bluuebunny/crossref_metadata_2025 huggingface dataset:
2408How can we improve the success of cardiac resynchronization therapy implantation?
Authors: Nunes Ferreira A , Antonio Silverio P , R Agostinho J , Aguiar-Ricardo I , Rigueira J , Santos R , Cunha N , Rodrigues T , Bernardes A , J Pinto F , De Sousa J , Marques P
Published: October 2019

Introduction

The left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT) is one of the most important and complex steps, leading to implantation failure in 10–15% of cases. New LV lead implantation techniques are needed to allow better resynchronization and decrease mortality and hospitalizations.

Objectives

To evaluate the efficacy and safety of the snare technique in the LV lead implantation in cases of standard technique failure.

Methods

Prospective, single-center study of patients undergoing CRT implantation since 2015. Demographic, clinical, and CRT implantation techniques were evaluated, taking into account the vessel with the best resynchronization capacity. The snare technique, through the active traction of the lead to the target vessel, was used in cases of standard technique failure. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods. Major complications, defined as reasons for prolonged hospitalization or potentially fatal, were evaluated.

Results

486 CRTs were implanted since 2015 (73.9% males, 73 years (IQR 66–79), median follow-up of 487 days (IQR 175–749), 91% for heart failure, dilated cardiomyopathy in 55.4%. In 17.3% of these patients (n=84), LV lead was implanted through the snare technique, 94% of the cases in a lateral vein, 100% efficacy in the positioning in the intended vessel.

Comparing the snare technique with the standard technique, patients implanted with snare presented a lower all-cause surgical revision (HR 0.31, 95% CI 0.094–0.98, p=0.035), with a number needed to treat of 25 patients to prevent one surgical revision, and a lower revision rate due to LV lead implant failure/dislodgement (Log Rank 5.1, p=0.024). There were no surgical revisions for LV lead repositioning in patients undergoing the snare technique. The rate of major complications (4.8% vs 3.0%, p=0.41), 30-day mortality (3.5% vs 1.8%, p=0.28) and all-cause mortality (13.1% vs 13.9%, p=0.47) were similar to the standard procedure. Major complications in both groups were pericardial effusion and contrast nephropathy.

The snare technique presented a longer procedure duration (104 vs 78 min, p<0.01) and fluoroscopy time (26.6 vs 15.5 min, p<0.01). Over time, there was a learning curve with reduction in procedure duration and fluoroscopy time.

Conclusion

The snare technique allows LV lead implantation in the vein with the best resynchronization characteristics, increasing the success rate in the implantation of CRT. It also reduced all-cause surgical revisions and surgical revisions due to LV lead implant failure/dislodgement, with a favourable safety profile similar to the standard technique.
2409ALERT-CS - Development of an ECG-based cardiac syncope risk calculator
Authors: Zimmermann T , Du Fay De Lavallaz J , Walter J E , Strebel I , Nestelberger T , Badertscher P , Boeddinghaus J , Twerenbold R , Koechlin L , Lohrmann J , Steude J S , Gualandro D M , Kuehne M , Reichlin T , Mueller C
Published: October 2019

Background

Syncope is a common symptom with rising incidence, often leading to emergency department (ED) visits. Early determination of diagnosis is often difficult in patients with syncope and there is an unmet clinical need for tools that can support physicians in their decision making. We hypothesized that an electrocardiogram (ECG)-based cardiac syncope risk calculator might create a simple and attractive clinical decision tool for the diagnosis and risk stratification of patients with syncope.

Methods

Based on a large prospective diagnostic international multicenter study enrolling patients who presented to the ED with syncope, we derived a cardiac syncope risk calculator by penalized stepwise backward-selection and multivariable logistic regression utilizing predefined ECG criteria. Primary diagnostic endpoint was cardiac syncope, as adjudicated by two independent physicians taking into account all available information including cardiac work-up and 12-month follow-up. Major adverse cardiac events (MACE) including life-threatening arrhythmias, myocardial infarction, pulmonary embolism, stroke, transient ischemic attack, valvular surgery, and death within 30 days were the prognostic endpoint.

Results

Median age in our cohort was 71 years and 40% of patients were women. Of all 2007 patients enrolled, 1696 patients were eligible for the prognostic analysis and 1550 patients were eligible for the diagnostic analysis.

We identified seven ECG criteria (rhythm, heart rate, corrected QT-interval, ST-segment depression, atrioventricular-block, bundle-branch-block and ventricular extrasystole/non-sustained ventricular tachycardia) as significant predictors for cardiac syncope and combined them into the bAseL Ecg Risk calculaTor for Cardiac Syncope (ALERT-CS). Diagnostic accuracy for cardiac syncope, as quantified by the area under the receiver operating characteristic curve (AUC), was high (AUC 0.80, 95%-confidence interval (CI) 0.77 to 0.83), and significantly higher compared to that of the EGSYS score (AUC 0.73, 95%-CI 0.70 to 0.76, p<0.001). Prognostic verification of the ALERT-CS to predict 30-day overall MACE showed similar accuracy (AUC 0.75, 95%-CI 0.71 to 0.79).

Comparison of diagnostic discrimination

Conclusion

Combining seven ECG criteria within a simple risk calculator for cardiac syncope may aid physicians in the diagnosis and risk stratification of patients presenting to the ED with syncope.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University Basel
P1232A subpopulation of epicardium-derived cells are preprogrammed towards fibroblast differentiation in the atrial myocardium
Authors: Suffee-Mosbah N , Moore-Morris T , Mougeneot N , Dilanian G , Puceat M , Hatem S N
Published: October 2019

Context and objectives

Fibro-fatty infiltrations of the sub-epicardium is an important component of the atrial cardiomyopathy that paves the way of atrial fibrillation (AF). We previously reported that epicardium-derived cells (EPDCs) can be a source of adipocytes contributing to fat depot. Here, we examined if EPDCs can contribute also to the fibrotic remodeling of atrial subepicardium.

Methods

Surgical samples of human right atria were used for histological study and to harvest EPDCs. Clinical and histological data were analyzed using generalized linear models. A model atrial remodeling associated with ischemic heart failure was created in rats and in a genetic lineage tracing WT1CreERT2+/−/Rosa-tdT+/− mice to follow epicardial progenitor fate. Primary cell culture models were used to study EPDC differentiation. Flow cytometry assays and single cell sequencing were used to characterize subpopulations of EPDCs.

Results

In human atria, epicardium could be a thin cell monolayer or be thick in continuity with dense fibro-fatty infiltrates. The latter aspect predominated in old patient (>70 year) with valve mitral diseases or in AF, clinical conditions associated with an atrial remodeling. This was further established in rat and mouse experimental model of atrial remodeling characterized by a thickening of the epicardium observed one week following the onset of the cardiopathy and, then, followed by a dense fibrotic remodeling of the subepicardium. Cells co-expressing markers of epicardial progenitors and fibroblasts were detected in the subepicardium of diseased atria both in human and murine models. Moreover, a number of myo/fibroblasts from WT1CreERT2+/−/Rosa-tdT+/− mice were detected in diseased atria attesting of their epicardial origin. Distinct EPDC clusters were detected from cells harvested from epicardium whereas only PDGFRa-positive cells could differentiated into fibroblasts. Angiotensin-II induced the differentiation of only PDGFRa-positive cells into fibroblasts.

Conclusions

Activation of the epicardium is an early event during atrial remodeling that results in the triggering of differentiation of a subpopulation of epicardial progenitors into fibroblasts. Angiotensin-II is part of the signaling switch than regulate the fate of EPDC between fibroblastic or adipogenic lineage. Hence, epicardium by regulating the balance between adipose expansion and fibrosis accumulation appears as an important determinant of the atrial cardiomyopathy.

Acknowledgement/Funding

ANR-10-IAHU-05
P1238Acute re-distribution of myocardial work by cardiac resynchronization therapy determines long-term remodelling of the left ventricle
Authors: Duchenne J , Aalen J , Cvijic M , Larsen K , Galli E , Bezy S , Beela A S , Unlu S , Pagourelias E D , Winter S , Hopp E , Fehske W , Donal E , Smiseth O A , Voigt J U
Published: October 2019

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 130 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±2 months after implantation. Characteristics of patients with the lowest and highest quartile of LV ESV reverse remodelling (ΔLV ESV <−9% and ΔLV ESV >−48%) were compared.

Results

Before CRT, myocardial work showed significant differences among the walls of the LV (Figure 1A). 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 1B). The acute change in the difference between lateral and septal wall work (Δlateral − septal work) correlated best and significantly with LV ESV reverse-remodelling (r=0.62, p<0.0001). The smallest changes in work were seen in the patients with the least LV ESV reverse remodelling (Figure 1C, red markers), while patients with the most LV ESV reverse remodelling showed the largest changes in work (Figure 1C, green markers). In a multivariate-linear-regression-analysis, including pre-implant QRS duration, LVEF, LV EDV and GLS, the re-distribution of work remained as the strongest determinant of volumetric reverse-remodelling after CRT (r=0.63, p<0.0001).

Figure 1

Conclusions

The acute re-distribution of regional myocardial work between the septal and lateral wall of the left ventricle is the main 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.
P1241Five-year risk of death and readmission for heart failure after implantation of de novo and upgrade cardiac resynchronization therapy devices
Authors: Engelbrecht M L , Madelaire C , Sindet-Pedersen C , Kober L , Torp-Pedersen C , Bo Lindhardt T , Biering-Sorensen T , Haider Butt J , Ruwald A C , Andersson C , Gislason G , Schou M
Published: October 2019

Background

De novo implantation of cardiac resynchronization therapy devices with and without an implantable cardiac defibrillator (CRT-D and CRT-P, respectively) is associated with a reduced risk of death and re-admission for heart failure (HF). Whether upgrade to CRT-P/D from a brady pacemaker or an implantable cardiac defibrillator is associated with a similar long-term clinical benefit as de novo implantations is unknown.

Purpose

To compare risk of death and HF readmission in patients receiving a de novo versus upgraded CRT-P/D device.

Methods

From the Danish nationwide administrative registers, we identified all patients who had a CRT-D or CRT-P implanted from 2006 through 2016. Patients were excluded if they had endocarditis within 12 months before implantation. The patients were divided into groups based on whether implantation was an upgrade of a previous device or a de novo implantation. The primary endpoint was the composite of all-cause mortality and HF readmission. Risk of the primary endpoint was assessed with Kaplan Meier estimator and multivariable Cox regression models adjusted for age, sex, ischemic heart disease, diabetes and chronic obstructive pulmonary disease.

Results

The study population comprised 6,324 patients, median age 70 years [25th-75th percentile: 63–77], 22% women. In total, 3,635 patients had a CRT-D, of whom 749 (20.6%) were upgraded from an implantable cardioverter defibrillator device and 2,689 patients had a CRT-P, of whom 496 (18.4%) were upgraded from brady-pacemakers. For patients with CRT-D, five-year event-free survival probability was 35.3% for de novo and 20.4% for upgrades (log-rank p-value<0.001). For patients with CRT-P, five-year event-free survival probability was 38.4% for de novo and 33.7% for upgrades (log-rank p-value=0.29) (Figure 1). In the CRT-D group, upgrade was associated with an increased risk of the primary endpoint, hazard ratio (HR): 1.49 (95%-confidence interval (CI): 1.34–1.65, p<0.001). In the CRT-P group, no significant difference between upgrade and de novo was observed, HR: 1.02 (95%-CI: 0.89–1.18, p=0.72).

Figure 1

Conclusions

Upgrade to a CRT-P was associated with a similar long-term clinical outcome as de novo device implantation. This was in contrast to upgrade CRT-D, which was associated with a worse outcome than de novo implantation. To understand the factors underlying this increased risk, more studies are warranted.
P1244Survival after septal myectomy in male and female patients with hypertrophic obstructive cardiomyopathy
Authors: Huurman R , Schinkel A , Van Slegtenhorst M , De Jong P , Hirsch A , Michels M
Published: October 2019

In recent years, studies have debated the impact of gender on the presentation and clinical course of HCM, with research showing that at time of myectomy, women are older, have worse diastolic function and more advanced cardiac remodeling. The clinical impact of these differences is unknown.

We included 221 HCM patients (57% men) who underwent septal myectomy and are followed in our center. Time to treatment was calculated in relation to symptom onset. Pre- and post-operative clinical and echocardiographic data were collected. Gender differences were assessed at baseline and in survival analyses for the composite endpoint of all-cause mortality, cardiac transplantation, re-intervention and aborted sudden cardiac death.

Women were older at time of myectomy, but time until treatment was similar (table). Pre-operative echocardiographic indices were comparable among groups, but were significantly higher in women when correcting for body surface area. At three months, no differences were found in clinical and echocardiographic results. After 6.1 [2.9–10.1] years, 24% of women and 23% of men had reached the composite endpoint (p=0.30, figure).

Gender comparison pre- and post-myectomy Men (n=125) Women (n=96) p value Age 49±14 54±17 0.02 Maximal wall thickness, mm 19.9±4.7 19.8±5.8 0.97 Indexed maximal wall thickness, mm/m2 9.8±2.5 11.5±4.5 0.001 Left atrial diameter, mm 48.1±7.3 45.9±7.3 0.06 Indexed left atrial diameter, mm/m2 23.5±3.5 26.5±7.5 0.002 LV end-diastolic diameter, mm 45.4±7.6 42.8±5.6 0.04 Indexed LV end-diastolic diameter, mm/m2 22.1±3.7 23.6±3.0 0.02 Gradient reduction, %* 75.1±25.0 72.9±28.6 0.63 Improvement in symptoms*† 97 (95%) 64 (89%) 0.34 MWT = maximal wall thickness; LV = left ventricle. *At three months follow-up; †Defined as a reduction of ≥1 NYHA class, measured in 102 men and 72 women.

Survival after myectomy

Although women present later in life and seem to have more advanced disease at time of myectomy, time to treatment is similar and survival after myectomy is excellent for both men and women.
P1246Myocardial transit time (MTT) - a novel and easy-to-perform CMR parameter to assess microvascular disease
Authors: Chatzantonis G , Bietenbeck M , Florian A , Meier C , Holtstiege V , Reinecke H , Yilmaz A
Published: October 2019

Background

Myocardial microvascular disease is primarily characterized by arteriolar obliteration and capillary rarefaction, and may occur during the disease course of different disorders. With the present study, we introduce a novel and easy-to-perform cardiovascular magnetic resonance (CMR) parameter named “myocardial transit time” (MTT).

Methods

N=20 patients with known hypertrophic cardiomyopathy (HCM) and N=20 control patients without relevant cardiac disease underwent dedicated CMR studies on a 1.5-T MR scanner (Ingenia, Philips, Best, The Netherlands). The CMR protocol comprised cine and late-gadolinium-enhancement (LGE) imaging and first-pass perfusion acquisitions at rest for MTT measurement: an imaging plane covering both the aortic bulbus and the coronary sinus was planned in order to track the flooding of gadolinium. MTT was defined as the time interval between first appearance of gadolinium in the aortic bulbus and the subsequent appearance of gadolinium in the coronary sinus reflecting the transit time of gadolinium in the myocardial microvasculature (in the absence of epicardial coronary artery disease).

Results

There was no significant difference in left ventricular ejection fraction (LV-EF) between both groups: 61% (55–68%) in HCM patients vs. 60% (58–67%) in controls (p=ns) whereas LV mass was significantly higher in HCM patients (79g/m2 (63–98g/m2) vs. 50g/m2 (45–56g/m2) in controls, p<0.001). The extent of LGE was 17% (6–22%) in HCM patients while there was no LGE at all in the control group (p<0.001). MTT at rest was substantially longer in HCM patients: 11.0sec (9.1–14.5sec) vs. 6.5sec (4.8–8.4sec) in controls (p<0.001). Correlation analyses revealed a significant relationship between LV mass and MTT (r = +0.64, p<0.001) as well as between LGE extent and MTT (r=0.75, p<0.001). ROC analysis resulted in an area-under-curve (AUC) of 0.90 for MTT and showed an optimal sensitivity/specificity cut-off of 7.85sec to differentiate HCM from controls.

Patient characteristics HNCM patients (N=20) Control group (N=20) p-value Absolute MTT, sec 11.0 (9.1–14.5) 6.5 (4.8–8.4) <0.001 MTT indexed to heart rate 0.159 (0.100–0.198) 0.081 (0.063–0.106) <0.001 No. of patients with MTT <7.85 sec, n (%) 2 (10) 15 (75) <0.001 MTT = Myocardial Transit Time, HNCM = Hypertrophic Non obstructive Cardiomyopathy.

Multiple images illustrating MTT method

Conclusion

“Myocardial transit time” (MTT) is a novel and easy-to-perform CMR parameter that allows a quick assessment of the extent of myocardial microvascular disease. This novel CMR parameter may open new vistas in the assessment of microvascular disease - not only in HCM patients. Future studies will show the usefulness and clinical relevance of this novel CMR parameter.
P1463Cardiology, cardiovascular clinical and economical beneficiary outcomes of tele-cardiology, e-audio-visual cardiology and m-cardiology: TEAM study at multi cardiac centre in India
Authors: Sen N , Tanwar S , Jain A , Shetty D , Cherian G , Kalra B , Mehta A
Published: October 2019

Background

Telemedicine has beneficiary aspect to manage health and reduce the burden of illness. It represent health promotion with support of many ways like tele (distance mode), e (electronic mode), audio visual mode and m (mobile or smart phones) mode etc.

Objectives

To evaluate the cardiovascular land economical outcomes of tele-cardiology, e-cardiology, audio-visual cardiology and m-cardiology in large population and to review with increase awareness and application of telemedicine.

Methods

We enrolled 12872 patients from different cardiac centres in india and registered in TEAM (Tele-cardiology, E-cardiology, Audio-visual cardiology and M-cardiology) registry from 2008 to 2018. We included tele diagnosis, tele assistance, tele monitoring, tele therapy, electronic remot media, audio visual media and mobile apps for management of different category of cardiovascular disease like coronary heart and structural heart disease, hypertension, heart failure and congenital heart disorders. We compared TEAM registry with usual group (n=13229) at the platform of beneficiary outcomes regarding diagnostic, therapeutic significance, economical burden, mortality and rate of hospitalization.

Results

Our data revealed that 34% more correction of the diagnosis of congenital heart diseases, 29% reduction of unnecessary transport of acute coronary syndrome and non cardiac chest pain from primary to higher cardiac centre. 38% patients of ST elevation of myocardial infarction were benefited by facilliated angioplasty and 50% mortality risk reduction in TEAM registry as compare usual group. In heart failure patients, 12 months clinical outcomes revealed that there was a significant reduction in rehospitalizations in the TEAM group compared with the usual-care group (19.6% versus 33.7%,) and also found 29% stroke reduction in TEAM group. Usual group showed 2.5 fold higher economical burden than TEAM registry.

Conclusion

Total approach of telemedicine in cardiology service may diagnose correctly at root level, prevent clinical instability, reduce rehospitalization and lower the cost of managing heart patients.
P1464Adoption of feedback to validate a machine learning model for single lead STEMI detection
Authors: Mehta S , Fernandez F , Villagran C , Matheus C , Ceschim M , Vieira D , Torres M A , Mazzini J , Quintero S , Pisana L , Nola F , Safie R , Munguia A , Krisciunas S , Sunkaraneni S
Published: October 2019

Background

We have explored the performance of a single lead EKG with Artificial Intelligence (AI) based algorithms in STEMI diagnosis, thus far lead V2 has yielded the best results. Anticipating the performance of the LUMENGT-AI model, we designed a feedback strategy with healthcare centers to expand the validation of our work.

Purpose

To create a pragmatic alternative to the existing gold standard, a 12-lead EKG, for STEMI diagnosis.

Methods

An observational, retrospective, case-control study. Sample: 2,543 exclusively STEMI (anterior, inferior and lateral wall) diagnosis, EKG records. Feedback: From healthcare centers, confirming STEMI diagnosis and location, was obtained (thrombolysis, primary Percutaneous Coronary Intervention (PCI), pharmaco invasive therapy or coronary artery bypass surgery). Records excluded other patient and medical information. Sample was derived from the private International Telemedical Systems (ITMS) database. LUMENGT-AI Algorithm was employed. Preprocessing: detection of QRS complexes using the wavelet system, segmentation of each EKG into individual heartbeats (53,667 total beats) with fixed window of 0.4s to the left and 0.9s to the right of main QRS; Classification: A 1-D convolutional neural network was implemented; “STEMI” and “Not-STEMI” classes were considered for each heartbeat per lead; individual probabilities were aggregated to generate the final label for each record. Training & Testing: 90% and 10% of the sample were used, respectively. Experiments: Intel PC i7 8750H processor at 2.21GHz, 16GB RAM, Windows 10 OS with NVidia GTX 1070 GPU, 8GB RAM.

Results

V2 was the most precise lead with an Accuracy of 93.6%, a Sensitivity of 89%, and a Specificity of 94.7%.

Conclusions

The strategic adoption of feedback from healthcare centers provided strong validation of our model. The results of AI-augmented, single lead EKG are encouraging. We anticipate that this approach will become a promising methodology in STEMI detection.
P1472Predicting significant ventricular arrhythmias in STEMI patients in middle-range and preserved EF
Authors: Krljanac G , Trifunovic D , Asanin M , Savic Spasic L , Aleksandric S , Dudic J , Cucic L , Sulovic V , Mrdovic I
Published: October 2019

Background

Predicting malignant ventricular and sudden cardiac death (SCD) in STEMI patients with middle-range and preserved EF is challenge.

Aim

To identify the best parameters to predict composite end-point defined as secondary VF, sustained/non-sustained VT and sudden death, 48h after and during the first year of follow up after STEMI in patients with middle-range and preserved EF.

Methods

In the 192 consecutive STEMI patients (pts) 57.8±10.4yr, 69.9% males, in PREDICT-VT study (NCT03263949) treated with pPCI, with EF ≥40%, early echo (5±2 days) was done including conventional parameters and comprehensive speckle tracking left ventricle (LV) deformation analysis with longitudinal (L), circumferential (C) strain (S; %) strain rate (SR, 1/sec), index mechanical dispersion (IMD) and rotational LV mechanics.

Results

Thirteen patients (8.3%) reached the end-point. Classical parameters of LV systolic function, including LVEF, wall motion score index and parameters of diastolic dysfunction were not significant predictors of the malignant arrhythmias. IMD of late rotation rate (63.7 vs. 40.7ms, p=0.055) and late diastolic untwisting rate (−48.85 vs. −63.18°/s, p=0.059) had trend to become the significant predictors. CS in papillary muscle level in endo and mid layers predicted the primary end-point (endo: −20.5±11.8 vs. −24.9±4.6, mid: −14.6±3.9 vs. −17.0±2.1, epi: −10.1±3.3 vs. −11.8±1.8) (table).

Parameter of circumferencial mechanics ROC area 95% CI p Cutt-off Sens Spec PM endo (%) 0.302 0.146–0.458 0.038 −22.75 70 67 PM mid (%) 0268 0.153–0.383 0.015 −15.65 80 62

Conclusion

Myocardial deformation imaging offers deeper insight into complex mechanical abnormalities during LV contraction and relaxation in STEMI patients with middle-range and preserved EF that predicts serious arrhythmic events.
P1479Deterioration in right ventricular strain precedes occurrence of pulmonary hypertension in patients with preclinical diastolic disfunction
Authors: Chilingaryan A L , Tunyan L G , Adamyan K G
Published: October 2019

Preclinical diastolic disfunction (PDD) often progresses to heart failure and distinct clinical predictors for this transformation are yet to be defined. Since deterioration of longitudinal strain (LS) can occur before the changes of more conventional parameters, we assumed that right ventricular free wall longitudinal strain (RVLS) might start deteriorating before the pulmonary hypertension can be established.

Methods

We followed up 243 patients (143 female) 67±9 years with PDD for 3 years. All patients had an impaired relaxation or pseudo normal transmitral patterns and E/e' 8–13 at rest, normal NT-proBNP values, and systolic pulmonary artery pressure (sPAP) ≤30 mm Hg. PDD was diagnosed by stress echocardiography (SE) if E/e' ≥13, transmittal E wave deceleration time reduction >50ms, systolic pulmonary artery pressure (sPAP) <30 mmHg, and patients remained asymptomatic during SE. RVLS as average of RV free wall 3 segments values, left atrial peak reservoir LS (LALS) as average of two LA basal segments in four chamber view and left ventricular peak systolic global LS (LVGLS) were measured by speckle tracking (ST). ST and SE was performed with 6 months intervals. 35 healthy subject served as controls.

Results

Patients with PDD had higher RVLS, LVGLS, and lower LALS compared with controls (RVLS –23.2±4.2% vs –27.3±5.1%, p<0.001; LVGLS –17.8±5.2% vs –21.9±2.8%, p<0.001; LALS 39.7±3.7% vs 44.1±4.9%, p<0.002). 76 (31.3%) patients developed sPAP increase >30 mmHg at rest or SE during follow up of which 34 (44.7%) had dyspnea. Patients with increased sPAP had higher RVLS and lower LALS values at baseline compared with the rest of PDD patients without significant differences in other parameters (RVLS –17.9±2.8% vs –24.8±3.6%, p<0.002; LALS 37.7±2.3% vs 41.5±3.6%, p<0.003; LVGLS –17.4±4.8% vs –18.2±5.1%, p>0.05). Both LALS and RVLS correlated with LA end diastolic volume index (LALS r=0.51, p<0.01; RVLS r=0.54, p<0.01). Additionally RVLS was an independent predictor of sPAP rise (OR=2.7; 95% CI=2.43–6.92; p<0.01).

Conclusion

RVLS is an independent predictor of sPAP increase in patients with PDD.
P1480Left atrial strain improves estimation of left ventricular filling pressure
Authors: Khan F H , Andersen O S , Gude E , Skulstad H , Smiseth O A , Remme E W
Published: October 2019

Background

The current algorithm in the 2016 recommendations for echocardiographic estimation of left ventricular filling pressure (LVFP) as normal or elevated, combines traditional indices of mitral inflow velocities, tissue Doppler, left atrial volume and tricuspid regurgitation velocity (Figure A). Some of the patients remain unclassified by this algorithm. Left atrial (LA) strain is a novel index that correlates well with LVFP and may improve estimation of LVFP in these patients.

Purpose

We tested if LA strain can improve estimation of LVFP for the patients that are unclassified by the 2016 algorithm.

Methods

We analyzed data from 100 patients who were referred to right heart catheterization due to unexplained dyspnea or suspected heart failure. Echocardiography was performed simultaneously with or within 24 hours of right heart catheterization. Pulmonary capillary wedge pressure (PCWP) was used as an estimate for LVFP and defined as elevated if above 12 mmHg. Elevated LVFP was first estimated using the 2016 algorithm. In patients who were unclassified by the algorithm due to conflicting indices or unattainable indices, LA strain was subsequently used to detect elevated LVFP using a cut-off found from ROC analysis of the whole cohort.

Results

Six patients were unclassified by the 2016 algorithm. The ROC analysis of all 100 patients showed that at an LA strain cut-off of above or below 16.2%, LVFP was correctly classified as normal or elevated, respectively, with a sensitivity of 83% and specificity of 88%. All 6 unclassified patients by the 2016 algorithm were correctly classified using the LA strain cut-off, effectively increasing the accuracy of the algorithm by 6 percentage points.

Conclusions

LA strain may have a role in non-invasive estimation of LVFP, particularly in patients who remain unclassified when using the conventional echocardiographic indices.

Acknowledgement/Funding

South-Eastern Norway Regional Health Authority
P1481B-lines and left atrial strain in outpatients with suspected heart failure with preserved ejection fraction
Authors: Agoston G , Gargani L , Szabo I , Illes B , Varga A
Published: October 2019

Background

Heart Failure with Preserved Ejection Fraction (HFpEF) is a growing healthcare burden and its prevalence is increasing. Diagnosing HFpEF is challenging. Lung ultrasound (LUS) and left atrial strain are promising tools to assess pulmonary congestion and left atrial dysfunction in outpatient settings in patients with suspected HFpEF.

Aim

To evaluate the correlation of LUS B-lines with left atrial strain in patients with HFpEF.

Methods

Thirty-six consecutive patients (24 women, mean age 70±6 years) with clinical signs of heart failure were prospectively enrolled. Exclusion criteria were: ejection fraction <55%, more than mild mitral and/or aortic valve disease, pulmonary disease, pulmonary arterial hypertension. Within one hour all patients underwent comprehensive echocardiographic evaluation including left atrial strain analysis (peak atrial longitudinal strain-PALS), lung ultrasound assessment of B-lines on the antero-lateral and posterior chest wall, and NT-proBNP levels.

Results

The mean ejection fraction was 65.5±8.6%. In 28 patients (85%) a significant number of B-lines (≥15) was observed. We found a positive correlation between the number of B-lines and NT-proBNP levels (p<0.0001, r: 0.76, Figure 1.), left atrial volume (p<0.05, r: 0.45), and PALS (p<0.05, r: −0.5, Figure 2.). We didn't found any correlation between the number of B-lines and E/e'ratio (p=0.1, r: 0.28), or between E/e' ratio and NT-proBNP level (p=0.2, r: 0.2).

Conclusion

LUS is a simple, feasible tool to detect pulmonary congestion in HFpEF and it seems to better characterize these patients. B-lines correlate well with NT-proBNP values and with parameters of left atrial dysfunction. PALS is a promising too which better reflects pulmonary congestion and elevated NT-proBNP values than the conventional echocardiographic parameter E/e'.
P1487The additive effect of diastolic dysfunction and renal insufficiency on mortality in patients undergoing coronary angiography
Authors: Teodorovich N , Fabrikant Y , Jonas M , Gandelman G , George J , Swissa M , Shimoni S
Published: October 2019

Background

Coronary artery disease (CAD) is the leading cause of diastolic dysfunction. Diastolic dysfunction is associated with adverse outcomes. Renal insufficiency is also associated with adverse outcomes in CAD patients. The interaction between diastolic dysfunction and renal insufficiency is not completely elucidated.

Aims

We evaluated the prognostic value of diastolic function assessed by echocardiography in patients with and without renal failure undergoing coronary angiography.

Patients and methods

An observational prospective study of 547 consecutive patients undergoing coronary angiography. The median follow up was 30 months. Significant diastolic dysfunction was defined as elevated LV filling pressure with e/e'>12. Renal insufficiency was defined as adjusted GFR<60 ml/min. One hundred seventy-nine patients (32.7%) had significant diastolic dysfunction and 259 (47.3%) had renal insufficiency. Patients were categorized into 4 groups according to the presence of both significant diastolic dysfunction and renal insufficiency (Table 1).

Results

Significant diastolic dysfunction and renal insufficiency had additive effect on mortality (Table 1). A significant association was observed between diastolic dysfunction and mortality in patients with and without renal insufficiency (p<0.0001 & p=0.005, respectively). The presence of either diastolic dysfunction or renal insufficiency was associated with mortality (Figure 1), with the combination of both leading to the highest mortality (p<0.0001). In Cox regression model which combined diastolic dysfunction, presence of AF, LVEF, obstructive coronary disease on angiography, presence of acute coronary syndrome and renal insufficiency, both elevated filling pressure and renal insufficiency were independently associated with higher mortality (HR 2.65, CI 1.65–4.24, p<0.001 and HR 2.92, CI 1.72–4.98, p<0.0001, respectively).

Table 1. Patients divided into 4 groups according to the presence of the significant diastolic dysfunction and renal insufficiency Patients' group N (%) Mortality Normal LV filling pressure / Normal renal function 230 (42.0%) 4.8% Elevated LV filling pressure / Normal renal function 58 (10.6%) 15.5% Normal LV filling pressure / Renal insufficiency 138 (25.2%) 15.9% Elevated LV filling pressure / Renal insufficiency 121 (22.1%) 38.8% P<0.0001 in Pearson Chi-Square.

Fugure 1

Conclusions

In patients undergoing coronary angiography, significant diastolic dysfunction with elevated filling pressure is associated with mortality in patients both with and without renal insufficiency. Both significant diastolic dysfunction and renal insufficiency are independent predictors of mortality.
P14893D strain echocardiography in assessing left ventricular diastolic dysfunction
Authors: Ozer H T , Ozer O , Coteli C , Kivrak A , Sahiner M L , Ozer N
Published: October 2019

Background

Diastolic dysfunction is an important factor in the development of heart failure with preserved ejection fraction (HFpEF). As the ejection fraction is preserved in HFpEF, the diagnosis of this disease with non-invasive methods is difficult.

Purpose

In this study, the relationship of BNP, NT-proBNP, Ghrelin, and echocardiographic 3D strain findings with diastolic dysfunction was investigated in patients undergoing left heart catheterization.

Methods

Our study is a cross-sectional study and included 78 patients in whom echocardiography was performed, and who underwent left heart catheterization based on relevant indications. The patient data recorded for evaluation included the findings from left heart catheterization, follow-up 3D echocardiography; and the levels of blood NT-proBNP, and Ghrelin.

Results

The rate of diastolic dysfunction was 42.3%. Longitudinal 2D and 3D mean strain as absolute values were observed to decrease more in patients with diastolic dysfunction. The median levels of BNP, NT-proBNP, and Ghrelin levels were higher in patients with diastolic dysfunction. The independent predictors of diastolic dysfunction were determined to be the left atrial volume index (LAVI) (OR=1.17; p=0.018), longitudinal 3D strain values (OR=1.88; p<0.001), NT-proBNP (OR=1.11; p=0.001), and Ghrelin (OR=1.40; p=0.001), respectively.

Relationship Between LV EDP and LV Longitudinal Strain LV EDP 2D Strain 3D Strain r p r p r p BNP, pg/ml 0.429 <0.001* 0.115 0.316 0.178 0.118 NT-proBNP, pg/ml 0.484 <0.001* 0.155 0.177 0.186 0.104 Ghrelin, pg/ml 0.478 <0.001* 0.086 0.455 0.157 0.169 SolV DB – – 0.481 <0.001* 0.591 <0.001* dP/dT −0.389 <0.001* −0.283 0.012* −0.307 0.006* Negative dP/dT −0.747 <0.001* −0.337 0.003* −0.458 <0.001* 2D. % 0.481 <0.001* – – 0.852 <0.001* 3D. % 0.591 <0.001* 0.852 <0.001* – – If p value is less than 0.05 shows statistical significance.

Measurement of longitudinal strain

Conclusion

In conclusion, our study found out that the reduced 3D strain absolute values and increased levels of NT-proBNP and Ghrelin biomarkers predicted diastolic dysfunction. If further large-scale studies prove the efficiency of these practical, they may not only allow for making a diagnosis of HFpEF more readily but may also eliminate the confusion in diagnostic algorithms.

Acknowledgement/Funding

None
P1492Is early repolarization pattern only an ion channel disease?
Authors: Colluoglu T , Onalan O , Cakan F
Published: October 2019

Background

Early repolarization pattern (ERP) has been generally described as a benign electrocardiographic (ECG) sign despite it is associated with the development of malign ventricular arrhythmias. Although the pathophysiological mechanism of malign ventricular arrhythmias in ERP has been explained only electrophysiologically, whether the presence of structural changes in myocardium has not been known yet.

Purpose

We hypothesized that ERP is not only an ion channel disease. The structural changes in myocardium begin in individuals with ERP sign on 12 lead surface ECG even if a young person. The aim of the present study was to determine myocardial dysfunction due to early decaying in myocardial structure in individuals with ERP sign by the use of 2D- speckle tracking echocardiography (STE).

Method

We prospectively included 99 individuals who admitted to our clinic between 01.04.2018 and 01.09.2018. 48 individuals had ERP. 12 lead surface ECG was taken from all individuals at admission, all individual's ECG were further analysed for presence of ERP and ERP was divided into three groups which were defined as presence of ST elevation, J wave and QRS slurring. 2D-STE (Philips Epiq 7C Ultrasound System for Cardiology (Andover, USA)) was performed in all individuals. All strain echocardiographic recordings were further analysed off- line by the use of associated software.

Results

ERP had significantly lower left ventricular (LV) global longitudinal strain (GLS), circumferential peak systolic strain rate (CPSSr) in basal segments of LV and left ventricular ejection fraction compared to controls. In addition, LV diastolic function especially in LV basal segments were significantly impaired in individuals with ERP when assessed by circumferential peak diastolic strain rate (CPDSr) compared to controls. GCS, LV- longitudinal peak systolic Sr (LPSSr) and LV- longitudinal peak diastolic Sr (LPDSr) in all of the apical chambers were similar between two groups (Table 1). There was not a relationship between type of ERP and all of these parameters including GLS, GCS, LPSSr, CPSSr, LPDSr, CPDSr. Finally, ST elevation pattern had higher GCS value while QRS slurring pattern had higher GLS value (Figure 1).

Figure 1 and Table 1

Conclusion

Our study firstly demonstrated ERP can be combined of structural and electrical heart disease. LV-GLS can be more closely associated with ERP than LV-GCS. In addition, the either of impaired of circumferential systolic and diastolic function in LV basal segments can be detected in individuals with ERP.
P1493Prognostic significance of right ventricular function during exercise in patients with non-obstructive hypertrophic cardiomyopathy
Authors: Hirasawa K , Izumo M , Mizukoshi K , Suzuki T , Sato Y , Watanabe M , Kamijima R , Ohara H , Harada T , Akashi Y J
Published: October 2019

Background

Hypertrophic cardiomyopathy (HCM) is a heterogeneous condition that may present crucial complication including life-threatening arrhythmia and sudden cardiac death. However, the risk stratification of HCM without left ventricular outflow tract (LVOT) obstruction had not been fully elucidated. Moreover, although recent studies have revealed the right ventricle (RV) involvement of HCM, the prognostic importance of RV function during exercise is unclear.

Purpose

To investigate the prognostic significance of RV function in patients with non-obstructive HCM using exercise stress echocardiography (ESE).

Methods and results

This study conducted on 100 HCM patients (age 62.9±13.6 years, 63% men) with preserved left ventricular ejection fraction who underwent ESE using semi-supine bicycle ergometer. Ten patients with significant LVOT obstruction (≥30mmHg) were excluded and 9 were also excluded because of the inadequate imaging quality or insufficiency of data. Among remaining 81 non-obstructive HCM patients, 9 patients suffered from HCM related cardiac events including cardiac death, unexpected hospitalization, life-threatening arrhythmias, and new-onset of syncope during the mean follow up period of 2.6±1.6 years. A multivariate Cox Hazard analysis revealed that low tricuspid annular plane systolic excursion during exercise (Ex-TAPSE, cut-off: 24mm) was an independent predictor of cardiac events. (hazard ratio: 18.66, 95% confidence interval: 3.66–338.46, P<0.001) The estimated cumulative cardiac event free survival using the Kaplan-Meier method was significantly lower in patients with reduced Ex-TAPSE (<24mm) than those with preserved Ex-TAPSE (Log-rank, P<0.01).

K-M curve according to Ex-TAPSE

Conclusion

Ex-TAPSE had a strong predictive value of clinical outcomes in non-obstructive HCM patients. Right ventricular function during exercise may have crucial role in the risk stratification of non-obstructive HCM.
P1495Energy loss by right ventricular pacing: normal left ventricular function vs. hypertrophic cardiomyopathy
Authors: Arakawa Y , Fukaya H , Kakizaki R , Oikawa J , Matsuura G , Kobayashi S , Shirakawa Y , Nishinarita R , Horiguchi A , Ishizue N , Nabeta T , Igarashi G , Kishihara J , Niwano S , Ako J
Published: October 2019

Background

Right ventricular (RV) pacing causes left ventricular (LV) dysfunction. On the other hand, RV pacing for hypertrophic obstructive cardiomyopathy (HOCM) is an established treatment. LV flow energy loss (EL) is a new hemodynamic index for assessing cardiac function. However, the impact of RV pacing on EL remains unknown.

Objective

The objective of this study was to investigate the EL by RV pacing on normal LV function and hypertrophic cardiomyopathy (HCM).

Methods

A total of 28 patients underwent echocardiography for EL assessment under AAI (without RV pacing) and DDD (with all RV pacing) mode. Among them, 16 were sick sinus syndrome (SSS) patients with normal LV function, and 12 were HCM patients. EL was calculated from color Doppler images using a vector flow mapping.

Results

There were no significant difference in patients' background parameters between the SSS and the HCM groups. In the SSS group, mean systolic EL was significantly increased from AAI to DDD mode (14.9 to 19.2 mW/m, P<0.01, Panel A), whereas diastolic EL was not changed from AAI to DDD mode (22.3 to 18.8 mW/m, P=0.12). In the HCM group, systolic mean EL was significantly decreased from AAI to DDD mode (29.9 to 22.5 mW/m, P<0.01, Panel B) irrespectively of with or without LV outflow obstruction, whereas diastolic mean EL was not changed from AAI to DDD mode (28.6 to 24.3 mW/m, P=0.47).

Change of flow energy loss

Conclusion

RV pacing increased mean systolic EL in normal LV function, but decreased in HCM with or without LV outflow obstruction. In the patients with HCM, the impact of RV pacing on EL is different compared with normal LV function.
P1509The novel application of speckle tracking during dobutamine stress echo for assessment of coronary artery diseases
Authors: Sen N , Tanwar S , Jain A , Kalra B , Mehta A
Published: October 2019

Background

Major cause of death across the world is coronary artery disease. The choice of treatment strategy should be primarily based on the hemodynamic significance of coronary artery stenosis. Two-dimensional speckle tracking provides valuable information for regional wall motion abnormalities. The purpose of this study was to determine the diagnostic value of left ventricular longitudinal strain and torsion to diagnose coronary artery disease during dobutamine stress echocardiography.

Purpose

The purpose of this study was to evaluate the diagnostic value of speckle tracking imaging-derived myocardial deformation parameters at rest and during dobutamine stress to determine the hemodynamic significance of coronary artery stenosis in patients with moderate and high probability of CAD.

Methods

We studied 204 patients (mean age 54.2±9.8 years, 128 male and 76 female) with known or suspected coronary artery disease, excluding those with prior history of transmural infarction. All of them underwent dobutamine stress echo and coronary angiography within one month. Wall-motion score index, left ventricular global longitudinal strain and torsion were measured at rest and peak stress. Optimal cut-offs were derived from receiver operating characteristic curves for strain and torsion values. Additionally, the respective differences between rest and stress were also calculated.

Results

During dobutamine stress echocardiography we revealed mean left ventricular ejection fraction was 53±6.2%. Coronary angiography revealed significant stenotic lesions in 124 patients (60.7%). Values regarding sensitivity, and specificity for wall motion score index difference were 76% and 84% respectively (area under curve 0.84). Global longitudinal strain difference (median 0.6%) illustrated 83% sensitivity and 74% specificity for disease detection (area under curve 0.82, cut-off value ≤0.5%). The respective values for torsion difference (median 5.1°) were 84% and 79% (area under curve 0.80, cut-off value ≤5.9°). Combination of wall motion score index difference and torsion difference for disease detection showed 89% sensitivity and 77% specificity (area under curve 0.84).

Conclusions

Left ventricular strain and strain rate analyses during DSE can be used in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high risk for CAD. The implementation of speckle tracking during dobutamine stress echo could serve as an adjunct method for coronary artery disease assessment, providing quantitative diagnostic information.