bluuebunny/crossref_metadata_2025 huggingface dataset:
P333 Left ventricular rotational abnormalities in hypereosinophilic syndrome as assessed by three-dimensional speckle-tracking echocardiography
Authors: Nemes A , Kormanyos A , Marton I , Domsik P , Kalapos A , Ambrus N , Modok S , Borbenyi Z , Forster T
Published: January 2020

Introduction

Hypereosinophilic syndrome (HES) is a very heterogeneous group of disorders with varied etiologies characterized by peripheral eosinophilia and eosinophilic tissue/end-organ damage. In the present study, the ability of a novel non-invasive clinical tool, three-dimensional speckle-tracking echocardiography (3DSTE) was investigated to reveal any change in left ventricular (LV) rotational mechanics in clinically asymptomatic HES patients without manifest organ damage as determined by conventional diagnostic methods.

Methods

The present study comprised 13 patients established diagnosis of HES. However, one patient with idiopathic HES has been excluded due to insufficient image quality. The remaining patient population contained 11 cases with idiopathic HES and one patient with acute T-lymphoma associated HES (mean age: 59.7 ± 13.7 years, 8 males). The control group consisted of 36 healthy volunteers (mean age: 52.9 ± 8.3 years, 23 males). All HES patients and controls underwent complete two-dimensional Doppler echocardiography and 3DSTE.

Results

Both LV apical rotation (4.86 ± 1.92 degree vs. 10.07 ± 3.92 degree, p < 0.0001) and LV twist (8.52 ± 2.79 degree vs. 14.41 ± 4.26 degree, p < 0.0001) showed significant deteriotations in most of HES patients. In 2 subjects absence of LV twist called as LV „rigid body rotation’ (RBR) was detected. One patient had 1.77 degree counterclockwise (abnormally directed) LV basal rotation and 14.29 degree counterclockwise (normally directed) LV apical rotation resulting in 12.59 degree LV apico-basal gradient. The other patient had normally directed -2.09 degree LV basal rotation and almost zero (-0.27 degree) LV apical rotation resulting in 1.82 degree LV apico-basal gradient.

Conclusions

Reduced LV apical rotation and twist could be demonstrated in HES. LV-RBR could be detected in some HES patients.
P350 Right atrial remodelling in atrial fibrillation using three dimensional transthoracic echocardiography and strain imaging
Authors: Chalard C , Soulat-Dufour L , Lang S , Ederhy S , Ancedy Y , Adavane-Scheuble S , Chauvet-Droit M , Nhan P , Ben Said R , Boccara F , Cohen A
Published: January 2020

Background

Evaluation of right atrial cavities and right atrial (RA) remodelling in atrial fibrillation (AF) has been poorly studied.

Purpose

The aim of this study was to evaluate in AF, the role of three-dimensional (3D) transthoracic echocardiography (TTE) and strain to refine the evaluation of the RA according to evolution of cardiac rhythm ad mid-term follow-up.

Methods

A complete 2D and 3D TTE was performed in patient hospitalized for AF. In addition to the usual parameters, RA parameters were specifically assessed: 3D RA end-systolic (ES) and end-diastolic (ED) volume, RA ejection fraction (EF) and the global longitudinal strain (GLS) of the RA. A complete clinical evaluation and electrocardiogram were performed at admission (M0) and 6 months after inclusion (M6) to determine the cardiac rhythm at follow-up.

Results

34 consecutive patients hospitalized for AF were analysed. At M0, there was no significant difference between 2D RA ES volume and the 3D RA ES volume. Three groups of patients were individualized according to cardiac rhythm at M0 and M6: AF at M0 and AF at M6 (AF-AF), AF at M0 and sinus rhythm (SR) at M6 (AF-SR), SR at M0 (spontaneous reduction before the admission ECG) and SR at M6 (SR-SR). At M0 echocardiography, in the AF-AF group and AF-SR in comparison with SR-SR group were as follow: the 3D RA ED volume was significantly higher (respectively 21.6 (18.2-26.6) and 26.9 (19.4-36.8) versus 11.3 (6.9-16.6) mL/m2 ; p = 0.0025), the 3D RAEF was significantly lower (42.2 (35.1-44.7) and 34.5 (24.1-38.6) versus 57.6 (53.4-62.2)%; p = 0.0105) and the RA GLS was also significantly lower (7.6 (6.5-10.5) and 9.1 (5.8-11.2) versus 26.6 (22.0-35.0)%; p = 0.0001) (Figure 1).

Conclusion

3D ultrasound and strain could be useful tools for evaluating the anatomical and functional RA remodelling in AF, to be further validated in a larger ongoing study.

Abstract P350 Figure 1
P354 Right heart catheterization parameters, echocardiography parameters and B-Type natriuretic peptide prediction of acute cellular rejection in the first year after heart transplant
Authors: Valentim Goncalves A A , Pereira-Da-Silva T , Soares R , Ilhao Moreira R , De Sousa L , Rio P , Feliciano J , Reis J , Mendonca T , Cruz Coutinho M , Mano T , Cruz Ferreira R
Published: January 2020

Introduction

Since the mid-1970s, the diagnosis of acute cellular rejection (ACR) has been made by endomyocardial biopsy (EMB). Whether B-Type Natriuretic Peptide (BNP), transthoracic echocardiography (TTE) parameters and right heart catheterization (RHC) parameters can detect rejection in heart transplant (HT) patients have yielded conflicting results and did not overcome the use of EMB in the first year after HT.

Purpose

The aim of this study was to evaluate whether BNP, TTE and RHC parameters can be used to detect ACR in the first year after HT.

Methods

Prospective study of consecutive EMB performed in the first year after HT. Plasma BNP levels, TTE and RHC were performed at the same day.

Clinical significant ACR was defined as ≥ 2R, according to the ISHLT 2004 grading. The area under the curve (AUC) was analysed for statistically significant associations to detect ACR.

Results

From 2017 to 2018, 50 EMB were performed with the following results: 2R - 5 (10.0%); 1R- 29 (58.0%); 0 – 16 (32%). Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

AUC results of BNP and several TTE and RHC parameters for the prediction of ACR are represented in the table. Right atrial pressure (RAP) value (p = 0.027) was the only significantly predictor of ACR, while isovolumic relaxation time measured by TTE revealed a borderline significant trend (p = 0.076).

RAP > 10mmHg had a sensitivity of 60.0% and a specificity of 84.4% for detecting ACR.

Conclusion

Detecting ACR without EMB remains a clinical challenge, but RAP measured by RHC was a significant predictor of ACR in the first year after HT, while BNP values did not correlate with ACR.

AUC values PARAMETERS AUC p 95% CI BNP 0.658 0.251 0.405-0.911 Troponin I 0.591 0.507 0.260-0.923 Left ventricular ejection fraction 0.416 0.541 0.218-0.614 E/A 0.480 0.895 0.282-0.678 Deceleration time 0.463 0.463 0.161-0.765 Isovolumic relaxion time 0.745 0.076 0.427-1.000 Cardiac index 0.595 0.488 0.346-0.845 Pulmonary capillary wedge pressure 0.628 0.401 0.329-0.926 Mean pulmonary artery pressure 0.684 0.181 0.511-0.857 Right atrial pressure 0.804 0.027 0.631-0.978 AUC values
P358 Prevalence of suicide in a cohort of subjects submitted to exercise echocardiography: clinical characteristics and exercise echocardiography results
Authors: Peteiro Vazquez J C , Bouzas-Mosquera A , Varela-Cancelo A , Barbeiro-Caamano C , Broullon J , Vazquez-Rodriguez J M
Published: January 2020

Patients with clinical symptoms and morbidities might be more prone to commit suicide. Suicidal rate reaches up to 25-30/100.000 subjects in the countries most affected by this problem. We aimed to establish the rate of suicides among a large cohort of patients submitted to Exercise echocardiography (ExE), and also to study their clinical and ExE results, to better understand possible explanations.

Methods

Retrospective analysis of prospectively collected data on 12,615 patients (age 62 ± 12 years, 63% men) with a first treadmill ExE performed in our center for known/suspected coronary artery disease. Exclusion criteria were significant valve disease, cardiomyopathy, congenital heart disease, and age <18 year-old. Ischemia was defined as the development of new wall motion abnormalities (WMAs) with exercise; abnormal ExE as ischemia or resting WMAs.

Results

During a follow-up of 4.7± 4.8 years (interquartil range 0.1-8.0 years) there were 2,578 deaths, including 21 due to suicide (rate 166/100.000 subjects). We compare clinical characteristics and ExE results between patients that committed suicide (S), patients that died of other causes (OC), and patients that survived (Surv). The worst clinical and ExE characteristics were found in patients that died of non-suicidal causes, whereas patients that committed suicide were in an intermediate risk position (Table).

In conclusion, suicidal rate seems to be very high among patients with a clinically indicated ExE. Clinical characteristics and ExE results of suicidal subjects are worse than in survivor patients and could in part explain this event.

Surv S OC P value Age, y 61 ± 12 65 ± 11 69 ± 9 <0.001 Male 60% 86% 72% <0.001 Diabetes Mellitus 17.5% 24% 31% <0.001 Achieved METS 9.7 ± 3.2 8.3 ± 3.6 7.6 ± 2.9 <0.001 Good functional capacity (≥10 METs) 55% 52% 29% <0.001 Symptoms during ExE 16% 14% 19% 0.01 Maximal double product 25.0 ± 5.9 22.5 ± 6.4 22.9 ± 6.0 <0.001 Submaximal test 20% 31% 32% <0.001 Ischemia 27% 38% 44% <0.001 ExE abnormal 37% 50% 63% <0.001 LVEF at rest 59 ± 7 53 ± 13 54 ± 11 <0.001 LVEF at peak 64 ± 11 60 ± 16 55 ± 15 <0.001
P364 The first prospective study of non-compaction cardiomyopathy patients with preserved ejection fraction using cardiac magnetic resonance feature tracking
Authors: Kiss A , Szucs A , Furak A , Gregor Z S , Horvath M , Toth A , Czimbalmos C S , Dohy Z S , Szabo L , Suhai F I , Merkely B , Vago H
Published: January 2020

Feature tracking (FT) is a new cardiac magnetic resonance (CMR) technique for strain measurement to reveal changes e.g. in noncompaction cardiomyopathy (NCMP) patients with good ejection fraction (EF).

Our aim was to describe, first in the literature, the functional and CMR-FT strain values of NCMP patients with good EF and to compare them with their previous scans taken 4 years ago.

At the Heart and Vascular Center of Semmelweis University 6743 CMR examinations were done between 2009-2015 and 232 NCMP patients were diagnosed. We followed up 27 patients, who had a previous examination at least 4 years ago, had no co-morbidities and whoes EF were above 50% (mean age: 37 ± 14.4 years, 18 males, mean follow up: 5.7 ± 1.5 years). Their parameters were compared to a matched control (C) group.

The Medis Suite software was used for analysis, the MedCalc software for statistics, (p < 0.05).

We compared the patient’s previous (PREV) and recent (REC) functional parameters but did not find significant changes. Comparing the global longitudinal and global circumferential strains (GLS, GCS) and rotation (R) no difference was found between the PREV and the REC values. The GCS showed significant difference between NCMP and C groups (-30.2 ± 5.0 vs -35.9 ± 4.5; p < 0.0001). We compared the segmental longitudinal and circumferential strain values of PREV vs. REC groups and NCMP vs C groups and found significant differences just in a few segments. The left ventricular (LV) apical part’s mean longitudinal strain value showed significant decrease on the REC scans compared to the PREV (PREV vs REC: -24.4 ± 7.7 vs -20.6 ± 5.1%; p < 0.05) and a non-significant decrease compared to the C (C vs REC: -22.8 ± 7.5 vs -20.6 ± 5.1%; p= n.s.).

The ratio of the average longitudinal strain value of the apical and basal part of the left ventricle was significantly smaller in the REC group compared to the PREV but did not differ from the C subjects ( PREV vs. REC: 1.5 ± 0.8 vs 1.0 ±0.3; C vs REC: 1.5 ± 0.3 vs 1.2 ± 0.5; p < 0.05)

We did not find worsening in the functional parameters of NCMP patients with good EF by the end of the follow up period. However, subclinical changes can be detected in the affected apical part of LV when using FT suggesting the need for follow up.
418 Ultrasound molecular imaging of the role of von willebrand factor-mediated platelet adhesion in atherogenesis
Authors: Ozawa K , Muller M , Varlamov O , Packwood W , Xie A , Lopez J A , Lindner J R
Published: January 2020

Funding Acknowledgements

JSPS Overseas Research Fellowship

Background

Platelets are known to be both pro-inflammatory and pro-mitogenic. However, the role of platelet-endothelial interactions in the initiation and growth of atherosclerotic lesions is not well understood.

Purpose

We used contrast-enhanced ultrasound (CEU) molecular imaging of the arterial endothelium to test the hypothesis that platelet attachment to endothelial Von Willebrand Factor (VWF) promotes atherogenesis.

Methods

We studied wild-type mice (WT), low-density lipoprotein deficient mice fed western diet to produce atherosclerosis (LDLR-/-), and LDLR-/- mice also deficient for ADAMTS-13 (LDLR-/-ADAMTS13-/-) which is the enzyme responsible for proteolytic cleavage of endothelial-associated VWF. Mice were studied at 20 weeks and 30 weeks of age. A subset of LDLR-/- mice were treated with recombinant ADAMTS13 1 hr prior to study. Proximal aortic CEU molecular imaging of P-selectin, vascular cell adhesion molecule (VCAM)-1, von Willebrand factor (VWF), and platelet GPIbα was performed. Aortic distensibility was assessed using high-frequency (30 MHz) transthoracic echocardiography and tail cuff blood pressure systems. NF-κB of aorta was assessed by ELISA kit. Plaque size and composition were assessed by histology. Platelets and macrophage immunohistochemistry were also performed on confocal microscopy.

Results

Aortic molecular imaging signal for P-selectin, VCAM-1, VWF, and platelet adhesion was significantly higher in LDLR-/- than WT mice, and increased by 2-fold between 20 and 30 wks of age. Signal for VWF and platelet adhesion was abolished 1 h after administration of ADAMTS13, confirming that platelet adhesion was VWF-mediated. At 20 and 30 wks of age, molecular imaging signal for all targets was 2-fold higher (p < 0.01) in LDLR-/-ADAMTS13-/- versus LDLR-/- mice. The LDLR-/-ADAMTS13-/- mice also had lower aortic distensibility (p < 0.05), had a 2-fold higher NF-κB signal (p < 0.05), and had a 2-fold greater total plaque area (p < 0.01). Fluorescent immunohistochemistry confirmed that the LDLR-/-ADAMTS13-/- mice also had greater platelets (p < 0.05) and increased macrophage content (p < 0.05) than LDLR-/- mice in aortic plaque.

Conclusion

In early to mid-stage atherosclerosis, abnormal regulation of endothelial-associated VWF results in platelet adhesion and secondary up-regulation of endothelial inﬂammatory adhesion molecules, thereby promoting atherosclerotic plaque progression. These results indicate an important role of platelet-endothelial interactions in early atherogenesis.

Abstract 418 Figure
496 A fatal case of MitraClip thrombosis
Authors: Andrikopoulou E , Mitchell R N M , Kim A Y K , Shook D C S , Kaneko T K , Shah P B S , Sun Y P S
Published: January 2020

Case

An 80 year old man presented with persistent dyspnea two months following placement of three MitraClip devices for severe degenerative mitral regurgitation (MR). On exam, he had an apical holosystolic murmur. A transesophageal echocardiogram revealed displacement of one of the MitraClip devices (Figure 1A, red arrow showing the displaced MitraClip) and moderate-severe MR (Figure 1B). He underwent implantation of a fourth MitraClip with reduction of his MR to mild-moderate (Figure 1C, 1D; yellow arrow showing the new MitraClip). Shortly after, he experienced severe melena and hematochezia and became lethargic and hypotensive. He was transferred to the Cardiac Intensive Care Unit, was intubated and aggressively supported. Extensive work-up revealed diffuse gastric body ischemia and ulceration. A transthoracic echocardiogram showed his most recent MitraClip being well seated with mild-moderate MR. He developed refractory multi-organ failure and expired eight days following the procedure. Autopsy revealed thrombi attached to the initially placed MitraClip’s (Figure 1E, 1F) and thromboemboli to the small bowel, spleen and brain.

Discussion

MitraClip is the predominant non-surgical alternative for percutaneous mitral valve repair in inoperable patients with symptomatic MR, either primary or secondary. Despite its growing use, there remains a paucity of data on its safety and the potential life-threatening complications, especially when more than one device are placed. Current recommendations include dual antiplatelet therapy with aspirin and clopidogrel. In patients already on anticoagulation, continuation of it is recommended. Very few cases of MitraClip thrombosis have been reported so far. Acute development of spontaneous echo contrast (SEC) and early thrombus was described in a patient with severe, primary MR receiving 2 MitraClip"s. Both SEC and the early thrombus resolved once the second device was removed. In another case, intraprocedural thrombus formation was described on the right side of the interatrial septum close to the MitraClip guide catheter. The underlying pathophysiologic mechanism and the predisposing factors to acute and subacute thrombosis associated with MitraClip are unclear. One plausible explanation could be the acute dramatic hemodynamic alterations related to the reduction in MR and new mild mitral stenosis. In addition, the MitraClip itself may act as a prothrombotic nidus. Potential risk factors include: advanced age and multiple comorbidities predisposing to proinflammation and prothrombosis. The use of MitraClip is only expected to increase in the future. Large scale clinical trials are needed to further define the safety of the device and delineate the optimal antiplatelet and/or antithrombotic regimen.

Abstract 496 Figure. Pre and post TEE and autopsy findings.
498 A missed and misdiagnosed case of pericardial agenesis
Authors: Altin C , Ozpelit E , Gezmis E , Ozpelit M E
Published: January 2020

Introduction

Pericardium is a fibroserous sac surrounding the heart and the roots of the great vessels. Pericardial agenesis which is a rare condition can be complete or partial and the most common form is absence of left hemipericardium. Pericardial agenesis is often an incidental finding, as it is usually asymptomatic. Moreover patients presenting with symptoms can be missed diagnosed, because it can be difficult to visualise the pericardium clearly with imaging modalities. Herein we present a misdiagnosed pericardial agenesis case.

Case Report

A 49 years old male was admit to our cardiology clinic for confirmation, and follow-up of a previous diagnosis of right ventricular cardiomyopathy (CMP). He had been previously diagnosed based on transthoracic and transesophageal echocardiography findings 13 years ago. Since then he had been attending routine follow-ups, he had also underwent several imagining modalities even cardiac magnetic resonance (CMR) to confirm the diagnosis of right ventricular CMP. No arrhythmia had been detected in Holter monitoring. He had no dyspnea, or other specific signs and symptoms. His medical and family histories were otherwise unremarkable. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm without having specific abnormalities. The chest X-ray revealed laevorotation of the heart (Fig A). The transthoracic echocardiography showed a laterally displaced left ventricle (LV) apex, and an enlarged right ventricle (RV) with normal systolic function (Fig B). Coronary computed tomography angiography (CCTA) revealed normal coronary arteries, leftward displacement of the heart with mild RV dilatation. The pericardium was only visible around right atrium (Fig C). CMR demonstrated mild RV dilatation (end-diastolic volume 167ml) with reasonable systolic function (EF 50%), normal LV dimensions with normal systolic function (Fig D). The absence of pericardium at both left and right sides, except around right atrium, was confirmed, whereas there was no additional finding such as wall motion abnormality. Therefore the patient was diagnosed with partial pericardial agenesis and scheduled for follow-ups.

Conclusion

The pericardial agenesis which is a rare disorder is generally benign. Although MRI is believed to be the gold standard technique, it might not be able to delineate entire pericardium, because of various artefacts or paucity of surrounding fat. Therefore physicians should be aware of the indirect signs on various imaging modalities like excessive laevorotation of the heart, as direct recognition can be tricky, and the patient can be easily missed and/or misdiagnosed. Our patient was asymptomatic. His pericardial defect was almost total and this abnormality hadn’t been recognized in his previous CMR or echocardiograpy, leading to a misdiagnosis of CMP. Complete or unilateral absence of the pericardium is considered to be benign, surgical pericardioplasty may only be considered for highly symptomatic patients.

Abstract 498 Figure.
500 Multiple cardiac myxomas on both mitral valve leaflets and left ventricular outflow tract: carney complex in a greek family
Authors: Siskos A , Giannakopoulou P , Gouliaros N , Poulios P , Zarifis I
Published: January 2020

Funding Acknowledgements

None to declare.

A 49 year old woman was admitted to our institution due to syncope. Her medical history was unremarkable, but her family history included a cerebral infract suffered by her daughter and attributed to a left atrial myxoma. Her physical examination revealed spotty skin pigmentation on her face, lips and neck; a palpable mass in her right breast; and a nodule on her right nipple. During her hospitalisation she developed aphasia and hemiparesis. Brain MRI revealed multiple acute ischemic infracts of her left middle cerebral artery. Bedside transthoracic echocardiography revealed three cardiac masses: one located at the left ventricle outflow tract, the aortic valve; and two on both mitral valve leaflets. The above findings were confirmed with transoesophageal echocardiography.

She undewent biopsy of the breast mass, and surgical excision of the nipple nodule and the cardiac masses. Histology revealed myxoma in all sites. The patient recovered without complications, aside of minor neurologic deficits. 1,5 year follow-up of the patient and her daughter showed no reccurence of cardiac masses.

DNA sequencing of both mother and daughter was positive for PRKAR1A mutation, confirming the diagnosis of Carney complex, a very rare multiple neoplasia syndrome. In addition to the cutaneous and cardiac findings, Carney complex is also associated with endocrine tumors, which neither patient had. The coexistence of myxomas, skin hyperpigmentaion (Lentiginosis) and endocrine abnormalities should always be a reminder of this entity, in order to prevent tumors from causing strokes and death.

Abstract 500 Figure.
504 Intramural hematoma post transcatheter valve replacement
Authors: Maresiu O C , Anton M , Boeangiu S , Margineanu C , Penes D , Marin G , Geavlete O , Kulcsar I , Radu R I , Stoica E , Parasca C , Iliescu V A , Antohi E L , Chioncel O
Published: January 2020

Background

Transcatheter valve replacement (TAVR ) is currently the optimal treatment for patients with severe aortic stenosis who are considered to have an intermediate to high operative risk for surgical intervention. Intramural hematoma secondary to balloon-expandable TAVR is a poorly reported complication with unknown outcome. Among the risk factors associated with this complication are advanced age, female gender, bulky calcifications, significant basal hypertrophy and severe prothesis oversizing.

Case report

We report the case of a 84 year old woman with a history of permanent atrial fibrillation, who was diagnosed with severe aortic stenosis symptomatic with heart failure NYHA class III. An important comorbidity was liver cirrhosis of viral etiology (hepatitis C virus) with secondary thrombocytopenia.

Transthoracic and transoesophageal echocardiography (TEE) showed severe aortic stenosis with asymmetric calcifications, with preserved gradient (a peak velocity of 4.7 m/s, mean gradient of 63.3mmHg), mild left ventricular disfunction (ejection fraction 45%), and calculated aortic valve area of 0,9 cm2.

As a frail, high risk patient, the heart team recommended transcatheter aortic valve implantation. After complete computer tomographic evaluation, a 26 mm Edwards Sapien 3 valve was implanted through a femoral approach.

Intraprocedural transesophageal echocardiography showed the developement of an intramural hematoma in the aortic root (right coronary and noncoronary sinuses), associated with a small pericardial effusion. After administration of Protamine, betablockers and strict blood pressure control, no extension of the hematoma was noted.

Serial TEE showed significant regression of the hematoma and of the pericardial effusion, with normal parametres of the prothesis, with a transprothetic gradient of 23 mmHg, no aortic leak, no other complications.The patient was discharged 12 days after the procedure, clinically stable.

Conclusion

Aortic intramural hematoma may occur during intra-TAVR procedure. Although it may have a benign course, timely recognition and adequate imaging follow-up are mandatory in order to limit the extent and prevent life-threatening complications.
545 Deep learning/artificial intelligence for automatic measurement of global longitudinal strain by echocardiography
Authors: Salte I M , Oestvik A , Smistad E , Melichova D , Nguyen T M , Brunvand H , Edvardsen T , Loevstakken L , Grenne B
Published: January 2020

Funding Acknowledgements

The Norwegian Health Association, South-Eastern Norway regional health Authority and the national program for clinical therapy research (KLINBEFORSK).

Background

Global longitudinal strain (GLS) by echocardiography has incremental prognostic value in patients with acute myocardial infarction and heart failure compared to left ventricular (LV) ejection fraction and provides more reproducible measurements of LV function. Recent advances in machine learning for image analysis now open the possibility for robust fully automated tracing of the LV and measurement of global longitudinal strain (GLS), without any operator input. This could make real-time GLS possible and remove inter-reader variability, thus resulting in saved time and improved test-retest reliability. The aim of the present study was to investigate how measurements by this novel automatic method compares to conventional speckle tracking analyses of GLS.

Methods

100 transthoracic echocardiographic examinations were included from a clinical database of patients with acute myocardial infarction or de-novo heart failure. Examinations were included consecutively and regardless of image quality. Simpson biplane LV ejection fraction ranged from 7 to 70%. Images of three standard apical planes from each examination were analysed using our novel and fully automated GLS method based on deep learning technology. The automated GLS measurements were compared to conventional speckle tracking GLS measurements of the same acquisitions using vendor specific format and software (EchoPAC, GE Healthcare), performed by a single experienced observer.

Results

GLS was -11.6 ± 4.5% and -12.8 ± 5.0% for the deep learning method and the conventional method, respectively. Bland-Altman analysis showed a bias of -0.7 ± 1,9% and 95% limits of agreement of -4,6 to 3.1. No clear value dependent bias was found by visual inspection (Figure A). Feasibility for measurement of GLS was 93% for the deep learning based method and 99% for the conventional method. The limits of agreement found in our study is comparable to findings in the intervendor comparison study by the EASCVI/ASE/Industry Task force to standardize deformation imaging.

Conclusion

This novel deep learning based method succeeds without any operator input to automatically identify and classify the three apical standard views, trace the myocardium, perform motion estimation and measure global longitudinal strain. This could further facilitate the clinical use of GLS as an important tool for enhancing clinical decision-making.

Abstract 545 Figure.
555 Right ventricular longitudinal strain of patients with pulmonary hypertension
Authors: Fontes Oliveira M , Trepa M , Costa R , Dias Frias A , Silveira I , Cabral S , Santos M , Torres S , Reis A
Published: January 2020

Introduction

Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Recently, speckle-tracking echocardiography has emerged as a new tool in the RV assessment. In this study, we aimed to study the value of global longitudinal strain in the RV evaluation of these patients.

Methods

We collected clinical, laboratory, echocardiographic and right heart catheterization (RHC) data from consecutive patients referred to an expert tertiary care referral centre from 12/2016 to 11/2018. Global RV systolic peak longitudinal strain (RVS) and RV free wall peak longitudinal strain (RVFWS) (mean of the basal, mid- and apical-segments) were measured by speckle-tracking technique with Echo-Pac software from GE Healthcare®.

Results

Of the 97 included patients, 76% were female. The mean age was 65 ± 15 years. Most patients were in NYHA class II. Median time between TTE and RHC was 70 days [IQR 34 - 184]. Group 2 PH was the most frequent aetiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7.

Both strain parameters significantly correlated with other echocardiographic parameters such as TAPSE, FAC, Tricuspid S wave, RV diastolic diameter, eccentricity index (EI), systolic pulmonary artery pressure (SPAP), pulmonary acceleration time and presence of RV outflow tract notching. Strain parameters were also associated with pulmonary artery pressures and pulmonary vascular resistance (PVR) measured by RHC. Strain parameters did not correlate with PECP (p > 0.05).

In multivariate analysis, RV global longitudinal strain predicted invasive mean pulmonary artery pressure and PVR independently of TAPSE and FAC (β=1.38, p < 0.001). RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02, AUC 0.72) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51, AUC 0.78). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72).

Conclusion

RV global and free wall longitudinal strain significantly correlate with other echocardiographic parameters of RV structure and function and with invasive pulmonary artery pressures and PVR.

Abstract 555 Figure.
562 Can 2D speckle tracking echocardiography have an additional impact on prediction of hospitalizations due to heart failure decompensation in patients with ischemic left ventricular systolic dysfunction
Authors: Szwoch M , Kaufmann D , Raczak G , Danilowicz-Szymanowicz L
Published: January 2020

Funding Acknowledgements

NA

Background

Despite advancements in medical therapy and device-based treatment, heart failure (HF) continues to impose enormous burden for both patients and health care system worldwide. Hospitalizations due to HF decompensation is well-known cause of mortality.

Objectives were to verify whether 2D speckle tracking echocardiography (2D STE) provides independently of other well-known clinical and echocardiographic parameters, information on the risk of HF decompensation in patients with left ventricular systolic dysfunction of ischemic origin.

Materials and Methods

In 193 stable ischemic HF patients with left ventricular ejection fraction (LVEF) ≤ 50%, global longitudinal strain (GLS), as well as other echocardiographic (GE VIVID E9, EchoPAC v201) and well-known clinical parameters were analyzed. During 34 (14 – 71) months of follow-up, 58 patients were hospitalized due to HF decompensation (EVENT).

Results

LVEF, GLS, diastolic function and well-known clinical parameters (age, renal function, hemoglobin, brain natriuretic peptide level, history of diabetes, diuretic treatment and the absence of beta-blockers), as well as cut-off values of these parameters identified in ROC analysis were significantly associated with the risk of EVENT in univariate Cox hazard regression analysis (Table). GLS value of -9.4% was the most accurate predictor of EVENT (AUC 80.7% [CI 57.6 – 100%]), whereas other parameters were characterized by lower discriminatory power. In multivariate Cox analyses GLS of -9.4% was still a significant predictor of the EVENT.

Conclusions

2D STE can provide additional information, independently of other well-known clinical and echocardiographic parameters, on the risk of HF decompensation in the patients with left ventricular systolic dysfunction of ischemic origin. GLS value worse than -9.4% can identify the patients with higher risk of this EVENT.

Hazard Ratio 95% CI p Age ≥ 71 yo 2.48 1.46 - 4.23 <0.001 GFR ≤ 30 ml/min/1.73 m² 4.67 1.65 - 13.22 <0.004 Hemoglobin ≤ 14.7 g/dl 3.02 1.19 - 7.70 <0.020 BNP ≥ 214 pg/ml 2.64 1.31 - 5.31 <0.007 LVEF ≤ 32% 2.76 1.55 - 4.90 <0.001 GLS ≥ -9.4% 15.16 1.81 - 56.91 <0.012 E/A ≥ 2.0 8.64 1.91 - 39.05 0.005
566 Myocardial left ventricular mechanical uniformity and adverse cardiac events following myocardial infarction
Authors: Stiermaier T , Backhaus S J , Lange T , Koschalka A , Navarra J L , Boom P , Lamata P , Kowallick J T , Lotz J , Hasenfus G , Gutberlet M , Thiele H , Eitel I , Schuster A
Published: January 2020

Background

Despite limitations as a standalone parameter, left ventricular ejection fraction (LVEF) is the preferred measure of myocardial function and marker for post-infarction risk stratification. LV myocardial uniformity may provide superior prognostic information after acute myocardial infarction (AMI), which was subject of this study.

Methods and Results:

Consecutive patients with AMI (n = 1082; median age 63 years; 75% male) undergoing cardiac magnetic resonance (CMR) in median 3 days after infarction were included in this multicenter, observational study. Circumferential and radial uniformity ratio estimates (CURE and RURE) were derived from CMR feature-tracking as markers of mechanical uniformity (values between 0 and 1 with 1 reflecting perfect uniformity). The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE), consisting of all-cause death, re-infarction, and new congestive heart failure.

Patients with MACE (n = 73) had significantly impaired CURE [0.76 (IQR 0.67-0.86) versus 0.84 (IQR 0.76-0.89); p < 0.001] and RURE [0.69 (IQR 0.60-0.79) versus 0.76 (IQR 0.67-0.83); p < 0.001] compared to patients without events. While uniformity estimates did not provide independent prognostic information in the overall cohort, CURE below the median of 0.84 emerged as an independent predictor of outcome in post-infarction patients with LVEF >35% (n = 959) even after adjustment for established prognostic markers (hazard ratio 1.99; 95% confidence interval 1.06-3.74; p = 0.033 in stepwise multivariable Cox regression analysis). In contrast, LVEF was not associated with adverse events in this subgroup of AMI patients.

Conclusions

CMR-derived estimates of mechanical uniformity are novel markers for risk assessment after AMI and CURE provides independent prognostic information in patients with preserved or only moderately reduced LVEF.
620 Normalized stroke volume in severe aortic stenosis with preserved ejection fraction: reference values and outcome implications
Authors: Bohbot Y , Rusinaru D , Rietzschel E , De Buyzere M , Buicuic O , Marechaux S , Gilebert T , Tribouilloy T
Published: January 2020

Funding Acknowledgements

none

Background

Appropriate normalization methods to scale Doppler-derived stroke volume (SV) in patients with aortic stenosis (AS) are poorly defined and reference values are lacking.

Purpose

We aim to establish reference values for normalized SV, to compare the prognostic value of SV normalized by different methods in AS and to examine the outcome of low-flow(LF) low-gradient(LG) AS with preserved ejection fraction(LVEF) based on newly defined reference values.

Methods

In 2781 normotensive adults without cardiovascular disease we defined normal relationships between SV and body size by nonlinear regression. We analyzed the prognostic performance of ratiometric and allometric normalized SV in 1450 patients with severe AS and preserved LVEF.

Results

The allometric exponents that described the SV-height (H) and SV-body surface area (BSA) relationships were 1.32 and 0.88, respectively. In males, LF reference values were: <28ml/m²,<30ml/m,<30ml/(m²)^0.88, and, respectively,<26 ml/m^1.32, and in females <27ml/m²,<28ml/m,<29ml/(m²)^0.88, and, respectively,<24 ml/m^1.32. In patients with severe AS, SV/H^1.32 was most consistently associated with mortality and showed better prognostic performance than other normalized SV parameters. Compared to H-normalization, BSA-normalization markedly overestimated the frequency of LF (2% vs. 11%). In 1354 AS patients managed initially medically, LF/LG AS defined based on the 35ml/m² cut-off showed better outcome than high gradient(HG) AS (adjusted HR 0.85[0.62-0.96]). When new reference values were used, the mortality risk of LF/LG AS was higher than that of HGAS (adjusted HR 1.37[1.06-1.89] for SV/BSA and adjusted HR 1.42[1.10-2.15] for SV/H^1.32).

Conclusion

We provide reference values and appropriate normalization methods for SV by Doppler-echocardiography. Patients with LG severe AS, preserved LVEF and "true" LF are at high risk of death during follow-up.

Abstract 620 Figure. Frequency of flow-gradient patterns
P632 Apical mass after acute myocardial infarction
Authors: Jimenez Arjona R , Cepas-Guillen P , Doltra A , Ortiz J T , Vidal B
Published: January 2020

Funding Acknowledgements

No financial support

53-year-old male, with a personal history of high blood pressure and current smoking.

He presented in the emergency department with typical chest pain. The initial electrocardiogram showed a ST segment elevation in DI and AVL leads. An emergency coronariography was performed showing a single vessel disease with two tandem lesions on the first diagonal, which were treated with pharmacoactive stents.

An echocardiography was performed, showing a mild apicolateral hypokinesia, with good contractility of the remaing segments. In addition, a rounded, pediculated and mobile mass in the apex was observed; the mass was hyperechogenic compared to the myocardium. In this setting, the differential diagnosis should include thrombus in context of acute coronary syndrome (despite a small infarction with early revascularization and good contractility of the segments involved) vs. tumoral mass. Anticoagulant treatment was maintained and a cardiac magnetic resonance (MR) was performed. The MR showed an apical round mass of 11 mm, with hyperintense signal in both T1- and T2-enhanced sequences in comparison to normal myocardium; although no contrast uptake was observed in early gadolinium enhancement sequence, the mass showed homogeneous enhancement in the late enhancement images, both with optimal TI and with long T1. These findings were suggestive of a benign tumoral mass of atypical location. In addition, a small anterior subendocardial enhancement with preserved ejection fraction was observed.

A control echocardiogram after 5 weeks of anticoagulant treatment showed no changes in either size or characteristics of the mass. After risk-benefit assessment and according to patient preferences, surgical resection of the mass was decided by a mini-thoracotomy approach. A surgical piece was obtained, described as a mobile pediculated tumour with a granulated surface and mucinous aspect. The postoperative period was uneventful. Subsequently, the pathological study confirmed the diagnosis of papillary fibroelastoma of atypical location.

This case summarizes the usefulness of MR to characterize cardiac masses and, in particular, to differentiate tumours from thrombus. Although in this setting (recent myocardial infarction) an apical thrombus was initially suspected, the MR exam correctly identified a contrast enhanced mass, which ruled out acute thrombus and suggested benign tumour.

Abstract P632 Figure.
P641 Severe pulmonary steno-insufficiency due to metastatic carcinoid tumor in a 57 years old patient treated with MTPV implantation: first experience
Authors: Viani G M , Paiocchi V L , Leo L A , Faletra F F , Pedrazzini G
Published: January 2020

Funding Acknowledgements

none

Background

Right side heart valve involvement is a well known phenomenon in metastatic carcinoid disease. In recent times bioprosthetic valves have been widely used for replacement of stenotic and regurgitant native heart valves. Melody Transcatheter Pulmonary Valve (MTPV, Medtronic, Minneapolis, MN, USA) has been approved for treatment of native pulmonary valves as well as failing biological prostheses and conduits. We present the first case to our knowledge of severe native pulmonary valve steno-insufficiency due to metastatic carcinoid syndrome treated with MTPV implantation.

Case report

A 57-year-old woman is known since 2007 for metastatic carcinoid syndrome treated with surgical resection followed by chemotherapy (tamoxifene, everolimus) and radiotherapy. For 2 years she has been known for tricuspid and pulmonary involvement, which aggravated progressively, leading to symptomatic right heart failure. She was therefore submitted for multimodality imaging evaluation (see picture) and right heart catheterization.

Transthoracic echocardiogram, cardiac MRI and right heart catheterization confirmed severe pulmonary valve steno-insufficiency. Cardiopulmonary exercise testing revealed a severe limitation of aerobic exercise capacity (VO2 max 14.4 ml/min/kg).

After heart team discussion it was decided to treat the patient in a 2 step approach, initially with implantation of a Melody valve in pulmonary position and subsequently with surgical repair of the tricuspid valve.

Pulmonary valve was treated by placement of a 39 x 25 mm ANDRA stent and subsequent implantation of a 22 mm Melody valve. Before stenting, coronary angiography with simultaneous balloon inflation in RVOT was performed to exclude coronary artery compression. During the procedure the patient developed hypotension, which was treated effectively with Octeotride.

Post-operative echocardiogram showed a significant reduction in pulmonary valve gradient and no significant residual regurgitation.

Conclusions

We treated effectively severe pulmonary steno-insufficiency due to metastatic carcinoid tumor with MTPV implantation. No complications occurred. Multimodality imaging is fundamental for patients selection and preoperative planning of prosthetic valve dimensions.

Abstract P641 Figure. Multimodality imaging of PV
P650 A rare form of cardiac mass: primary cardiac lymphoma
Authors: Yagmur B , Simsek E , Ozbay B , Calkavur T , Kayikcioglu M , Can L
Published: January 2020

Funding Acknowledgements

We declare no conflict of interest and no financial support

A rare form of cardiac mass

primary cardiac lymphoma

Introduction

Primary tumors of the heart are rare and constitute 5% of all cardiac masses. Primary cardiac lymphoma is a curable form of cancer that responds well to early diagnosis and chemotherapy.

Case report

56 year old male patient presented to our outpatient clinic with abdominal swelling. Echocardiography revealed a mass lesion that surrounded the right ventricle and restricted ventricular diastolic function. The mass lesion was poorly discernable from normal myocardial tissue. Magnetic resonance imaging (MRI) showed an infiltrative mass lesion that filled the right pericardial space, and that surrounded the junction between vena cava superior and the right atrium, as well as the root of the aorta. Subxyphoidal biopsy revealed diffuse large B cell lymphoma. Patient died on the 10th day of chemotherapy.

Discussion

Primary cardiac lymphoma constitutes only 2% of all primary cardiac tumors. Cardiac lymphomas are curable in early stages with chemotherapy without the need for surgical excision. Cardiac lymphoma should be kept in mind when faced with a cardiac mass lesion and imaging modalities such as MRI and PET scanning and tissue biopsy should be utilized before planning surgical interventions since these lesions respond well to chemotherapy

Abstract P650 Figure.
P660 Arterial hypertension as confounding factor in the echocardiographic assessment of patients with significant aortic stenosis
Authors: Velegraki E , Stefanidis A , Barmpatzas N , Filippou K , Kranidis A
Published: January 2020

Purpose

Increased arterial pressure affects the accuracy of clinical conclusions in a number of cardiac pathologies, including valvulopathies. We investigated the influence of increased blood pressure in the assessment of multiple echo variables in patients with significant aortic stenosis of different physiologies.

Methods

Seventy two patients (33 women, aged 72 ± 12 years old, EF: 56 ± 9%) with significant aortic stenosis [18 (25%) with low flow low gradient (LFLG) and 7 (10%) with paradoxic LFLG (PLFLG) physiology] and arterial systolic pressure ≥140 mmHg on admission, were assessed with a full 2D and Doppler echocardiographic study including non-invasive assessment of pressure recovery and valvuloarterial impedance (z). Echo study was performed on two occasions during their hospitalization, on admission and after normalization of blood pressure. Arterial pressure was controlled by any therapeutic means at the discretion of the referring physician. Significant serial changes between echo variables were assessed by the Student paired t-test.

Results

Arterial pressure and heart rate were significantly lowered between the two studies (from 152 ± 13 to 116 ± 11 mmHg and 78 ± 7 to 73 ± 5, p< 0,001 respectively). Differences between the echo variables are depicted in the following table.

Conclusions

Small but significant changes were noticed in several echo parameters after lowering blood pressure in patients with significant aortic stenosis. These patients should always be assessed after normalization of their blood pressure since the degree of stenosis can be erroneously overestimated and affect clinical decision.

p < 0,001

Echo variable 1st study 2nd study Stroke vol index (i) (ml/m2) 37,1 ± 9,5 44,1 ± 10* Mean gradient (mmHg) 42 ± 6,2 44 ± 5,8 * Pressure recovery (mmHg) 8,4 ± 2,5 9,5 ± 2,7* Z (mmHg/mL * m2) 5,4 ± 1,5 3,8 ± 1,1* AVAi (cm2/m2) 0,44 ± 0,06 0,49 ± 0,06*