bluuebunny/crossref_metadata_2025 huggingface dataset:
P1376 The utility of platelets indices in predicting the presence of left atrial appendage thrombus in patients with atrial fibrillation
Authors: Vijan A , Delcea C , Andrus A , Daha I , Dan G A
Published: January 2020

Background

Atrial fibrillation (AF) is the most frequent arrhythmia with a high risk for thromboembolic events. The presence of left atrial appendage (LAA) thrombus is associated with a greater risk for stroke, yet few papers investgated predictor factors for LAA thrombus. Platelets indices-Mean platelet volume (MPV) and plateletcrit (PTC)-have been correlated with platelet reactivity, thrombogenicity and a high cardiovascular risk.

Purpose

The aim of this study is to determine if MPV-to-PCT and MPV-to-platelet (PLT) ratios could predict the presence of LAA thrombus in nonvalvular AF patients.

Methods

This retrospective study includes 112 patients screened with trans-esophageal echography (TEE) for LAA thrombus from January 2018 to Aprilie 2019. We excluded patients with manifest, deep vein thrombosis, pulmonary trombembolism and malignancies. The platelets indices were measured on admission.

ROC curve analysis and the Youden index associated criterion was used to determine the cut-off values and Chi –square test to estimate associated risks.

Results

The focus group consisted of 112 AF patients, with a mean age of 67 ± 10.02 and 52.3% males. 71% patients had persistent AF, 19.64% (22) patients had LAA thrombi.

Higher MPV-to-PCT, respectively MPV-to-PLT ratios were associated with LAA thrombus. In ROC curve analysis MPV-to-PLT ratio (AUC 0.618 95% CI 0.521 to 0.708, p = 0.0729) and MPV-to-PCT ratio (AUC 0.627, 95% CI 0.530 to 0.716, p = 0.05) predicted LAA thrombi, with a cut-off value of >38 for MPV-to-PCT and >0.049 for MPV-to-PLT ratio.

Patients with an MPV-to-PCT ratio > 38 had a risk ratio of 1.21 (95% CI 1.03 - 1.44, p = 0.039) and those with an MPV-to-PLT ratio> 0.049 a risk ratio of 1.27 (95%CI 1.03 - 1.58, p = 0.01 ) of having a LAA thrombus.

Conclusion

Platelets indices are cost efficient, readily available thrombogenesis biomarkers that could be auxilliary parameters useful for the associtation of LAA thrombi in non-valvular AF patients undergoing TEE before cardioversion. We suggest the cut-off values of MPV-to-PCT> 38 and MPV-to-PLT > 0.049 to be considered as risk indicator.
P1386 A change in left ventricular global longitudinal strain is a prognostic indicator in congestive heart failure patients with preserved ejection fraction
Authors: Sakaguchi E , Yamada A , Hoshino M , Takada K , Hoshino N , Kawada Y , Yamabe S , Ozaki Y
Published: January 2020

Purposes

We examined how changes in left ventricular (LV) global longitudinal strain (GLS) were associated with prognosis in patients with preserved LV ejection fraction (LVEF) after congestive heart failure (HF) admission.

Methods

We studied 123 consecutive patients (age 70 ± 15 years, 55% male) who had been hospitalized due to congestive HF with preserved LVEF (> 50%). The exclusion criteria were atrial fibrillation and inadequate echo image quality for strain analyses. The patients underwent speckle-tracking echocardiography and measurement of plasma NT-ProBNP levels on the same day at the time of hospital admission as well as in the stable condition after discharge. Differences in GLS, LVEF and NT-ProBNP (delta GLS, LVEF and NT-ProBNP ; 2nd – 1st measurements) were calculated. The study end points were all-cause mortality and cardiac events.

Results

Mean periods of echo performance after hospitalization were 2 ±１days (1st echo) and 240 ± 289 days (2nd echo), respectively. During the follow-up (974 ± 626 days), 12 patients died and 25 patients were hospitalized because of HF worsening. In multivariate analysis, delta GLS and follow-up GLS were prognostic factors, whereas baseline and follow-up LVEF, NT-ProBNP, changes in LVEF and NT-ProBNP could not predict cardiac events. Delta GLS (p = 0.002) turned out to be the best independent prognosticator. Receiver operating characteristics analysis revealed that -0.6% of delta GLS was the optimal cut-off value to predict cardiac events and mortality (sensitivity 76%, specificity 67%, AUC 0.75). Kaplan-Meier analysis showed that patients with delta GLS more than -0.6% experienced significantly less cardiac events during the follow-up period (p < 0.0001, log-rank).

Conclusion

A change in LV GLS after congestive HF admission was a predictor of the prognosis in patients with preserved LVEF. It would be useful to check the changes in GLS in those with preserved LVEF after discharge.
P1391 Global longitudinal strain in chronic asymptomatic aortic regurgitation: a meta-analysis
Authors: De Campos D , Teixeira R , Botelho A , Saleiro C , Lopes J , Puga L , Ribeiro J M , Sousa J , Goncalves L
Published: January 2020

BACKGROUND Previous studies have shown that left ventricle global longitudinal strain (GLS) assessed with 2D-speckle tracking echocardiography, is an independent predictor of outcome in asymptomatic moderate to severe chronic aortic regurgitation (AR) patients.

OBJECTIVES

To assess GLS impact on mortality and need for aortic valve replacement (AVR) or symptom development in chronic asymptomatic AR patients and preserved left ventricular ejection fraction (LVEF).

METHODS A literature search was performed according with these key terms "aortic regurgitation" and "longitudinal strain." The primary endpoint was all-cause mortality. Secondary end-points were: a composite of all-cause mortality, need for AVR or symptom development; and only AVR plus symptom development. Data was pooled using random-effects meta-analysis models. Pooled Hazard Ratio (HR) was performed using its log transformation and inverse variances as weights were then calculated for each study .

RESULTS Six studies were included, with a total of 1,571 asymptomatic patients with at least moderate AR and preserved LVEF. There were 996 events (death, AVR, symptom development) reported during follow-up. Pooled adjusted mortality HR tended to be higher for patients with worse GLS (1.14 [0.96–1.35], P = 0.13, I2 51%). GLS performed better in predicting AVR or symptom development (mean difference -0.72 [-1.29, -0.15], P = 0.01, I2 88%), with an estimated HR of 1.36 ([1.01–1.84], P = 0.04, I2 65%).

CONCLUSIONS In asymptomatic chronic moderate to severe AR patients, impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value on risk stratification as well as on decision-making.

Abstract P1391 Figure 1
P1395 New predictors of burned-out phase in hypertrophic cardiomyopathy
Authors: Adamczak D M , Rogala A , Antoniak M , Oko-Sarnowska Z
Published: January 2020

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a heart disease characterized by hypertrophy of the left ventricular myocardium. The structural and functional abnormalities cannot be explained by flow-limiting coronary artery disease or loading conditions. HCM has a benign course, however approximately 5% of these patients suffer from the end-stage of the disease. The so-called burned-out phase, characterized by systolic dysfunction with a left ventricular ejection fraction ≤50%, is often associated with wall thinning and chamber dilation. These patients should have more frequent clinic visits and have a more intensive treatment plan. They are also candidates for heart transplantation. Currently there are no risk factors of progression to burned-out phase before the onset of heart failure symptoms. Therefore, the potential risk factors: left ventricular global longitudinal strain (GLS), left ventricular average strain (ASI), right ventricular average strain (RV-ASI) and left atrial volume index (LAVI), have been examined. GLS, derived from speckle tracking echocardiography, and ASI, derived from tissue doppler imaging, are the sensitive and noninvasive methods of assessing the ventricular function. LAVI more accurately characterizes the size of the left atrium, which usually increases in the course of the disease.

METHODS

A total of 252 patients with HCM (aged 20-88 years, 49,6% were men), treated in our Department have been enrolled in the study. GLS, ASI, RV-ASI and LAVI assessment has been made in addition to standard echocardiographic examination. Burned-out was characterized as systolic dysfunction with a left ventricular ejection fraction ≤50%.

RESULTS

5.6% patients in the study population were diagnosed with burned-out phase in hypertrophic cardiomyopathy.

The t-Student test and t-Student test with Cochran-Cox adjustment showed statistically significant differences of GLS and ASI values between burned-out and non-burned-out groups; p = 0.000001 and p < 0.000001, respectively. Average and median values of GLS in burned-out group were -7.4% ± 2.9%, -7.1% and -15.3% ± 4.3%, -15.4% in non-burned-out group. For ASI those values were respectively -7.6% ± 2.2%, -7.1% and -12.9% ± 4.5%, -13.0%.

The Mann-Whitney test showed statistically significant differences of RV-ASI and LAVI values between burned-out and non-burned-out groups; p = 0.000208 and p = 0.005302, respectively. Median value of RV-ASI in burned-out group was -15.8% and -27.1% in non- burned-out group. Median value of LAVI in burned-out group was 52.6 ml/m2 and 37.8 ml/m2 in non-burned-out group.

CONCLUSIONS

Each of the proposed new risk factors of burned-out development was statistically significant in the study population. Therefore, all HCM patients should have regular echocardiographic examinations and those with deteriorating values of new parameters should become the subjects of intensified medical care.
P1462 Additive value of global longitudinal strain measurement in patients with known or suspected ischaemic heart disease undergoing stress echo
Authors: Castellano F , Lupo A , Nugara C , Triolo O F , Evola G , Di Lisi D , Trapani R , Novo S , Novo G
Published: January 2020

BACKGROUND

Speckle-tracking echocardiography (STE) can be applied in a large variety of clinical conditions.

Global longitudinal strain (GLS) shows high diagnostic accuracy for the detection of myocardial

ischemia as it reflects changes in subendocardial fibers deformation that are more exposed to

ischemic damage, even before alterations in segmental kinetics are revealed.

PURPOSE

Aim of our study was to assess whether the measurement of global longitudinal strain during

stress-echo can provide additional information compared to the assessment of conventional

parameters such as left ventricular ejection fraction (LVEF) and wall motion abnormalities. We

also evaluated the added value of strain in patients with complete (CRP) and incomplete

revascularization (IRP).

METHODS

We enrolled 69 patients, 39 with known (IHD) and 30 with suspected ischaemic heart disease

(SIHD) with indication to perform a stress echocardiogram. Inclusion criteria were: known or

suspected CAD, age <85 and >18, adeguate acoustic window. Cardiological evaluation and stress

echo were performed in all patients. Primary end point was evaluating whether in patients with

negative stress test the presence of reduced GLS identifies patients with an adverse prognosis at

follow up and to assess if in IRP and negative stress test there is evidence of left subclinical ventricular

dysfunction identifiable by GLS analysis compared to CRP.

RESULTS

LVEF was significantly reduced in IHD patients compared to SIHD patients (54 ± 7vs 60 ± 4 at rest;

55 ± 8vs62 ± 3 at peak; p < 0.0001). We also observed a significant reduction of GLS in IHD patients

compared to SIHD patients (-16.7 ± 4,3vs-19 ± 2.2 - p = 0.07 at rest, -18 ± 4.6vs22 ± 3.4-p = 0.004 at

peak). In CRP patients GLS did not change significantly with a tendency to improve (-17.6 ± 4 at rest

vs -19 ± 4.5 at peak - p = 0.4). Instead in IRP patients, significant reduction of GLS was observed at

peak (17.5 ± 0.7 at rest vs 14.2 ± 0.3 at peak, p value 0,03). LVEF did not significantly differ in CRP

(54 ± 5 at baseline vs 55 ± 7 at peak, p = 0.5) and IRP (52 ± 9 at baseline vs. 52 ± 9 at peak, p =

0.9) .

CONCLUSIONS

Our study shows that strain analysis during stress echocardiography can provide additional information in identifying a subclinical reduction of myocardial function at baseline and

a reduction in contractile reserve under stress, secondary to coronary flow reduction. Being GLS a

powerful prognostic marker probably patients with negative stress test and incomplete

revascularization, reduced baseline GLS and reduction of GLS at peak exercise represent a population at higher risk of coronary artery disease progression and development of left ventricular dysfunction who need a closer follow up. To verify our hypothesis we plan to increase our sample size and to

prospectively follow up our patients.
P1472 Concealed thrombus in a 12-year-old boy diagnosed by disappearance of intricate comb-like pectinate muscle form in the left atrial appendage
Authors: Takeuchi Y , Suzuki S , Tsuneyoshi H , Sakamoto H , Shimada T
Published: January 2020

Background

As previously known, patients with prolonged atrial fibrillation often have atrial thrombus. However, in children, cardiogenic embolism due to atrial fibrillation is rare. Also, the diagnosis of residual thrombus in the left atrial appendage is sometimes difficult even by transesophageal echocardiography (TEE). We have obtained a meaningful comparison between TEE findings and surgical specimen of bilateral atrial appendage.

Case report

A 12-year-old boy admitted to the nearby hospital, because of sudden onset of right-side hemiplegia. Till then, he was born at normal weight and grew up without any problem. The electrocardiogram indicated atrial fibrillation. He was transferred to the pediatric cardiology department of a hospital with higher function for the treatment of cardiogenic thromboembolism.

After 72 hours from the onset of first thromboembolism, a new embolic event happened in his left brachial artery. The contrast-enhanced computed tomography (CT) showed thrombus of bilateral atrium and coronary sinus. Consequently, residual thrombus led to the potential risk of additional embolization. Therefore, catheter cerebral thrombectomy was performed, and then surgical thrombectomy for the bilateral atrium was planned. Preoperative CT showed thrombus in the left atrial appendage (LAA). However, intraoperative TEE showed no obvious thrombus in the LAA. Intricate pectinate muscle formation in the left atrial appendage almost disappeared (figure1A), which suspected remaining thrombus. In addition, massive thrombus was seen in the right atrium and coronary sinus. Coronary sinus thrombus was removed as far as possible, and bilateral atrial appendage resection and myocardial biopsy were performed. Simultaneously, modified-Maze was also done. Heart rhythm returned into sinus rhythm after surgery. Pathological findings did not show specific findings of myocarditis or pericarditis.

Until now, the cause of thrombotic factors has not been fully clarified. Although the time of onset is unknown, probably, heart failure was triggered by atrial fibrillation, and consequently thromboembolism occurred. In the resected left atrial appendage, small thrombus remained among pectinate muscle (figure1B); therefore, postoperative anticoagulation should be needed.

Conclusion

We experienced a boy with thrombus in bilateral atrial appendages. In the resected left atrial appendage, multiple small thrombi remained in the pectinate muscle. From our experience, the disappearance of comb-like form in pectinate muscle by TEE suspects the residual thrombus, especially in the case of cardiogenic embolism.

Abstract P1472 Figure.
P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography
Authors: Makino K , Hashimoto G , Ide S , Hayama H , Isekame Y , Otsuka T , Iijima R , Hara H , Moroi M , Suzuki M , Nakamura M
Published: January 2020

【Background】

Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare.

【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion.

CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery.

The postoperative course was good and he was discharged without any complications.

【Discussion】

False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture.

We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space.

We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case.

Abstract P1480 Figure. Triple aneurysms
P1482 Surviving free wall rupture
Authors: Pomiato E , Milewski P , Comunello A , Schoepf E , Oberhollenzer R , Cemin R
Published: January 2020

Introduction

Free wall cardiac rupture (CR) is a rare event accounting for 0.1–0.3% of the patients suffering acute myocardial infarction. Its outcome is very poor and it is the third most common cause of early mortality after hospitalization for ST Elevation Myocardial Infarction (STEMI).

Purpose

We report a case of a 63 years-old woman surviving a free wall rupture after ST Elevation

Myocardial Infarction.

Methods

The patient was referred to our cath-lab to undergo primary PCI in ST elevation myocardial infarction.

Results

Coronary angiography showed long thrombotic occlusion of left anterior descendent (LAD) artery and critical stenosis of posterior descending artery. The CULPRIT lesion on the anterior descending artery was treated with angioplasty and implantation of three drug eluting stents (3.0x31 mm; 2.75x15 mm; 2.5x30 mm).

Twenty four hours later the patient developed a double cardiac arrest with pulseless electrical activity, which were immediately managed with ALS protocol. The patient recovered both time within a couple of minutes and point-of-care transthoracic echocardiogram (TTE) showed a newly developed circumferential pericardial effusion (maximum diastolic diameter 9 mm), associated to a significant thinning of the anterior interventricular septum. A fibrin clot was tamponating a suspected free wall rupture. Emergent coronary angiography showed an in-stent thrombosis but failed to restore adequate blood flow in the LAD artery.

In the following days, the patients developed cardiogenic shock handled with i.v. dobutamine and intra-aortic balloon pump (IABP). Only after day 10 hemodynamic parameters started to improve gradually, allowing IABP removal and finally discharge on day 30.

A second TTE, performed on day 7, confirmed massive necrosis of the anterior wall with severely reduced ejection fraction (EF 22%), pericardial thrombus and aneurismatic evolution of the apex and the mid-anterior septum. To support our finding we performed a cardiac magnetic resonance which confirmed missing ventricular wall at the anterior apex. It also showed transmural late gadolinium enhancement (LGE) of the anterior mid-apical septum and of the apex and a huge pericardial thrombus encompassing the whole mid-anterior septum (Figure 1, a-f).

Before discharge the patient underwent two cardiac surgery visits which contraindicated surgical treatment in the acute phase. Therefore she was sent to cardiac rehabilitation program.

Six months later, the patient finally underwent cardiac surgery and the covered free wall rupture was confirmed in the operating theatre.

Conclusion

This is a very rare case of covered free wall rupture, treated 6 months after the acute event. Multimodality imaging was essential to confirm the diagnosis and to guide the following management.

Abstract P1482 Figure 1
P1494 Incidental finding of aortic aneurysm formation following 34 years of coarctation repair by dacron patch aortoplasty
Authors: Khalifa E A , Helmy S , Mohamed S F , Alkuwari M
Published: January 2020

Introduction

Aneurysms are found following all types of surgical repair of aortic coarctation, especially after Dacron patch aortoplasty.

We describe the finding of an aortic aneurysm in an asymptomatic 52-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 34 years earlier.

Case report

A 52-year male, smoker, hypertensive on medication He had previous history of surgical repair of aortic coarctation at age of 18 years .

Repair was by Dacron patch aortoplasty. Since then, his regular follow up was unremarkable. Recently, he was referred for cardiac evaluation as a part of pre-employment general check-up. He was asymptomatic with no history of shortness of breath or chest pain.

Physical examination revealed that the pulse in the left arm was reduced in volume in comparison to the right one. The heart sounds were essentially normal but a pericardial murmur was audible, perhaps reflecting residual collateral flow. Blood pressure was 156/83 mmHg in right arm and 142/81 in the left arm.

Transthoracic echocardiography revealed mild left ventricular hypertrophy with normal global and regional contractility and an ejection fraction of 58%. Supra sternal window images showed dilatation of the three aortic arch branches. The distal portion of aortic arch just distal to origin of left subclavian artery was narrowed with a peak systolic gradient across of 34 mmHg. A cystic structure (1.7 cm x 1.9 cm) was visualized attached to the narrowed segment of the aorta, suggestive of a saccular aneurysm, (figures A&B&C).

Computed tomography aortogram showed a narrow-necked aneurysm arising from the posterolateral aspect of the distal aortic arch (anticipated site of the coarctation repair graft anastomosis). A small laminated thrombus was also noted within. Aneurysm measured approximately 2.2 x 3.3 cm in its craniocaudal and anteroposterior dimensions respectively, with no evidence of aortic luminal compromise. (figures D&E&F).

Management

Aneurysmectomy was performed subsequently. Interposition polyester grafts were used to reconstruct the aortic arch and proximal descending aorta and to connect this aortic segment to the subclavian artery via a lateral thoracotomy. The postoperative course thereafter was uneventful. Conclusion: This is a rare insidious complication of Dacron patch aortoplasty that occurred after more than 3 decades, which highlights the importance of diagnostic imaging in the follow up of these patients

Abstract P1494 Figure.
P1495 Suddenly haunted by a turbulent heart beat in the right ear. Post-traumatic monolateral pulsatile tinnitus caused by cervical arteriovenous malformation: colour-Doppler ultrasound and angio-CT find
Authors: Silvestri V , Mele RITA
Published: January 2020

Funding Acknowledgements

No financial disclosure to be added

INTRODUCTION

Tinnitus, the perceived sensation of sound in absence of corresponding external acoustic stimulus, has a prevalence of 15% among adults [1]; it may impair quality of life in about 1-2% of cases. When pulsatile, objective and synchronous with heart beat, it may be secondary to vascular abnormalities [2]; in some patients a post-traumatic pathogenesis ( head and neck) has been reported, with a prevalence up to 10% .

CASE REPORT

We report the case of a 28 year old male patient with a history of a right side pulsatile tinnitus occurred three days after head trauma. Described as "hearing heart beat in the right ear as a turbulent sound", it corresponded with an audible bruit and palpable fremitus in latero-cervical region. History was negative for medical or surgical comorbidities as laboratory investigation; color Doppler ultrasound revealed an external carotid artery collateral- internal jugular vein fistula, resulting in a pulsatile turbulent flow, synchronic with heart beat.

Angio-CT scan of epiaortic vessels confirmed findings in the context of occipital articulation, near jugular foramen. Patient postponed further investigations for personal reasons.

DISCUSSION

Vascular post-traumatic lesions may cause post-traumatic pulsatile tinnitus. Symptom onset may be delayed from several days up to twelve weeks after trauma and it can be a sign of life-threatening disorders such as carotid cavernous fistulas, arteriovenous malformations, and carotid dissections [3 ] .

Clinical management includes basic diagnostic steps ( history, assessment of tinnitus severity, clinical ear examination, audiological and a neurovascular examination [2] . CT and MR with angiography, following colour-Doppler ultrasound , are used to determine the anatomical cause of vascular pulsatile tinnitus and to study surrounding structures. Angiography may be helpful for diagnosis and treatment planning [4].

CONCLUSIONS

Pulsatile tinnitus may occur after head and neck trauma, may affect quality of life and can be caused by live-threatening lesions. Arteriovenous fistulae between carotid artery branches and jugular vein may be treatable anatomical cause of symptoms, and have to be considered in differential diagnosis .

Abstract P1495 Figure. Pulsatile tinnitus:Imaging and Pathology
P1502 A clinical case of mitral annulus disjunction syndrome revealed by cardiac MRI
Authors: Mitrousi K , Hamilton M
Published: January 2020

A 39year old female patient with a family history of probable sudden cardiac death/long QT syndrome (sister died aged 36) was referred to our Arrhythmia/inherited cardiac conditions clinic. Patient was fit and well. She described occasional postural presyncope and some chest pain with stress. Not on any medication that could prolong QT. On examination she appeared well with normal heart sounds and no clinical signs of heart failure.

Her ECG in clinic confirmed sinus rhythm with normal QTc at 418msec. There were U waves which may reflect late repolarisation of His Purkinje system.

Diagnostic techniques and findings

A 24-hour ECG tape to look at the average QT interval, an exercise tolerance test to look for appropriate shortening of QT interval with exercise and an echocardiogram to exclude significant structural abnormality were requested.

The 24-hour ECG tape confirmed underlying sinus rhythm with multi-focal aberrant beats <1% of total. One symptom demonstrated short run of ventricular bigeminy.

During the exercise tolerance test, QT interval was not obviously prolonged. There were frequent bifocal ventricular ectopic beats in recovery.

The echocardiogram showed minor abnormality with mild left ventricular dilatation, otherwise normal findings.

Patient referred for cardiac MRI In order to rule out any cardiomyopathy.

Cardiac MRI did not show any prolapse on the 3 chamber cine. In addition, the inferior and inferolateral annulus showed thinning passing into the LV, which is a feature of some patients with mitral annulus disjunction syndrome.

We went through the echocardiogram and in one single frame images are suspicious of focal P2 prolapse.

Learning points:

Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. It has been associated with mitral valve prolapse and sudden cardiac death.

MAD is usually revealed with echocardiogram.

In this case report we showed that CMR revealed a MAD previously missed by echo.

Abstract P1502 Figure.
P1515 Hemodynamic determinants of tricuspid annular pulmonary systolic excursion (TAPSE)/ systolic pulmonary arterial pressure (SPAP) ratio in Heart Failure with reduced Ejection Fraction
Authors: Bandera F , Ghizzardi G , Agnifili M , Pizzocri S , Boveri S , Alfonzetti E , Saviano M , D"alesio G , Bedogni F , Guazzi M
Published: January 2020

Background

the TAPSE/SPAP ratio has gained a role as an easy-to-use surrogate of right ventricle-to-pulmonary circulation (RV-PC) coupling, showing a strong prognostic significance in heart failure (HF) patients. The hemodynamic determinants of TAPSE/SPAP ratio, as assessed by invasive approach, have not been fully clarified.

Aim

To identify the right heart hemodynamic variables correlated with TAPSE/SPAP in a HF with reduced EF (HFrEF) cohort, both at rest and during exercise.

Methods

30 HFrEF patients (age 68 ± 10 years LV EF 28 ± 7) underwent to rest and exercise echocardiography and performed right heart catheterization within 24 hours. Bivariate correlations between TAPSE/SPAP ratio (at rest and during exercise), right heart hemodynamic variables, RV systolic function and NTproBNP have been explored.

Results

TAPSE/SPAP ratio at rest showed a moderate correlation with pulmonary artery wedge pressure (PAWP: r= 0.441; p= 0.039), pulmonary artery pressures (PAP systolic: r = 0.481; p= 0.026; PAP diastolic: r= 0.434; p= 0.043; mPAP: r= 0.476; p= 0.025), pulmonary vascular resistance and compliance (r= 0.475; p= 0.041). A stronger correlation was identified with right atrial (RAP systolic: r= 0.586; p= 0.017; RAP diastolic: r= 0.681; p= 0.006) and right ventricular pressures- in particular diastolic ones (RVP systolic: r= 0.584; p= 0.004; RAP diastolic: r= 0.652; p= 0.002). No significant correlation with NTproBNP and RV 3D EF emerged. Exercise TAPSE/SPAP ratio significantly correlated with right atrium (RAP systolic: r= 0.564; p= 0.036) and right ventricle systolic pressures only (RVP systolic: r= 0.789; p< 0.001).

Conclusions

TAPSE/SPAP ratio at rest showed a stronger correlation with invasively derived diastolic right heart pressure rather than pulmonary vascular bed pressures. A similar correlation was also observed for exercise TAPSE/SPAP ratio. This tight correlation with RV, rather than with vascular pressures, supports the significance of this ratio as a marker of RV adaptation to vascular overload.
P1528 Prognostic impact of pulmonary arterial wave reflection in heart failure
Authors: Hayama H , Uejima T , Cho J , Takahashi L , Hara H , Hiroi Y , Hashimoto G , Masao M , Nakamura M
Published: January 2020

Background

Pulmonary hypertension (PH) is prevalent and is associated with adverse outcomes in heart failure. The pathophysiology of PH is heterogeneous, including pre-capillary PH and combined pre- and post-capillary PH. The latter PH has been reported in experimental studies to cause wave reflection in pulmonary circulation, putting additional burden on right ventricle. This study tested the hypothesis that separating wave reflection would enhance risk stratification in heart failure.

Methods

This study included 152 patients with clinical stable heart failure associated with PH who were referred to echocardiography for hemodynamic assessment (age = 72 ± 13 years old, ejection fraction = 49 ± 21%). Pulmonary arterial wave reflection was characterised by separating PA pressure waveform into forward (Pf) and backward pressure (Pb) waves, based on the concept of wave intensity. PA pressure waveform was estimated from continuous Doppler tracing of tricuspid regurgitation. Flow velocity was measured by pulse Doppler at right ventricular outflow tract. Outcome data was obtained by reviewing medical charts. The endpoint was hospitalization for worsening heart failure (WHF).

Results

Figure A compares PA pressure waveforms (total and separated waves) obtained from 2 patients with and without WHF event. The patient with event had higher total pressure associated with late peak than the patient without event. Pb appeared later than Pf; it was markedly higher in the patient with event than the patient without event, although Pf was similar between both patients. Kaplan-Meier analysis demonstrated a significant separation of survival curves stratified by Pb (chi-square = 25.1, p < 0.001, figure B). During follow-up period of 1.5 ± 1.8 years, 65 patients (43%) experienced the endpoint. Sequential Cox analysis revealed that PASP remained significant after adjusted for left ventricular ejection fraction and E/e’ (hazard ratio = 1.017, p = 0.019). Pb also remained significant after the same adjustment (hazard ratio = 1.066, p = 0.003); the addition of Pb to a baseline model resulted in greater increase in predictive power than the addition of PASP (model chi-square: from 27.4 (baseline), to 37.6 (p = 0.004) for Pb, to 31.6 (p = 0.027) for PASP, figure C)

Conclusions

Pressure wave reflection in pulmonary artery is associated with early decompensation in heart failure.

Abstract P1528 Figure.
P1537 Myocardial work in patients with aortic stenosis before and short term after transcatheter aortic valve replacement
Authors: Jasaityte R , Thiele A , Ernst L P , Baldenhofer G , Spethmann S , Laule M , Dreger H , Stangl K , Knebel F
Published: January 2020

Objective

The newly introduced noninvasive myocardial work analysis could potentially be beneficial in predicting the best timing for aortic valve replacement as well as clinical outcomes in patients with high grade aortic valve stenosis (AS), which is the leading valvular disease in the modern aging society. However, to date there is little data on the applicability of the method in the setting of extremely increased left ventricular (LV) afterload.

Purpose

In this pilot study, we aimed to apply myocardial work analysis in patients with increased LV afterload due to severe AS and to investigate the differences of myocardial work parameters in patients with different AS entities. In addition, we analyzed the early changes of myocardial work after the afterload reduction by transcatheter aortic valve replacement (TAVR).

Methods

We retrospectively studied echocardiographic data of 28 consecutive patients with severe AS before and 7 days after TAVR. Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE) were calculated using commercially available software based on noninvasive pressure-strain loops. In order to correct for underestimation of intraventricular pressure, we added the mean aortic valve pressure gradient to the peripheral systolic blood pressure used by the software.

Results

From the included patients (mean age 76 ± 10 years) 13 were classified as having normal flow (NF) severe AS, 8 had low flow low gradient (LFLG) and 7 paradoxical low flow low gradient (PLFLG) AS. GWI and GCW were significantly lower in patients with LFLG AS compared to patients with NF or PLFLG AS (936 ± 528 mmHg% vs. 2493 ± 485 mmHg% vs. 1959 ± 469 mmHg% [p < 0.005] and 1132 ± 477 mmHg% vs. 2770 ± 507 mmHg% vs. 2189 ± 603 mmHg%, [p < 0.005], respectively). 7 days after TAVR, GCW and GWI decreased significantly in patients with NF AS. In other AS entities, a trend towards increased GWI and GCW was observed, but the difference did not reach statistical significance. GWI and GCW remained significantly lower in LFLG AS group when compared to NF and PLFLG groups (1069 ± 378 mmHg% vs. 1919 ± 310 mmHg% vs. 2064 ± 842 mmHg% [p < 0.005] and 1286 ± 346 mmHg% vs. 2107 ± 258 mmHg% vs. 2227 ± 949 mmHg% [p < 0.005]) early after TAVR. GWE and GWW did not differ between the groups and were not influenced by TAVR.

Conclusion

In this pilot study we applied the adapted myocardial work analysis in patients with increased afterload due to severe AS. We have shown that GCW and GWI are significantly higher in patients with NF AS when compared to LFLG and PLFLG AS. The differences between the groups persisted early after TAVR in spite of significant reduction of GWI and GWC in patients with NF AS. The clinical and prognostic importance of these findings are still to be investigated in a bigger cohort study.
P1542 Reference values for multilayer longitudinal strain in children: preliminary findings from healthy individuals
Authors: Chinali M , De Roberto A M , Esposito C , Del Pasqua A , Iacomino M , Ciliberti P , Galderisi M , Rinelli G
Published: January 2020

BACKGROUND

Strain echocardiography is a reliable echocardiographic modality to measure myocardial mechanical deformation and evaluate regional and global myocardial systolic function, and has been demonstrated to be a useful tool for the evaluation of cardiac function in children with acquired and congenital heart diseases. Recent advancements in echocardiographic technology allow to analyze myocardial strain in multiple layers. To our knowledge, there are no published reference values for echocardiographic multilayer-specific strain measurement.

AIM OF THE STUDY

Aim of our study was to establish normal reference values for left ventricular (LV) and right ventricular (RV) longitudinal strain (LS) in a wide population of Italian children and to provide normal reference values of layer-specific LS in a healthy pediatric population.

METHODS AND RESULT

At present we have analyzed data from two-hundred (target: n = 500) healthy, consecutive subjects (age <18 years, mean age 7.5 ± 4yrs; range from 1 month to 17,5 years). All subjects underwent a clinical cardiological evaluation including ECG and physical examination. Subsequently, a complete echo Doppler examination including LS evaluation using speckle-tracking echocardiography was performed. Individuals were excluded if any significant abnormality was found at echocardiography (e.g. valvular regurgitation more than trivial, any structural abnormalities including small ASDs or VSDs; patients with isolated PFO were included). Subendocardial, midwall, subepicardial LS, and strain gradient (LSsubepi - LSsubendo) were also determined. LS% analysis was considered acceptable if missing data were present in no more than one segment per echocardiographic view, according to current consensus. Echocardiographic yield for LS analysis was 98.5 % for 4-chamber views, 82.5% for 2-chamber views and 84.5% for 3-chamber views. Accordingly Global Longitudinal Strain (GLS) was available overall in 82% of the population analyzed so far (n= 164 children) on all layers, with a total of 8,872 echocardiographic available segments analyzed. Normal distribution was found for global subendocardial, midwall and subepicardial LS. As displayed in figure 1 (panels A-B-C), means ± SD were -20.8 ± 1.9% for LSsubendo, -19.2 ± 1.8% for LSsubepi and -19.9 ± 1.8% for LSmidwall. Accordingly higher value (95ile) for normal LS were -17.9%, -16.4% and -17.1% for LSsubepi, LSsubendo and LSmidwall, respectively. A significant subepicardial to subendocardial gradient was found in all children with higher absolute values found at the endocardial level, with a mean difference of 1.6 ± 0.9% (Panel D).

CONCLUSIONS

We provide preliminary data on 200 children to establish normal reference values for echocardiographic multilayer-specific strain measurement in a wide population of healthy italian children.

Abstract P1542 Figure.
P1550 Detection of symptom related coronary arteries in patients with coronary artery disease by 4D stress echo with adenosine triphosphate
Authors: Nelassov N , Morgunov M , Doltmurzieva N , Sidorov R , Arzumanjan E , Safonov D , Nechaeva A , Kreneva E , Eroshenko O
Published: January 2020

Background

In previous publications, we have proposed new algorithm of pharmacologic Stress Echo with possibility of stepwise adenosine triphosphate (ATP) i/v dose increase (Figure 1).

Purpose

In this study we decided to compare the effectiveness of detection of symptom related coronary arteries in patients with coronary artery disease (CAD) by ATP 4D Stress Echo of left ventricle (LV) and a) traditional visual evaluation of LV segmental hypokinesis b) Automatic Function Imaging (AFI) technology longitudinal LV strain (LS) analysis.

Material and methods. 26 patients with CAD (male 24, mean age 63.1 ± 7.5 years, single vessel obstructive disease 7, multivessel - 19) underwent ATP LV 4D Stress Echo (Vivid E95, GE). Number of cases when it was possible to detect symptom related arteries by visual analysis of LV segmental hypokinesis and by AFI LV LS analysis were compared.

Results

In 11 (42.3%) patients expansion of existing hypokinetic areas and appearance of new LV segments with hypokinesis during stress test were detected by visual analysis. Using AFI technology expansion of initial areas of LS disturbances and appearance of new LV segments with LS disturbances were found in 21 (80,7%) patients (р=0.0044).

Conclusion

Utilization of AFI LV LS analysis during ATP LV 4D Stress Echo significantly increases the frequency of symptom related coronary arteries detection in patients with CAD.

Abstract P1550 Figure1
P1577 Mitral regurgitant "splay": an important clue to severity of regurgitation
Authors: Wiener P C , Friend E , Bhargav R , Kadem L , Pressman G
Published: January 2020

Background

Visual assessment of mitral regurgitation (MR) severity by color Doppler can be difficult, especially in eccentric jets. Examination of the proximal flow acceleration signal (PISA) on the ventricular side of the mitral valve can be helpful but, is not always intuitive. We describe a color signal ("splay") on the atrial side of the valve that can often be helpful in recognizing significant MR.

Methods

Clinical echocardiograms were reviewed to obtain two data sets: 100 patients with reported mild MR and another 100 with reported severe MR. All echocardiograms were reviewed to confirm that MR was truly mild or severe. Splay was defined as a non-physiologic arc of color (figure) centered at the point where the MR jet emerges into the atrium.

Results

Splay was present in the large majority of severe MR cases (table). It was seen across 3 vendors’ machines and was present with normal and reduced EF as well as primary and secondary MR. Color scale and transducer frequency did not differ according to presence or absence of splay, but gain was higher when splay was present (57.5 ± 6.8 vs 55.2 ± 6.1, p = 0.04). In mild MR patients, splay was present on fewer frames and had lesser dimensions vs severe MR. Splay was particularly prevalent in patients with wall hugging jets (28/30, 93%).

Conclusions

The splay signal occurs as a side lobe artifact, at the point where a high energy MR jet emerges into the left atrium. Its presence often indicates significant MR and may be a useful clue in highly eccentric jets which are otherwise difficult to grade.

Table 1 Mild MR Severe MR P value Splay Present (%) 18 82 <0.0001 No. of Frames 2 ± 1.6 3.6 ± 1.3 <0.0001 Width of Splay (cm) 2.2 ± 0.5 3.2 ± 0.9 <0.0001 Depth of Splay (cm) 0.36 ± 0.11 0.47 ± 0.16 0.01

Abstract P1577 Figure. Splay Image
Cardiomyopathy associated with Ceutzfeld–Jakob disease: a diagnosis of exclusion: a case report
Authors: Itzhaki Ben Zadok Osnat , Orvin Katia , Inbar Edna , Rechavia Eldad
Published: January 2020

Background

Creutzfeldt–Jakob disease (CJD), the most common prion disease in humans, is primarily known for its adverse neurological impact and inevitable mortality. Data regarding myocardial involvement in CJD are scarce.

Case summary

A 54-year-old female patient, presented with progressive effort dyspnoea, was diagnosed with unexplained non-ischaemic cardiomyopathy. An extensive cardiac work-up including cardiac magnetic resonance imaging (MRI) did not reveal any underlying aetiology. Simultaneously, the patient developed involuntary limb movements and progressive cognitive decline. Thalamic high-signal abnormalities on diffusion-weighted images were apparent on brain MRI. Based on these findings, she was subsequently referred to a neurology department, where she suddenly died the day after her admission. Brain autopsy demonstrated spongiform encephalopathy. A genetic analysis performed to her son revealed a mutation in the PRNP gene; all of these were consistent with CJD.

Discussion

This case describes the clinical association of CJD and cardiomyopathy and the diagnosis prion-induced cardiomyopathy by exclusion. It is not inconceivable that the coexistence of these two clinical entities may be related to genetic expression and contemporaneously deposition of infectious prions in myocardial muscle and brain tissue. Awareness of this possible association could be of important public-safety concern, and merits further collaborative cardiac-neurological work-up to elucidate this phenotype among patients with unexplained cardiomyopathy with neurological symptoms that resemble CJD.
Aetiology and outcomes of severe right ventricular dysfunction
Authors: Padang Ratnasari , Chandrashekar Nikhitha , Indrabhinduwat Manasawee , Scott Christopher G , Luis Sushil A , Chandrasekaran Krishnaswamy , Michelena Hector I , Nkomo Vuyisile T , Pislaru Sorin V , Pellikka Patricia A , Kane Garvan C
Published: January 2020

Aims

Right ventricular dysfunction (RVD) is an important determinant of functional status and survival in various diseases states. Data are sparse on the epidemiology and outcome of patients with severe RVD. This study examined the characteristics, aetiology, and survival of patients with severe RVD.

Methods and results

Retrospective study of consecutive patients with severe RVD diagnosed by transthoracic echocardiography (TTE) between 2011 and 2015 in a single tertiary referral institution. Patients with prior cardiac surgery, mechanical assist devices, and congenital heart disease were excluded. Primary endpoint was all-cause mortality. In 64 728 patients undergoing TTE, the prevalence of ≥mild RVD was 21%. This study focused on the cohort of 1299 (4%) patients with severe RVD; age 64 ± 16 years; 61% male. The most common causes of severe RVD were left-sided heart diseases (46%), pulmonary thromboembolic disease (18%), chronic lung disease/hypoxia (CLD; 17%), and pulmonary arterial hypertension (PAH; 11%). After 2 ± 2 years of follow-up, 701 deaths occurred, 66% within the first year of diagnosis. The overall probability of survival at 1- and 5 years for the entire cohort were 61% [95% confidence interval (CI) 58–64%] and 35% (95% CI 31–38%), respectively. In left-sided heart diseases, 1- and 5-year survival rates were 61% (95% CI 57–65%) and 33% (95% CI 28–37%), respectively; vs. 76% (95% CI 68–82%) and 50% (95% CI 40–59%) in PAH, vs. 71% (95% CI 64–76%) and 49% (95% CI 41–58%) in thromboembolic diseases, vs. 42% (95% CI 35–49%) and 8% (95% CI 4–15%) in CLD (log-rank P < 0.0001). Presence of ≥moderate tricuspid regurgitation portended worse survival in severe RVD.

Conclusion

One-year mortality of patients with severe RVD was high (∼40%) and dependent on the aetiology of RVD. Left-sided heart diseases is the most common cause of severe RVD but prognosis was worst in CLD.