bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of temporal changes in longitudinal strain distribution during the systolic period to determine left ventricular activation sequence: a study using 2D speckle-tracking echocardiography
Authors: Hara H , Nakata T , Nagata T , Igarashi T , Murakami M , Ito H , Niwano S , Ako J
Published: November 2020

Background

Evaluation of two-dimensional (2D) speckle-tracking longitudinal strain (LS) is useful for assessing global and regional left ventricular (LV) dysfunction.

Purpose

The purpose of this study was to test the hypothesis that temporal changes in regional 2D-LS distribution, (i.e., changes in area and intensity of the negative strain), during the systolic period may reflect the LV activation sequence.

Methods

We studied 52 patients with an ejection fraction <35% who were classified into four groups: complete left bundle branch block (LBBB, QRS 162±17 ms, n=17); right ventricular pacing from inferior septum (RVP, QRS 180±29 ms, n=16); left VP from lateral branch of the coronary sinus (LVP, QRS 182±21 ms, n=9); and no conduction block (Narrow QRS, QRS 100±9 ms, n=19). Longitudinal strain was evaluated in three standard apical views, and then bulls-eye distribution maps were constructed every 50 ms from the QRS onset to aortic valve closing (AVC) and at the time of the end of QRS. Segments indicating negative strain at the end of QRS were regarded as an early contraction site. Segments with intensifying negativity of strain as it got closer to the AVC were regarded as a late contraction site.

Results

In patients with LBBB, negative strain appeared initially in the septum region. Then, the contracted area enlarged including the apical region, and the basal lateral region contracted late. On the other hand, Narrow QRS showed a few regional differences in strain at the end of QRS (standard deviation in 17-segments: Narrow QRS 1.3±0.4%*, LBBB 3.3±1.1%, RVP 3.2±1.0%, LVP 3.3±1.1%, *p<0.001), and contracted homogeneously during the systolic period. RVP and LVP showed negative strain at the end of QRS in septum and lateral regions respectively, with the contracted area becoming enlarged towards the opposite regions of the early contracted regions.

Conclusion

The 2D-LS distribution during the systolic period reflects the LV contraction process in patients with an altered ventricular activation sequence, and may have potential for identifying the regions of early activation site and subsequent activation propagation.

Funding Acknowledgement

Type of funding source: None
Key changes in indices of myocardial work in cardiometabolic disease states
Authors: Chen H.H.L , Bhat A , Chandrakumar D , Fernandez F , Kodsi M , Gan G , Tan T.C
Published: November 2020

Background

Hypertension (HTN) and diabetes mellitus (DM) are prevalent cardiovascular disease states which have been shown to be associated with adverse cardiac remodelling and subclinical myocardial dysfunction. Myocardial work (MW) indices are novel non-invasive measures of left ventricular (LV) function. We aimed to characterise key differences in MW indices in patients with these conditions.

Methods

Outpatients with HTN and DM undergoing transthoracic echocardiography (TTE; 2016–2019) at our institution were assessed and compared to healthy controls. Only patients without cardiac disease with normal diastolic parameters on TTE were recruited. Patients with impaired LV function, cardiac ischaemia or arrhythmia, structural and valvular heart disease or poor-quality images were excluded. Recruited patients were stratified into 3 groups (Group1: Healthy Controls; Group 2: HTN; Group 3: HTN-DM). MW assessment was performed using GE E-95 EchoPac v2.2 system.

Results

Three hundred patients (57.3±17.4y, 51% female) were recruited. HTN and HTN-DM patients were associated with higher resting systolic blood pressure (SBP), indexed LV mass (LVMI), e' and E/e' compared to controls but no differences were noted in these parameters between HTN and HTN-DM. Global myocardial work index (GWI) was higher in HTN patients compared to Controls but not different compared to HTN-DM. Of interest, HTN-DM patients had higher global myocardial wasted work (GWW) and lower global myocardial work efficiency (GWE) compared to HTN patients and Controls.

Conclusions

MW indices may be a sensitive tool for the detection of subclinical changes in cardiac function in cardiometabolic disease states.

Funding Acknowledgement

Type of funding source: None
Longitudinal strain reflects the interaction of myocardial contractility to afterload in rat models of hemodynamic overload-induced heart failure
Authors: Ruppert M , Lakatos B.K , Tokodi M , Karime C , Hizoh I , Olah A , Sayour A.A , Barta B.A , Merkely B , Kovacs A , Radovits T
Published: November 2020

Background

Two-dimensional (2D) speckle tracking echocardiography (STE)-derived myocardial strain parameters are sensitive markers of left ventricular (LV) systolic function. Novel findings suggest that the contractile state of the myocardium, afterload and preload are major determinants of STE measurements. However, the hypothesis that longitudinal strain expresses the interaction between contractility and loading conditions rather than contractility alone in hemodynamic overload-induced heart failure (HF) has not been tested.

Purpose

This study aimed to explore the connection between longitudinal strain and contractility, afterload and preload in rat models of pressure overload (PO)- and volume overload (VO)-induced heart failure (HF).

Methods

Pressure overload (PO)-induced HF was evoked by transverse aortic constriction ([TAC], n=14). Volume overload (VO)-induced HF was established by an aortocaval fistula ([ACF], n=12). Age-matched sham operated animals served as controls. Pressure-volume analysis was carried out to compute cardiac contractility (slope of end-systolic pressure-volume relationship [ESPVR]), afterload (arterial elastance [Ea]) and ventriculo-arterial coupling ([VAC] = Ea/ESPVR). Preload was evaluated by meridional end-diastolic wall stress (σend-diastolic). STE was performed to assess global longitudinal strain (GLS).

Results

GLS was impaired in both PO-induced HF (−5.9±0.6 vs. −12.9±0.5%, TAC vs Sham, P<0.001) and VO-evoked HF (−11.7±0.7 vs. −13.5±0.4%, ACF vs Sham, P=0.048). Hemodynamic measurements indicated that the TAC group presented with maintained ESPVR, increased Ea and enhanced σend-diastolic. In contrast, the ACF group was characterized by reduced ESPVR, decreased Ea and enhanced σend-diastolic. Ordinary least squares non-linear regression revealed that GLS was predominantly determined by afterload (Ea) in the TAC model and by contractility (ESPVR) in the ACF model. In accordance, GLS showed a strong correlation with Ea in case of PO-induced HF (R= 0.848, P<0.001) and with ESPVR in case of VO-evoked HF (R=−0.526; P=0.008), respectively. Furthermore, GLS also demonstrated strong correlation with VAC in both the TAC and the ACF models. Of particular interest, a robust correlation between VAC and GLS could also be detected in the entire study population (R= 0.654, P<0.001).

Conclusion

Both afterload and contractility define GLS. Hence, under conditions when both factors become altered, GLS reflects VAC.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NVKP_16-1-2016-0017
Atrial fibrillation recurrence after transcatheter ablation worsens left atrial strain
Authors: Annunziata R , Notaristefano F , Spighi L , Piraccini S , Giuffre' G , Deluca F , Bearzot L , D'Ammando M , Reccia M.R , Verdecchia P , Zingarini G , Cavallini C
Published: November 2020

Introduction

Left atrial strain (LAs) shows correlation with atrial fibrosis and is a predictor of atrial fibrillation (AF) recurrence after transcatheter ablation. Little is known about LAs evolution after ablation.

Purpose

We sought to evaluate the atrial function with echocardiographic strain before and 6 months after AF ablation.

Methods

65 consecutive patients undergoing radiofrequency or cryoballoon ablation for atrial fibrillation at our centre were enrolled. They underwent a transthoracic echocardiography before the procedure and at 6 months follow-up. 5 patients were excluded because of low quality images. Global left atrial strain during the reservoir phase (LASr) was calculated as a mean of the values obtained in 4 and 2 chamber apical view; the ventricular end-diastole was set as reference to allow the calculation both in patients in AF and sinus rhythm during the echocardiography. Recurrence was defined as any atrial arrhythmia episode lasting more than 30 seconds recorded on an EKG strip after the 3 months blanking period; all patients underwent a 24 hours EKG Holter after the blanking period to detect asymptomatic recurrence. Quality of life was assessed before the procedure and at follow-up with the EQ-5D-3L model.

Results

At 6 months 14 patients (13%) had AF recurrence. Patients with recurrence (AF-R) had similar baseline characteristics compared to those without recurrence (AF-NR) but the former had a longer history of AF (39±53 vs 85±94 months, p=0,018). LASr, LA volume and left ventricle ejection fraction (EF) were similar at baseline between groups. At follow-up LASr was significantly impaired in the AF-R group compared to AF-NR (14±6% vs 26±10% respectively, p<0,0001) whereas LA volume, LV end systolic volume and EF remained similar. Compared to baseline LASr worsened in patients experiencing AF recurrence (22±11% vs 14±6%, p=0.016) and this finding was consistent also in patients in sinus rhythm during both examinations (29±8 vs 17±7, p=0,005). Compared to baseline LASr (22±10% vs 26±10%, p=0.024), LV end-systolic volume (29±15 ml vs 22±6 ml, p=0,006) and EF (51±9% vs 58±18%, p=0,038) improved in the AF-NR group but the effect was driven mainly by patients restoring sinus rhythm. Both groups showed a significant improvement of the quality of life (55±23 vs 85±13, p<0,0001 AF-NR; 63±17 vs 80±12, p=0,012 AF-R).

Conclusions

Atrial fibrillation recurrence after transcatheter ablation is associated with significant left atrial strain worsening which indicates disease progression and may predispose to further long-term recurrences whereas a successful ablation has a protective effect on atrial function.

Funding Acknowledgement

Type of funding source: None
Left atrial size derived by non-contrast cardiac computed tomography and risk of incident atrial fibrillation
Authors: Fredgart M.H , Lindholt J.S , Brandes A , Steffensen F.H , Frost L , Lambrechtsen J , Karon M , Busk M , Urbonaviciene G , Egstrup K , Diederichsen A.C.P
Published: November 2020

Introduction

Left atrial (LA) size is an independent predictor of cardiovascular outcome. While performing non-contrast computed tomography (NCCT), LA size is readily available, and a single cross-section area provides a accurate estimate of LA enlargement.

Purpose

The purpose of this study was to examine if enlarged LA measured by a NCCT scan was an independent risk factor of subsequent atrial fibrillation or flutter (AF).

Methods

The Cardiovascular Screening Trial; a population-based multicenter randomized screening trial, consisting primarily of men aged 60–74 years were randomly allocated (1:2) for screening.

NCCT was performed and LA area was manually traced in a single axial slice excluding the pulmonary veins at mitral valve level. LA size was indexed to body surface area. Indexed LA area was divided into five categories (defined by standard deviations). Hospital admission due to AF were identified using data from the National Patient Registry using ICD-10 codes (DI48-DI489).

Results

Between 2014 and 2019, 14,986 participants were enrolled, of these 13,410 without known AF were eligible for follow-up. During 2.3±1.0 years of follow-up 301 developed incident AF, corresponding to an incidence rate of 10.0 per 1,000 person-years.

Figure 1 shows the Kaplan-Meier of incident AF stratified by categories of LA (p<0.0001). A very large LA was associated with a four-fold higher risk of incident AF in the fully adjusted analysis (HR (95% CI): 4.0 (2.6–5.8), p<0.0001), and a two-fold higher risk by a large LA (HR (95% CI): 2.0 (1.5–2.6), p<0.0001) (Table 1).

Conclusion

An enlarged LA area measured by NCCT was associated with a two to four-fold higher risk of incident AF. The prognostic use of LA area provides an individual risk assessment during NCCT for other purposes.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported by the University of Southern Denmark and the Region of Southern Denmark.
Clinical risk score for prediction of early left ventricular thrombus after percutaneous coronary intervention for ST-elevation myocardial infarction
Authors: Reinstadler S , Holzknecht M , Reindl M , Tiller C , Lechner I , Mayr A , Brenner C , Klug G , Bauer A , Metzler B
Published: November 2020

Background

Cardiac magnetic resonance (CMR) is the reference standard for left ventricular (LV) thrombus detection in patients with acute ST-elevation myocardial infarction (STEMI). However, routine CMR imaging is currently not recommended post-STEMI.

Objective

This observational study sought to develop a practical risk score for the prediction of early LV thrombus formation after STEMI to identify patients in whom routine CMR might be appropriate.

Methods and results

Five hundred and fifty-six consecutive patients underwent transthoracic echocardiography (TTE) and CMR at 3 [IQR: 2–4] days after primary percutaneous coronary intervention (PCI) for acute STEMI. A LV thrombus was visualized in 12 patients (2.2%) using TTE and in 22 patients (4%) using CMR. A weighted risk score including multivariable associates of LV thrombus formation (LV ejection fraction by TTE, peak high-sensitivity cardiac troponin T and peak high-sensitivity C-reactive protein) and left anterior descending coronary artery as culprit vessel, with a range of 0 to 7 points (median risk score: 2 points) showed a strong and significantly higher area under the curve (0.93 (95% CI 0.88–0.97; p<0.001)) for LV thrombus prediction than each individual risk factor alone (p<0.001). The sensitivity and the specificity of the risk score was 91% and 80%, respectively. The incidence of LV thrombi was 0% in the very low risk group (0 to 1 points, n=248), 1.8% in the low risk group (2 to 4 points, n=219) and 20.2% in the high risk group (5 to 7 points, n=89). Eighty-two percent of all LV thrombi occurred in the high risk group (number needed to scan to detect one LV thrombus=5).

Conclusions

The proposed risk score provides incremental value for the prediction of early LV thrombus and could be useful to identify STEMI patients in whom routine CMR for LV thrombus evaluation could be most meaningful. Additional investigation is warranted to validate the clinical application of the score.

Funding Acknowledgement

Type of funding source: None
Role of myocardial T1 mapping in arrhythmogenic right ventricular cardiomyopathy
Authors: Georgiopoulos G , Zampieri M , Molaro S , Chaloupka A , Barra B , Roberts L , Monje-Garcia L , Evans C , Sheikh N , Bastiaenen R , Masci P.G , Carr-White G , Finocchiaro G , Chiribiri A
Published: November 2020

Background

T1 mapping by cardiovascular magnetic resonance (CMR) is an accurate tool to assess myocardial extracellular space with wider clinical applications in the aetiological characterization of cardiomyopathies. The aims of the study were to explore a possible role of myocardial T1 mapping in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and in first-degree relatives at risk and to investigate the possible relationship between left ventricular (LV) involvement at CMR and ECG features.

Methods

Thirty patients with ARVC (47% males, mean age 42±22 years) and 59 first-degree relatives who did not fulfil ARVC diagnostic Task Force criteria, underwent full diagnostic work-up including CMR with native and post-contrast T1 mapping.

Results

The CMR was abnormal in 26 (86%) patients with ARVC. The RV was affected in isolation in 13 (43%) patients. Prior to T1 mapping assessment, 2 (7%) patients exhibited isolated LV involvement and 11 (36%) patients showed features of biventricular disease. Left ventricular involvement was manifested as detectable LV late gadolinium enhancement (LGE) in 12 out of 13 cases. According to pre-specified septal T1 mapping thresholds, 11 (37%) patients showed abnormally high native T1 values. Myocardial T1 mapping was higher than normal in 5 (17%) patients who would have been classified as exhibiting a normal LV by conventional imaging. The proportion of patients with abnormal T1 values was similar in patients with or without LGE. Myocardial T1 mapping was higher than normal in 22 (37%) of the 59 first-degree relatives.

Conclusions

Native and/or post contrast myocardial T1 values are raised in almost half of patients with ARVC and in a similar proportion of unaffected first-degree relatives. T1 mapping offers the potential for early detection of LV involvement in patients with ARVC and in first-degree relatives at risk.

Funding Acknowledgement

Type of funding source: None
Contrast-agent free evaluation of cardiomyopathies with T1 mapping and the new fast strain-encoded (fSENC) magnetic resonance imaging
Authors: Hirschberg K , Paul O , Salatzki J , Andre F , Riffel J , Ochs M , Vago H , Merkely B , Katus H.A , Friedrich M
Published: November 2020

Background

Cardiomyopathies (CMP) may cause impairment of cardiac function and structure. Cardiac Magnetic Resonance Imaging (CMR) is used for analysis and risk stratification of CMP by Late Gadolinium Enhancement (LGE). However, T1 mapping (T1) and fast strain encoded (f-SENC) sequences allow contrast-free and faster exams. The aim of this study was to characterize CMP by T1 and f-SENC to develop a faster and safer CMR protocol (fast-CMR).

Methods

CMP scans from our CMR database were retrospectively analyzed. All patients were scanned at 1.5T/3T scanner. Study groups were divided as follows: Patients with normal findings, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), hypertensive heart disease (HHD) and cardiac amyloidosis. Global T1 times, longitudinal (GLS) and circumferential (GCS) strain using f-SENC of study groups were compared to healthy individuals (controls). Scan time and amount of gadolinium-based contrast agent (CA) in CMR-protocol with LGE were compared to fast-CMR.

Results

174 patients and 31 controls were recruited. T1 times, GLS and GCS were similar between controls and normal individuals. T1 times were significantly increased (p<0.05), while GLS and GCS were significantly reduced (p<0.05) in all CMR study groups compared to controls (Table 1). Using fast-CMR 21 (±6) min of scan time were saved, about 47%, and 9 (±2) ml of CA were saved per patient.

Conclusion

Normal findings could be identified by fast-CMR without contrast agent. Fast CMR might also be a useful tool to identify different forms of CMP.

Funding Acknowledgement

Type of funding source: None
Cardiomyopathy phenotyping and risk-stratification in danon disease
Authors: Rigolli M , Khan A , Brambatti M , Contijoch F , Adler E
Published: November 2020

Background

Danon Disease (DD) is a rare, X-linked vacuolar myopathy due to mutations in Lysosomal Associated Membrane Protein 2 (LAMP-2). Though it is strongly associated with severe cardiomyopathy, heart failure and sudden death, there is no data on typical cardiac magnetic resonance (CMR) imaging characteristics in DD and their association with clinical severity and outcome.

Purpose

To phenotype and risk-stratify DD patients.

Methods

CMR scans of confirmed DD patients recruited in a global registry were prospectively analyzed for biventricular volumes, ejection fraction (EF), left ventricular (LV) strain, mass (LVM) and late gadolinium enhancement (LGE) in a core-lab blinded fashion. A major adverse cardiac event (MACE) was a composite of death, heart transplant and implantable cardioverter defibrillator (ICD) for secondary prevention.

Results

12 DD patients (5 males [42%], median age 13 yrs [interquartile range (IQR) 5]) were included. LV hypertrophy (LVH) was present in 10/12 (83%), associated with LV dilation in 2 females. LVH was typically asymmetric in females (5/7) and concentric in males (3/5); right ventricular (RV) hypertrophy frequent in females (4/7). LV strain was reduced (global circumferential strain [GCS] −12±4%) and LGE common (73%), often extensive and always sparing the basal-mid septum. LGE was strongly associated with heart failure (BNP r=0.9, p=0.0021). Patients with MACE (6 [50%], median follow-up 2.9 yrs) had elevated LVM (241±63 g, p=0.032), impaired LV strain (GCS: −9.8±3.9, p=0.02) and higher LGE mass (median 56 g [IQR 35], p=0.021) compared to those without events during follow-up (LVM 155±56 g, GCS −14.9±1.6, LGE mass 0 g [IQR 8]). CMR characteristics were predictors of MACE (LV strain: hazard ratio [HR] 1.4, p=0.021; LGE mass: HR 1.1, p=0.03).

Conclusions

LGE sparing the basal-mid septum was pathognomonic in DD. LVH with reduced LV strain was the most common DD phenotype but the spectrum included LV dilation and RV hypertrophy in females. CMR characteristics (LV strain and LGE) were associated with heart failure and predicted worse outcome (heart transplant and fatal arrhythmias). CMR phenotyping and risk-stratification of this severe and underrecognized cardiomyopathy may aid diagnosis and clinical management in DD patients who need selection for early heart transplant, ICD implantation and targeted gene therapy.

Danon Disease Phenotypes and Outcome

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): National Institute of Health and Rocket Pharmaceuticals
Clinical significance of left atrial geometry in patients with dilated cardiomyopathy: a cardiovascular magnetic resonance study
Authors: Yazaki M , Nabeta T , Inomata T , Maemura K , Oki T , Fujita T , Ikeda Y , Ishii S , Naruke T , Ako J
Published: November 2020

Background

Left atrial (LA) enlargement is associated with cardiac events in patients with dilated cardiomyopathy (DCM). However, the clinical significance of LA function and geometry in patients with DCM remains uncertain. Cardiac magnetic resonance (CMR) is the current gold standard modality to assess LA function and geometry.

Purpose

The aim of the present study was to investigate the clinical significance of LA parameters assessed by CMR in patients with DCM.

Methods

The present study included patients with DCM and sinus rhythm who underwent CMR between December 2007 and April 2018. LA volume was measured using CMR. LA empty fraction was calculated according to LA volume differences. The LA sphericity index was computed as the ratio of the measured LA maximum volume to the volume of a sphere with maximum LA length diameter (Figure 1A). We investigated the relationship between LA parameters measured by CMR and hospitalization for heart failure (HF).

Results

We included 255 patients in this study. During the mean follow-up of 3.66 [1.85–6.25] years, hospitalization for HF occurred in 37 patients (14.5%). Although there were no significant differences in LA volume and LA empty fraction between patients with HF hospitalization and those without, LA sphericity index was significantly higher in patients with HF hospitalization than in those without (0.78±0.35 vs. 0.58±0.18, P<0.001). Multivariable Cox regression analysis identified higher LA sphericity index (per 0.1 increase) as an independent predictor of hospitalization for HF (hazard ratio, 1.23; 95% confidence interval, 1.10–1.35, P<0.001). Moreover, Patients were categorized based on the median of the LA sphericity index. The Kaplan-Meier curve showed that patients with high LA sphericity index (≥0.57) had a significantly higher risk of hospitalization for HF than those with low LA sphericity index (<0.57) (Figure 1B).

Conclusions

LA sphericity index was an independent predictor of hospitalization for HF. Assessment of LA geometric parameter including LA sphericity might be useful for risk stratification toward worsening HF in patients with DCM.

Figure 1

Funding Acknowledgement

Type of funding source: None
Structural and functional reverse myocardial remodeling following transcatheter aortic valve replacement
Authors: Lange T , Backhaus S.J , Beuthner B.E , Topci R , Rigorth K.R , Lotz J , Seidler T , Puls M , Jacobshagen C , Hasenfuss G , Schuster A
Published: November 2020

Background

Myocardial reverse remodeling determines outcome in patients with severe aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR). However, little is known about the interplay of myocardial function and structure after TAVR. Since cardiac magnetic resonance (CMR) imaging allows comprehensive quantification of both structure and function we aimed to assess changes in myocardial tissue composition and deformation before and following TAVR.

Methods

CMR imaging was performed in 40 prospectively enrolled patients with severe AS before and one year after TAVR. Myocardial function was characterized using volumetry and CMR-feature-tracking (FT) deformation imaging of left ventricular (LV) global longitudinal strain (GLS) and atrial function (atrial reservoir ES, conduit Ee and booster pump strain EA). Myocardial structure was assessed using T1 mapping and late gadolinium enhancement (LGE) analysis. LV cellular and matrix volumes were calculated based on extra cellular volume fraction (ECV) and LV mass. CMR-FT results were compared to a control group of twenty patients with normal biventricular function. Moreover, biomarkers (NT-proBNP), functional (six-minute-walking-test) and clinical status (NYHA, Minnesota LIVING WITH HEART FAILURE score) were determined at baseline and one-year follow-up.

Results

Regression of both cellular (−20.6%, p<0.001) and matrix volumes (−12.3%, p=0.003) and subsequently increased ECV (+9.0%, p=0.001) were documented one year after TAVR. Ventricular and atrial strains were impaired at baseline (GLS p=0.004, Es p<0.001, Ee p<0.001) and recovered during follow-up (GLS p<0.001, Es p=0.005, Ee p=0.001). These changes were paralleled by improvements in NYHA (p<0.001) and Minnesota (p<0.001) scores as well as decline in NT-proBNP levels (p=0.001). There was a significant association of LV fibrosis as defined by matrix volume and extent of LGE and ventricular and atrial functional impairment (correlation of matrix volume and: GLS r=0.57, p<0.001, Es r=−0.44, p=0.009; correlation of LGE%LV and: GLS r=0.41, p=0.015, Es: r=−0.4, p=0.02, and Ea: r=−0.41, p=0.02).

Conclusion

Regression of fibrosis and cellular hypertrophy determine improved myocardial function and recovery from heart failure following TAVR. Prognostic implications of the observed changes will need to be explored next to identify makers and therapeutic targets for optimized management of these patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation (DFG, CRC 1002, D1)
Right ventricular longitudinal strain measured using feature-tracking cardiac magnetic resonance is an independent predictor of all cause mortality in patients with severe tricuspid regurgitation
Authors: Romano S , Dell'atti D , Judd R , Kim R , Weinsaft J , Kim J , Heitner J , Farzaneh-Far A
Published: November 2020

Introduction

Tricuspid regurgitation imposes a volume overload on the right ventricle (RV) that can lead to progressive RV dilation and dysfunction. Overt RV dysfunction is associated with poor prognosis and increased operative risk. Abnormalities of myocardial strain may provide the earliest evidence of ventricular dysfunction. CMR feature-tracking techniques now allow assessment of strain from routine cine-images, without specialized pulse sequences. Whether abnormalities of RV strain measured using CMR feature-tracking have prognostic value in patients with tricuspid regurgitation is unknown

Purpose

To evaluate the prognostic value of CMR feature-tracking derived RV free wall longitudinal strain (RVFWLS) in a large multicenter population of patients with severe tricuspid regurgitation.

Methods

Consecutive patients with severe tricuspid regurgitation undergoing CMR at four US medical centers were included in this study. Feature-tracking RVFWLS was calculated from 4 chamber cine-views (Figure-left panel). The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between RVFWLS and death. The incremental prognostic value of RVFWLS was assessed in nested models.

Results

Of the 406 patients in this study,115 died during a median follow-up of 8.8 years. By Kaplan-Meier-analysis, patients with RVFWLS ≥median (−16%) had significantly reduced event free survival compared to those with RVFWLS < median (log-rank p<0.001) (Figure-right panel). By Cox multivariable regression modeling, each 1% worsening in RVFWLS was associated with a 13% increased risk-of-death after adjustement for clinical and imaging risk factors (HR=1.13 per %; p<0.001). Addition of RVFWLS in this model resulted in significant-improvement in the global-chi-square (26 to 65; p<0.0001).

Conclusions

CMR feature-tracking derived RVFWLS is an independent predictor of mortality in patients with severe tricuspid regurgitation, incremental to common clinical and imaging risk factors.

Funding Acknowledgement

Type of funding source: None
Cardiac magnetic resonance derived left atrial function after ST-elevation myocardial infarction: an important prognostic indicator
Authors: Nayyar D , Nguyen T , Pathan F , Vo T , Richards D , Thomas L , Dimitri H , Otton J
Published: November 2020

Background

The prognostic value of cardiac magnetic resonance (CMR) derived left atrial (LA) strain, ejection fraction (LAEF) and volumes (LAVImax and LAVImin) after STEMI is controversial.

Aim

To assess the relationship between LA function and major adverse cardiovascular events (MACE) within 2 years after STEMI.

Methods

We prospectively recruited 213 consecutive STEMI patients who underwent CMR at median day 4. 202 patients had complete CMR data for feature tracking assessment. LA reservoir and booster strain were quantified by one blinded observer based on the average of three independently repeated measurements from two- and four-chamber views. MACE was a composite of all-cause mortality, reinfarction, new or worsening heart failure, stroke and sustained ventricular arrhythmias.

Results

The cohort included 174 (86.1%) males, median age 56 years (IQR 50–65 years). MACE occurred in 35 (17.3%) patients. Patients with MACE had lower median reservoir strain (18.9 vs 29.4%, p<0.001), booster strain (9.4 vs 13.0%, p=0.002) and LAEF (41.5 vs 49.2%, p<0.001), and higher LAVImax (43.5 vs 38.6ml/m2, p=0.019) and LAVImin (23.7 vs 19.3ml/m2, p<0.001) than patients without MACE. Patients with reduced left ventricular ejection fraction (LVEF≤40%) had lower median reservoir strain (22.5 vs 30.1%, p<0.001), booster strain (11.3 vs 12.9%, p=0.021) and LAEF (43.3 vs 50.3%, p<0.001) than patients with LVEF>40%. AUC analyses showed reservoir strain (AUC 0.769; 95% CI 0.676–0.861, p<0.001), booster strain (AUC 0.684; 95% CI 0.558–0.810, p=0.002) and LAEF (AUC 0.698; 95% CI 0.596–0.800, p<0.001) predicted MACE. Kaplan Meier analyses showed a difference in MACE between high- and low-risk groups for reservoir strain (cutoff 21%, p<0.001), booster strain (cutoff 9.6%, p<0.001) and LAEF (cutoff 41%, p<0.001). Univariate Cox regression analyses showed all LA parameters had a significant effect on MACE, while multivariate analyses found additional prognostic utility using reservoir strain.

Conclusion

LA reservoir strain provided incremental prognostic value beyond established clinical and CMR parameters for predicting MACE after STEMI.

Kaplan Meier analyses

Funding Acknowledgement

Type of funding source: None
Performance of different myocardial tissue tracking algorithms and acquisition-based strain imaging to characterise myocardial pathology
Authors: Backhaus S.J , Metschies G , Zieschang V , Erley J , Zamani S.M , Kowallick J.T , Lapinskas T , Pieske B , Lotz J , Kutty S , Hasenfus G , Kelle S , Schuster A
Published: November 2020

Background

Myocardial deformation imaging is superior in risk-stratification compared to volumetric approaches. Myocardial Feature-Tracking (FT) allows easy post-processing of routinely acquired cine images. Since there is no clear recommendation regarding FT post-processing we sought to compare different FT-strains with reference standard techniques including tagging and strain encoded (SENC) magnetic resonance imaging.

Methods

CMR-FT software from 4 different vendors (TomTec, Medis, Circle, Neosoft), CMR tagging (Segment) and fastSENC (MyoStrain) were used to determine left ventricular (LV) global longitudinal and circumferential strains (GLS and GCS) in 12 healthy volunteers and 12 heart failure patients. Variability and agreements were assessed using intraclass correlation coefficients, coefficients of variation and Bland Altman plots.

Results

Compared to tagging, FT-based strain was software independently significantly higher except for GCS using Medis (p=0.178). Compared to fSENC, mean-differences of GLS were smaller within a range of ±1.5%. For GCS this only applied to CVI and Medis (<1.5%) but not TomTec (>7%) or Neosoft (>4%). Absolute agreements comparing FT to tagging were best for CVI (GLS ICC0.70) and Medis (GCS ICC0.85). Compared to fSENC agreement of GLS was generally excellent (ICC>0.77), but only CVI and Medis revealed excellent agreement for GCS (ICC0.88 and 0.85). Consistency and correlation of GLS were software independently high compared with tagging and fSENC (ICC>0.86, r>0.76) while being lower for GCS (ICC>0.68, r>0.72).

Conclusion

Although agreement differs between deformation assessment approaches, consistency and correlation are high irrespective of the method chosen, thus indicating reliable strain assessment. Further standardisation and introduction of uniform references is warranted for clinical routine implementation.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): DZHK - German Centre for Cardiovascular Research
Safety and prognostic value of vasodilator stress CMR in patients with heart failure and reduced ejection fraction
Authors: Pezel T , Sanguineti F , Kinnel M , Landon V , Garot P , Hovasse T , Unterseeh T , Champagne S , Louvard Y , Morice M.C , Garot J
Published: November 2020

Background

Recent data suggest that patients with HFrEF (heart failure with reduced left ventricular ejection fraction (LVEF) <40%) referred for stress cardiovascular magnetic resonance (CMR) may have a less optimal haemodynamic response to intravenous vasodilator. The prognostic value of stress CMR has been poorly investigated in this population.

Purpose

To assess the safety and the prognostic value of vasodilator stress perfusion CMR in patients with HFrEF.

Material

Between 2008 and 2018, we prospectively included consecutive patients with HFrEF referred for vasodilator stress perfusion CMR with dipyridamole. HFrEF was defined by a previous history of HF and known LVEF <40%. All patients with LVEF ≥40% measured by CMR were excluded.

They were followed for the occurrence of major adverse cardiovascular events (MACE) defined by cardiovascular death or nonfatal myocardial infarction (MI). The secondary endpoint was a composite outcome of cardiovascular death or rehospitalization for acute HF defined by the use of intravenous diuretics. The safety of the stress perfusion CMR was assessed by clinical monitoring for 1 hour after the end of the CMR.

Univariable and multivariable Cox regressions were performed to determine the prognostic association of inducible ischemia or late gadolinium enhancement (LGE) by CMR.

Results

Of 1084 patients with HFrEF (65±11 years, median LVEF 34.6±4.9%), 1049 (97%) completed the CMR protocol and among those 952 (91%) completed the follow-up (median 5.6±2.4 years). Reasons for failure to complete CMR included declining participation (n=11), renal failure (n=9), intolerance to stress agent (n=8), claustrophobia (n=4) and poor gating (n=3).

Stress CMR was well tolerated without occurrence of death or severe disabling adverse event. Among patients who underwent CMR, 600 (57%) were diagnosed with MI defined by LGE. Patients without inducible ischemia or LGE experienced a substantially lower annual event rate of MACE (1.8%) than those with ischemia and without LGE (9.4%), or those with both ischemia and LGE (12.0%; p<0.001 for all). Using Kaplan-Meier analysis, the presence of inducible ischemia and LGE were significantly associated with the occurrence of MACE (hazard ratio [HR], 2.46 [95% CI, 1.69–3.59]; p<0.001) (Figure). In multivariable stepwise Cox regression including clinical characteristics and CMR, the inducible ischemia was an independent predictor of a higher incidence of MACE at follow-up (adjusted HR, 2.26 [95% CI, 1.52–3.35]; p<0.001). However, there was no significant difference between patients with or without ischemia for the secondary outcome (p=0.28).

Conclusions

Stress CMR is safe and has a good discriminative prognostic value to predict the occurrence of MACE in patients with HFrEF.

Kaplan-Meier curves for MACE

Funding Acknowledgement

Type of funding source: None
T1 mapping for myocardial tissue evaluation in patients with ischemia and stable coronary artery disease: MASS V-Trial Study Group
Authors: Ribeiro M , Hueb W , Rezende P.C , Rochitte C.E , Nomura C.H , Morais T , Lima E.G , Boros G.A.B , Ribas F.F , Carvalho F.P.C , Carvalho G.F , Mocha M.R , Serrano C.V , Ramires J.A.F , Kalil Filho R
Published: November 2020

Background

T1 mapping is a magnetic resonance imaging (MRI) technique that enables the identification of myocardial structural changes during acute ischemic injury. However, it is not known whether these structural changes are present in patients with chronic effort induced ischemia.Thus, we sought to document the possible T1 mapping changes in chronic coronary artery disease (CAD) patients with documented myocardial ischemia.

Methods

Multivessel CAD patients from MASS V Trial with indication of myocardial revascularization, were evaluated for the presence of ischemia by myocardial scintigraphy. MRI with T1 mapping was performed in all patients. Based on the results of the scintigraphy, the myocardial segments were identified as ischemic and non-ischemic segments. The corresponding segments of scintigraphy and MRI were compared in relation to native T1 map (NT1), post-contrast T1 (CAT1) and extracellular volume (ECV).

Results

Of the 720 myocardial segments analyzed, there were 161 ischemic and 559 non-ischemic segments. Comparing ischemic vs non-ischemic segments, respectively, NT1 was 1022.7 (980.0–1052.0) versus 1029.3 (985.0–1066.3), p=0.57, ECV results were 25.4 (24.0–28.1) versus 26.4 (25.3–29.9), p=0.75 and CAT1 results were 492 (461.9–515.4) versus 488 (469.2–521.7), p=0.09. Myocardial segments supplied by obstructive coronary arteries were compared to those supplied by non-obstructive coronary arteries in relation to NT1 and ECV. NT1 values in obstructive and non-obstructive territories were, respectively, 1024.7 (998.5–1043.5) versus 1036.8 (1008.6–1046.9), p=0.30 and ECV results were 26.8 (24.4–29.9) versus 26.8 (24.4–30.0), p=0.90.

Conclusion

In this study, MRI identified structural similarities between chronic ischemic myocardium compared to the non-ischemic myocardium. This finding supports myocardial tissue stability in the presence of stress induced ischemia.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Zerbini Foundation and also by the FAPESP (2011/ 20876-2)
Cardiac tissue characterization with t1 and t2 mapping in anderson fabry patients: new pathophysiological concepts and early cardiac involvement
Authors: Zanoni R , Ferrara V , Lanati G , Vitale G , Di Nicola F , Pasquale F , Graziosi M , Berardini A , Ditaranto R , Niro F , Lovato L , Rapezzi C , Galie' N , Biagini E
Published: November 2020

Background

Anderson Fabry (AF) disease is a X-linked lysosomal storage disorder with multiorgan involvement. Cardiac disease, mainly represented by left ventricular hypertrophy (LVH) and arrhythmias, is the most frequent cause of premature death. It is well know that specific therapy is less effective after the development of LVH and myocardial fibrosis, therefore early cardiac detection (before LVH) is important. New cardiac magnetic resonance (CMR) parametric imaging techniques (T1 and T2 maps) enable myocardial tissue changes associated with AF disease.

Purpose

To evaluate the relationship between CMR tissue characterization and clinical and instrumental manifestations of AF disease to find early markers of cardiac involvement.

Methods

31 AF patients (9 males, mean age 49±16 years) underwent ECG, echocardiogram and contrast CMR. TnI, BNP, pro-BNP and serum lyso-Gb3 were dosed. T1 mapping was performed in a pre-contrast acquisition with the modified Look-Locker inversion recovery (MOLLI) sequences. CMR results were compared with those of 43 healthy age and gender-matched controls.

Results

In AF patients native septal T1 values were significantly lower compared to healthy controls (median 949 vs 991 msec, p=0.0137) and were inversely related to Lyso-Gb3 serum levels (p=0.003). Patients with LVH had lower T1 septal values in comparison with patients without LVH (892 vs 981 msec; p=0.0012). Patients with classic form had abnormal low T1 values more frequently than pts with late onset variant (78 vs 23%; p=0.038).

In AF patients native septal T2 values were significantly higher compared to the control group (53 vs 49 msec; p=0.0004) and correlated with troponin I (p=0.008) and NT-pro BNP (p=0.006) serum levels. No difference was found between pts with and without LVH (53.5 vs 52.5 ms; p=0.797) and the prevalence of abnormal high T2 values was similar between patients with late onset AF and pts with classical form (53% vs 50%; p=1.000). All patients with late onset AF and high T2 values were females.

Conclusions

CMR T1 (low values) and T2 (high values) mapping are useful tools to detect early cardiac involvement before LVH and to better understand the pathophysiology of cardiac disease in AF patients. Subclinical tissue inflammation, detectable through T2 maps, seems to be an additional pathogenetic mechanism related to the Gb3 storage that contributes to organ damage and precedes LVH, particularly in females patients with late onset phenotype.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Sant'Orsola-Malpighi Hospital
Cardiac amyloidosis in patients undergoing aortic valve replacement for aortic stenosis
Authors: Fukuzawa S , Fukuzawa S , Okino S , Ishiwaki H , Iwata Y , Kuroiwa N , Uchiyama T , Shibayama N
Published: November 2020

Background

Transthyretin cardiac amyloidosis (ATTR) has been increasingly recognized in patients with degenerative aortic stenosis (AS). In some reports, the uptake of Tc-99m labeled bone radiotracers in cardiac amyloidosis has been documented. Tc-99m pyrophosphate (PYP) scintigraphy in the absence of evidence of a monoclonal gammopathy was diagnostic for transthyretin cardiac amyloidosis, providing a cost-effective and non-invasive technique with a specificity and positive predictive value of nearly 100%. We sought to determine the prevalence of ATTR as detected by the bone scan tracer among the patients with severe AS requiring surgical valve replacement.

Methods

We retrospectively analyzed clinical and echocardiographical data for 44 patients with severe AS requiring surgical valve replacement between Jan. 2009 and Dec. 2016. All eligible patients were offered Tc-99m PYP scintigraphy. Retention of Tc-99m PYP in the heart was assessed using both a semiquantitative visual score (range, 0 [no uptake] to 3 [uptake greater than bone]). Positive uptake was defined score 2 and 3.

Results

Myocardial deposition of Tc-99m PYP (Score 2–3) was identified in 4 of 44 patients (9%), all >70 years and 75% male. Patients with myocardial deposition of the tracer were older (78±8 years vs. 70±12 years), and had more mean interventricular septum thickness (18±3 mm vs. 14±5 mm). Both groups had at least ejection fraction and abnormal global longitudinal strain with no significant difference between groups. Pre-operative serum median NT-pro BNP level was similar between two groups, but post-operative improvement of NT-pro BNP was larger in non-deposition of the tracer group. During the post operative follow-up, survival was significantly worse if patients had amyloid deposition compared with no deposition subjects (25% vs. 7.5%).

Conclusion

Incidental transthyretin cardiac amyroidosis had a prevelance of 9% among patients undergoing surgical aortic valve replacement and was associated with a poor outcome.

Funding Acknowledgement

Type of funding source: None
Thrombus formation on bioprosthetic aortic valves
Authors: Bing R , Andrews J , Williams M , Clark T , Semple S , Van Beek E , Lucatelli C , Sellers S , Leipsic J , Tavares A , Stephens A , Koglin N , Dweck M , Newby D
Published: November 2020

Background

18F-GP1 is a novel radiotracer with a high affinity for the platelet glycoprotein IIb/IIIa receptor. Subclinical bioprosthetic valve thrombus has been postulated as a trigger for accelerated valve degeneration.

Purpose

To determine the feasibility of 18F-GP1 positron-emission tomography-computed tomography (PET-CT) for the detection of subclinical bioprosthetic aortic valve thrombus.

Methods

(i) Explanted degenerated aortic valve prostheses underwent histology and imaging. (ii) In a prospective observational study, patients with bioprosthetic aortic valve replacement (AVR) underwent echocardiography and 18F-GP1 PET-CT. Valves were assessed for hypoattenuating leaflet thickening (HALT), hypo-attenuation affection leaflet motion (HAM) and GP1 uptake.

Results

(i) GP1 correlated with thrombus on explanted valves (Figure). (ii) The first 6 patients (Table) were asymptomatic and had normally functioning surgical bioprostheses on echocardiography. At a median of 166 (range 122–189) days post-AVR, no patients had HALT or HAM on CT. There was avid focal GP1 uptake on the leaflets of all 6 patients which appeared most prominent along the leaflet edges (Figure). Only one patient had focal uptake in the valve frame, remote from the leaflets. In a separate cohort undergoing 18F-GP1 PET-CT for other conditions, there was no uptake on normal, native aortic valves (n=8).

Conclusion

For the first time, we demonstrate that 18F-GP1 PET-CT is a highly sensitive method of assessing platelet activation on bioprosthetic aortic valves. Despite the absence of CT evidence, early thrombus appeared to be a universal finding on recently implanted valve prostheses. The biological and clinical implications of subclinical bioprosthetic aortic valve thrombus have yet to be established.

GP1 uptake in AVR

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation