mitral valve prosthesis and an intra-aortic balloon pump for hemodynamic support were placed. After four days the balloon pump was removed and the tenth day after admission the patient was extubated.

Conclusion

Acute severe mitral regurgitation due to papillary muscle rupture is a rare but potential fatal complication of a blunt trauma. TOE is essential in early diagnosis.

Abstract 505 Figure 1
553 Acute re-distribution of regional left ventricular work by cardiac resynchronization therapy determines long-term remodelling
Authors: Duchenne J , Aalen J M , Cvijic M , Larsen C K , Galli E , Bezy S , Beela A S , Winter S , Penicka M , Hopp E , Kongsgard E , Donal E , Fehske W , Smiseth O A , Voigt J U
Published: January 2020

Background

In patients with dilated cardiomyopathy and left bundle branch block (LBBB), different regions of the left ventricle (LV) have been shown to perform different amounts of work. In this study, we investigate the acute impact of cardiac resynchronization therapy (CRT) on regional LV work distribution and its relation to long-term reverse-remodelling.

Methods

We recruited 140 heart failure patients, referred for CRT. Regional myocardial work was calculated from non-invasive echocardiographic segmental stress-strain-loop-area before and immediately after CRT. The magnitude of volumetric reverse-remodelling was determined from the change in LV end-systolic volume (ESV), 11 ± 3 months after implantation. Characteristics of patients with the lowest and highest quartile of LV ESV reverse remodelling (LV ESV reduction of less than 10% and LV ESV reduction of more than -48%) were compared.

Results

Before CRT, myocardial work showed significant differences among the walls of the LV (Figure A). CRT caused an acute re-distribution of myocardial work, on average with most increase in the septum and most decrease laterally (all walls p < 0.05) and lead to a homogeneous work distribution (Figure B). The acute change in the difference between lateral and septal wall work (Δ Lateral-to-septal work) correlated significantly with LV ESV reverse-remodelling (r = 0.63, p < 0.0001). The smallest changes in work were seen in the patients with the least LV ESV reverse remodelling (Figure C, red markers), while patients with the most LV ESV reverse remodelling showed the largest changes in work (Figure C, green markers). In multivariate linear regression analysis, including conventional parameters such as pre-implant QRS duration, LV ejection fraction, LV end-diastolic volume and global longitudinal strain, the re-distribution of work across the septal and lateral walls appeared as the strongest determinant of volumetric reverse-remodelling after CRT (R²=0.393, p < 0.0001).

Conclusions

The acute re-distribution of regional myocardial work between the septal and lateral wall of the left ventricle is an important determinant of long term reverse-remodelling after CRT-implantation. Our data suggest that modification of regional loading is the mode of action of CRT treatment.

Abstract 553 Figure.
557 Left ventricular diastolic function is a predictor of volumetric response to cardiac resynchronization therapy
Authors: Galli E , Aalen J , Duchenne J , Larsen C , Hubert A , Saade E , Le Rolle V , Leclercq C , Smiseth O , Voigt J U , Donal E
Published: January 2020

Background

Conflicting data exist about the effects of cardiac resynchronization therapy (CRT) on diastolic function (DF). Aims of the study are: 1) to assess diastolic patterns in patients undergoing CRT; 2) to evaluate the role of DF in predicting CRT-response.

Methods

193 patients (age: 67 ± 11 ms, QRS width: 167 ± 21 ms, LVEF 28 ± 8%) were prospectively included in this multicentric study. 2D-standard echocardiography was performed before CRT and at 6-month follow-up (FU). DF was assessed according to recommendations from grade I to III. In case of data in the "grey zone", DF was defined as "indeterminate". A reduction of left ventricular (LV) end-systolic volume >15% at FU identified CRT-responders (CRT-R).

Results

At 6-month FU, 132 patients (68%) were CRT-R. Figure 1 shows DF parameters in the overall population, CRT-R, and CRT-non responders (CRT-NR) before and after CRT. At multivariable analysis, grade I diastolic dysfunction at baseline was a significant independent predictor of CRT response (OR 3.02, p = 0.001) (Table 1). The addition of grade I diastolic dysfunction to a model including clinical (sex, NYHA class, ischemic cardiomyopathy) and echocardiographic parameters (LV size), significantly increase the model power for the prediction of CRT-response (χ2: 29 vs 44, p = 0.001).

Conclusions

Before CRT, DF parameters are significantly altered in CRT-NR with respect to CRT-R. Moreover, CRT-NR experience a significant deterioration of DF after CRT. In our population, grade I diastolic function at baseline was a significant independent predictor of positive response to CRT.

Table 1 Univariable analysis Multivariable analysis Age 1.01 (0.99-1.05) 0.25 Males 0.36 (0.17-0.76) 0.008 0.57 (0.22-1.47) 0.25 CAD 0.21 (0.11-0.40) <0.001 0.31 (0.15-0.65) 0.002 NYHA 0.52 (0.31-0.88) 0.01 0.57 (0.22-1.47) 0.25 QRS 1.01 (0.99-1.02) 0.44 LVEDV 0.99 (0.99-1.00) 0.003 0.98 (0.97-1.01) 0.18 LVESV 0.99 (0.98-0.99) 0.005 1.01 (0.99-1.03) 0.28 LVEF 1.00 (0.97-1.05) 0.63 Grade I DD 4.13 (2.16-7.91) <0.0001 3.02 (1.26-7.23) 0.001 Grade II DD 0.57 (0.40-0.80) 0.001 0.87 (0.35-2.19) 0.79 Grade III DD 0.76 (0.58-1.02) 0.06

Abstract 557 Figure.
563 Early systolic function is impaired in patients with heart failure and preserved ejection fraction and is a more important predictor of clinical outcomes than diastolic function
Authors: Gu H , Webb J , Razavi R , Shah A , Carr-White G , Chowienczyk P
Published: January 2020

Funding Acknowledgements

British Heart Foundation

Aims

First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction may be impaired in heart failure with preserved ejection fraction (HFpEF), with homeostatic mechanisms preserving the overall ejection fraction. We examined whether EF1 is impaired and whether it predicts adverse outcomes in patients with HFpEF.

Methods and Results

We examined EF1 in patients with HFpEF diagnosed according to European Society of Cardiology guidelines, in subjects with pre-clinical diastolic dysfunction and in control subjects with no evidence of heart failure. The predictive value of EF1 for a combined end-point of re-hospitalisation for heart failure and death from any cause was compared to that of conventional echocardiographic and other indices. There was a progressive impairment of EF1 in patients with diastolic dysfunction and HFpEF compared to those without evidence of heart failure (P < 0.001). In 180 HFpEF patients followed for a median of 14.7 months, 101 patients reached the primary endpoint (61 deaths and 40 hospitalisations). EF1 was the most powerful predictor of events (table 1). A cut-off value of 19.4% gave hazard ratios (for EF1 < 19.4% compared to ≥19.4%) of 3.04 (figure 1), (95% confidence interval 2.014 – 4.604, P < 0.001) unadjusted, and 2.976 (1.887 – 4.695, P < 0.001) adjusted for age, gender, other echocardiographic indices (including EF, E/e’ ratio, stroke volume and left atrial volume index) and N-terminal pro-brain natriuretic peptide.

Conclusion

Early systolic function is impaired in HFpEF and is a powerful predictor of clinical outcomes. Therapies targeted at improving early systolic function may improve outcomes in HFpEF.

Table 1 HR CI (95%) P value Age 1.020 1.001 - 1.039 0.042 Female Gender 1.989 1.254 - 3.156 0.003 ln NT-proBNP 1.354 1.096 - 1.672 0.005 Haemoglobin 0.992 0.980 - 1.005 0.225 eGFR 0.997 0.988 - 1.006 0.568 Structural Heart Disease 0.748 0.439 - 1.274 0.285 Diastolic Dysfunction 0.694 0.445 - 1.082 0.107 Ejection Fraction 1.031 0.996 - 1.068 0.082 Stroke Volume index 0.963 0.940 - 0.986 0.002 TPAVF 0.995 0.980 - 1.005 0.230 EF1 0.900 0.869 - 0.932 <0.001 Multivariate analysis of predictors of events

Abstract 563 Figure 1 Kaplan-Meier Curve
565 Impact of right atrial physiology on heart failure and adverse events after myocardial infarction
Authors: Schuster A , Backhaus S J , Navarra J L , Stiermaier T , Rommel K P , Koschalka A , Kowallick J T , Lotz J , Bigalke B , Kutty S , Gutberlet M , Hasenfus G , Thiele H , Eitel I
Published: January 2020

Background

Right ventricular (RV) function is a known predictor of adverse events in heart failure and following acute myocardial infarction (AMI). While right atrial (RA) involvement is well characterized in pulmonary arterial hypertension, its relative contributions to adverse events following AMI especially in patients with heart failure and congestion needs further evaluation.

Methods

1235 MI patients underwent CMR after primary percutaneous coronary intervention (PCI) in 15 centers across Germany (n = 795 with ST-elevation MI and 440 with non ST-elevation MI). Right atrial (RA) performance was evaluated using cardiac magnetic resonance myocardial feature tracking (CMR-FT) for the assessment of RA reservoir (total strain εs), conduit (passive strain εe), booster pump function (active strain εa) and associated strain rates (SR) in a blinded core-laboratory. The primary clinical endpoint was the occurrence of major adverse cardiac events (MACE) 12 months post MI.

Results

RA reservoir (εs p = 0.061, SRs p = 0.049) and conduit functions (εe p = 0.006, SRe p = 0.030) were impaired in patients with MACE as opposed to RA booster pump (εa p = 0.579, SRa p = 0.118) and RA volume index (p = 0.866). RA conduit function was associated with clinical onset of heart failure and MACE independently of RV systolic function (multi-variable analysis HR 0.95, 95% CI 0.91-0.99, p = 0.006) while RV systolic function was no independent prognosticator (HR 0.98, 95% CI 0.96-1.00, p = 0.055). Furthermore, RA conduit strain identified low- and high-risk groups within patients with relatively preserved and reduced RV and LV systolic functions (p < 0.019 on log rank testing).

Conclusions

Right atrial impairment is a distinct feature and independent risk factor in patients following AMI and can be easily assessed using CMR-FT derived quantification of RA strain.
616 Aortic stenosis: changing with age?
Authors: Ramos Jimenez J , Hernandez S , Plaza Martin M , Zamorano Gomez J L
Published: January 2020

Introduction and aim

Aortic stenosis (AS) represents the main valve disease, thus, addressing its epidemiology and natural history becomes crucial. The aim of the present study is to shed light in the differences appearing with age in severe AS.

Methods

Observational, multicentre and prospective study of consecutive cases. Patients with severe AS, defined as aortic valve area (AVA) <1.0 cm2, and preserved left ventricle ejection fraction (LVEF≥50%) were included. Subjects under and above 85 years were compared. Low gradient (LG) was defined by mean transaortic gradient (MG) <40 mmHg and low flow (LF) by indexed stroke

volume (iSV) <35 mL/m2. LV geometry was defined according to current chamber quantification guidelines.

A p-value <0.05 was considered significant.

Results

A total of 636 patients were included, with slight predominance of females (53.9%; n = 343). No differences were found in AVA, LVEF, end-diastolic indexed values, LV mass or LV geometry between both age groups. MG and SVi were significantly lower in people over 85, who also presented more frequently with atrial fibrillation (AF) and significant mitral (MR) and tricuspid regurgitation (TR). Flow and gradient pattern vary significantly as shown in the graphic.

Conclusions

In our cohort, flow and gradient pattern in severe AS varies with age, despite no differences in LV geometry. This contrasts with previously assumed, relating LF and LG to more severe concentric hypertrophy. LF and LG can be explained by AF, significant MR and TR affecting more frequently those over 85.

Age-related differences in severe AS Less than 85 y.o. ≥85 y.o. p-value AVA (cm2) 0.73 (± 0.16) 0.72 (±0.18) 0.46 LVEF (%) 65 (±7.9) 64 (±7.8) 0.21 MG (mmHg) 41 (±14.2) 37 (±13) 0.04 iSV (mL/m2) 40 (±11) 36 (±11) 0.01 iLVEDV (mL/m2) 47 (±16) 45 (±16) 0.07 iLVMass (g/m2) 126 (±36) 127 (±36) 0.66 Normal geometry (%) 3.9 2.5 0.64 Concentric remodelling (%) 24.3 24.4 Concentric hypertrophy (%) 64.2 66.4 Eccentric hypertrophy (%) 7.6 6.7 AF (%) 12.3 19.3 0.04 Significant MR (%) 11.3 18.7 0.02 Significant TR (%) 50.4 65.7 <0.01 iLVEDV indexed LV end-diastolic volume iLVMass: indexed LV mass

Abstract 616 Figure. Age-related flow and gradient pattern