bluuebunny/crossref_metadata_2025 huggingface dataset:
P1363 Risk factors of severe tricuspid regurgitation after left-sided valve surgery
Authors: Horita R , Mahara K , Izumi Y , Terada M , Kishiki K , Takanashi S
Published: January 2020

Background

Tricuspid regurgitation (TR) sometimes deteriorate late after left-sided valve surgery. The recent guidelines recommend tricuspid valve repair at the same time as the left-sided valve surgery. However, little is known about the pathophysiology that leads to severe TR after left-sided valve surgery.

Purpose

To clarify the risk factors of the patients with severe TR after left-sided valve surgery.

Methods

We retrospectively investigated consecutive 526 patients diagnosed as severe TR from January 2004 to December 2018 at our hospital. Clinical background, echocardiographic parameters were evaluated. Demographic information and clinical data (including age, electrocardiograms, type of left-sided valve surgery, underlying valve diseases and history of pacemaker or ICD implantation) were obtained by chart review.

Results

Of the 526 patients with severe TR, 107 patients were after a left-sided valve surgery. Patients developed severe TR at a mean of 14.8 ± 8 years after surgery.The surgical indications were as follows: mitral valve stenosis (74 patients, 69%), mitral valve regurgitation (43 patients, 40%), aortic valve stenosis (37 patients, 35%) and aortic regurgitation (28 patients, 26%), respectively. The mean age at diagnosis of severe TR was 74 ± 10 years and 75 were female (70%). Among those patients, 32 patients (30%) had a tricuspid annuloplasty (TAP) with the first left-sided valve surgery. Ninety-five patients (88%) had atrial fibrillation (AF), 75 patients (70%) were diagnosed as rheumatic heart disease, 64 patients (60%) had pulmonary artery hypertension (PH) and 28 patients (26%) had a permanent pacemaker or ICD implantation.

There were only 12 patients who had severe TR without AF. Eight of 12 patients without AF had PH, and permanent pacemakers were implanted in remaining 4 patients.

Conclusions

Almost all patients with severe TR after left-sided valve surgery present with AF and prevalence of rheumatic heart disease were about 70 percent. These two factors may be one of the important risk factors for severe TR after left-sided valve surgery.
P1369 Mitral regurgitation reduction after transcatheter aortic valve implantation (TAVI)
Authors: Ostrowska Kaim E , Stapor M , Trebacz J , Sobczynski R , Konstanty-Kalandyk J , Wiewiorka Ł , Nawara-Skipirzepa J , Musial R , Zmudka K , Kapelak B , Legutko J
Published: January 2020

BACKGROUND

Concomitant mitral regurgitation (MR) is frequently observed in patients with severe aortic stenosis. Improvement of functional MR after TAVI has previously been reported, although influence of TAVI on organic MR remains unclear.

METHODS

We analyzed 136 patients who underwent TAVI in years 2017-2018 in our center. 16 of them had none or trivial preprocedural MR, 80 had mild preprocedural MR (nonsignificant MR group) and 40 had moderate or severe regurgitation (significant MR group). Specific etiology of each significant MR was classified as functional (11 patients), organic or mixed (29 patients). In addition, left ventricular ejection fraction (EF) was assessed using Simpson"s method. Follow-up (discharge) transthoracic echocardiographywas performed 1 to 5 days after TAVI.

RESULTS

MR diminished in 33,9% of patients undergoing TAVI (nonsignificant and significant MR group, p = 0,0118). Reduction of MR was pronounced in both: functional MR (45,4%, p = 0,0152) and organic or mixed etiology (72,4%, p = 0,0000). Left ventricular EF did not change after TAVI (p = 0,976).

CONCLUSIONS

Mitral regurgitation decreases significantly after TAVI, regardless of the etiology.
P1370 Correlation of aortic stenosis by integrated transthoracic and transesophageal echocardiography with calcium score
Authors: Schwartzenberg S , Shapira Y , Vaturi M , Nassar M , Hamdan A , Yedidya I , Ofek H , Kazum S , Monakier D , Kornowski R , Sagie A
Published: January 2020

Funding Acknowledgements

None

BACKGROUND

Aortic stenosis (AS) classification depends on left-ventricular ejection-fraction (LVEF <≥50%), aortic valve area (AVA<≥1cm2), mean pressure gradient (MG<≥40mmHg), peak velocity<≥400 cm/sec, and stroke-volume index (SVI<≥35ml/m2). Aortic Valve Agatston CT score (AVC) correlates with AS severity by trans-thoracic echo (TTE), but its association with AS severity determined by integrated TTE and TEE is unknown.

PURPOSE

We investigated correlation of AVC with dichotomous AS grouping by Integrated TTE + TEE vs TTE only.

METHODS

64 TAVI candidates underwent sequential TTE and TEE, of which 24 underwent coronary CT within 4 months. Based on recommended conservative vs invasive treatment implication (A/B respectively), AS types were aggregated separately by TTE or Integrated TTE-TEE into two groups: Group-A (Moderate AS and Normal-Flow Low-Gradient), and Group-B (High-Gradient, Low-EF Low-Flow Low-Gradient, and Paradoxical Low-Flow Low-Gradient). Continuous and dichotomous AVC correlation (cutoffs based on guidelines) with echo binary classification was then determined.

RESULTS

Patients were 81.1(77.3-84.6) years old, 18(48.6%) were women, and had LVEF of 60% (49-65). AVC-score distribution in the two AS A/B Groups by two echo modalities is presented in the boxplot Figure. Only classification by TTE held discriminative accuracy in A/B grouping, with Area-Under-Curve of 0.736 (CI 0.57-0.9), and optimal threshold value of 1946 AU having 77% sensitivity and 74% specificity. Compared with AVC dichotomous classification, integrated TTE + TEE upgraded AS class (from A to B) in 5/6 (83.3%) patients vs 12/18 (66.7%) in which it downgraded AS class from B to A.

CONCLUSIONS

Aortic valve calcification correlates well with AS class dichotomized by operative implication through conventional TTE but not through integrated TTE + TEE. Our preliminary results appear to be caused by initial selection bias of patients in whom coronary CT performance was deemed to be justified by the treating physician rather than reflect a true better correlation between CT score and AS assessment by TTE vs by integrated TTE + TEE.

Abstract P1370 Figure.
P1373 Cardiac source of embolism diagnosed by transeophageal echocardiography - what to expect in nowadays clinical practice
Authors: Branco Mano T , Aguiar Rosa S , Timoteo A T , Rio P , Moura Branco L , Galrinho A , Abreu J , Castelo A , Vaz Ferreira V , Garcia Bras P , Mendonca T , Leal A , Gameiro F , Cruz Ferreira R
Published: January 2020

Background

Transeophageal echocardiography (TEE) is an essential tool to diagnose cardiac source of embolism (CSE) and to define treatment approach. Purpose: To review the identified CSE in 25 years experience in TEE at a tertiary centre. Methods: Retrospective study of consecutive patients (pts) who underwent TEE to search for CSE, from 1994 to 2019. Results: 2936 pts (55% males, mean age 53 ± 13 years). Ischemic cerebral event (96%) was the main location of embolism. TEE identified potential CSE in 41.5% and 7% had more than one diagnostic. The most frequent CSE were patnt foramen ovale (PFO) (16.3%) and atrial septal aneurysm (ASA), among these 65% had concomitant PFO or atrial septal defect (ASD) (14.1%). Aortic plaques ≥ 4mm were noted in 9.6%, followed by valve disease or prosthesis (5.4%), intracavitary thrombi (3.9%), vegetations (1.6%), ASD (1.5%), dilated cardiomyopathy (1.4%) and tumors (0.7%). In the last 15 years, the diagnostic effectiveness increased (35.6% vs 45.95%) and there was a shift in etiologies with an increased in the diagnose of PFO/ASD (26.8% vs 38.5%) and valve disease or prosthesis became less frequent (29.9% vs 3.7%). Overall, in elderly pts there was a preponderance of atherosclerotic plaques in the aorta, contrasting with younger pts who presented a predominance of PFO (Table1). The prevalence of spontaneous echo contrast increased with age. Pts with ischemic cerebral event were younger, mostly male and PFO was the main source of embolism (17%), while in pts with peripheral embolism the most frequent etiologies were intracavitary trombi (16%) and aortic plaques ≥ 4mm (14%). Conclusion: The main cause to perform a TEE to search for CSE was cerebral embolism, with a diagnostic effectiveness overall of 41.5%, that increased in the last 15years.

Table 1 Characteristics <50 years (n = 1191) 50-75 years (n = 1569) ≥75 years (n = 171) Male (%) 601 (50%) 931 (59%) 80 (47%) Atrial septal defect (%) 23 (2%) 20 (1%) 0 Patent foramen ovale (%) 239 (20%) 226 (14%) 12 (7%) Atrial septal aneurysm (%) 70 (6%) 130 (8%) 13 (8%) Vegetations (%) 8 (0.7%) 29 (2%) 9 (5%) Tumors (%) 10 (0.8%) 8 (0.5%) 4 (2%) Intracavitary trombi (%) 28 (2%) 74 (5%) 14 (8%) Aortic plaque ≥4mm (%) 31 (3%) 203 (13%) 48 (28%) Valve disease or prothesis (%) 54 (4.5%) 109 (6%) 11 (6%) Spontaneous echo contrast (%) 36 (3%) 155 (10%) 32 (19%) Distribution of cardiac source embolism by age
P1378 Impact of maternal diabetes on fetal left atrial function
Authors: Pathan F , Lam P , Sivapathan S , Orde S , Negishi K , Nanan R
Published: January 2020

Background/Introduction: Diabetes impacts 12- 14% of pregnancies. Evaluating the impact of maternal diabetes on the fetal heart is challenging due to variable image quality and limited time for structural changes to manifest. Left atrial reservoir strain (ER) is a sensitive marker of early left atrial dysfunction which may elucidate fetal atrial dysfunction resulting from maternal diabetes.

Purpose

We sought to evaluate if fetal ER can detect impairment of left atrial function in the fetal heart as a result of maternal diabetes.

Methods

We performed a prospective observational study evaluating patients who were referred to the high risk pregnancy service as a result of maternal diabetes (pre-existing or gestational) and healthy controls.

Patients were excluded if adequate imaging of the fetal myocardium was not possible. Baseline characteristics of the mother and cardio-metabolic risk factors were recorded.

The fetal echocardiogram focused on the 4 chamber view. We used the 4 chamber view with closure of the mitral valve as the zero reference point (R-R) gating. The strain curves from 6 atrial segments were averaged.

Normality of the data was assessed using the Shapiro-Wilk test. The Mann-Whitney U test was used to compare ER between fetuses, whose mothers had diabetes versus those fetuses whose mothers were healthy controls.

Results

A total of 120 fetal scans were performed. 5 were excluded due to poor image quality, which prevented strain analysis. 115 fetal scans were analysed (87 with maternal diabetes and 27 healthy controls). The diabetic subjects and controls did not defer significantly in age Mean ± SD (31± 5 vs 30± 5, p= 0.81). The mothers with diabetes had a higher body mass index than controls (Median [IQR]) (30.5 kg/m2 [25.1, 35.3] vs 24.6 kg/m2 [22.1, 28.6] p < 0.001).

The presence of maternal diabetes resulted in lower fetal ER (28.5% [22.1, 36.2] vs 33.4% [26.6, 41.6] P = 0.01).

Figure 1 illustrates the Box-Whisker plot comparing Fetal ER between fetuses exposed to maternal diabetes and fetuses where mothers were healthy controls.

Conclusion

The presence of maternal diabetes results in impaired fetal left atrial function as measured by fetal left atrial strain (ER).

Abstract P1378 Figure 1
P1382 Evidence for longitudinal aorta strain relationship with noninvasive left ventricular myocardial work: another component for the ventricular-aorta coupling?
Authors: Armenis I , Demerouti E , Motsi A , Athanassopoulos G
Published: January 2020

The force required to produce longitudinal strain of the aorta represents an often overlooked mechanical load imposed on the left ventricle (LV). 2D speckle tracking strain analysis (2D-SpTa) may be applied on aorta wall in order to evaluate regional longitudinal strain (AoSTR). A noninvasive method for measuring LV myocardial work (MW) has been recently proposed, based on 2D-SpTa combined with estimated pressure curve.

Aim of the study was to assess the relationship of both LV conventional functional indices and the new MW ones with the aorta function estimated by AoSRT in normals and to interrogate the potential effect of aging.

Methods

Fifty four normals, 24 males (M) and 30 females(F), age: 52 ± 13 (25-75 years), were selectively studied, provided that they had an efficient image quality to apply both AFI analysis for MW estimation and ascending aorta interrogation for AoLSTR (EchoPac GE) .

LAoLSTR was measured in the posterior aorta wall (apical long axis view). Aortic wall borders were traced longitudinally adjusting width using 4 points of interest. The first point was put at the sinotubular junction and approximately 3-4 cm of the ascending aorta were analyzed. 2D-SpTa divided the regions of interest into proximal, middle and distal segments and the respective peak LAoSTR were considered.

The following indexes of MW were estimated: GWI (global work index = total work from mitral valve closure to mitral valve opening), GCW (global constructive work = total work contributing to pump function, namely due to shortening during isovolumic contraction and ejection and lengthening during isovolumic relaxation), GWW (global wasted work = elongation during isovolumic contraction/ejection and shortening during isovolumic relaxation), GWE (global work efficiency = fraction of GCW/[GCW + GWW]).

AFI derived LV strain (LVGS), biplane LV ejection fraction and stroke volume (SV) were also calculated.

Results

LAoSTR in any wall position was not affected by age. LAoLSTR of the proximal segment was related to both EF and LVGS (r = 0.31, p = 0.03 and r=-0.28 p = 0.05, respectively). Middle and distal LAoSTR were not related to either EF or LVGS. SV was not related to any of LAoSTR.

LAoSTR of the proximal segment was related to both GWI and GCW ( r = 0.34 p = 0.016 and r = 0,31 p = 0.03 respectively).

LAoSTR of the middle and distal segments were not related with any LV MW parameters.

Conclusion

Longitudinal aorta strain evaluation by 2D-SpTa is feasible and it is related with functional performance of the LV estimated by either conventional or MW indices based on 2D-SpTa. Moreover , the longitudinal performance of the proximal segment of the aorta above the sinotubular junction is linked to the constructive component of the LV myocardial work thus providing an alternative evidence for the LV ventricular–aorta coupling which was independent from aging.
P1398 Echocardiographic continuous monitoring of exercise stress test using probe fixation device
Authors: Wdowiak-Okrojek K , Wejner-Mik P , Bednarkiewicz Z , Lipiec P , Kasprzak J D
Published: January 2020

Background

Stress echocardiography (SE) plays an important role among methods of noninvasive diagnosis of ischemic disease. Despite the advantages of physical exercise as the most physiologic stressor, it is difficult (bicycle ergometer) or impossible (treadmill) to obtain and maintain the acoustic window during the exercise. Recently, an innovative probe fixation device was introduced and a research plan was developed to assess the feasibility of external probe fixation during exercise echocardiography on a supine bicycle and upright treadmill exercise for the first time.

Methods

37 subjects (36 men, mean age 39 ± 16 years, 21 healthy volunteers, 16 patients with suspected coronary artery disease) were included in this study. This preliminary testing stage included mostly men due to more problematic probe fixation in women. All subjects underwent a submaximal exercise stress test on a treadmill (17/37) or bicycle ergometer (11/37). Both sector and matrix probes were used. We assessed semi-quantitatively the quality of acquired apical views at each stage – the four-point grading system was used (0-no view, 1-suboptimal quality, 2-optimal quality, 3-very good quality), 2-3 sufficient for diagnosis.

Results

The mean time required for careful positioning of the probe and image optimization was 12 ± 3 min and shortened from 13,7 to 11,1 minutes (mean) in first vs second half of the cohort documenting learning curve. At baseline, 9 patients had at least one apical view of quality precluding reliable analysis. Those patients were excluded from further assessment. During stress, 17 patients maintained the optimal or very good quality of all apical views, whereas in 11 patients the quality significantly decreased during the stress test and required probe repositioning. The mean image quality score at baseline was 2,61 ± 0,48 and 2,25 ± 0,6 after exercise. Expectedly, good image quality was easier to obtain and maintain in the supine position (score 2,74 ± 0,44) points as compared with upright position (score 2,25 ± 0,57).

Conclusion

This preliminary, unique experience with external probe fixation device indicates that continuous acquisition and monitoring of echocardiographic images is feasible during physical exercise, and for the first time ever - also on the treadmill. This feasibility data stem from almost exclusively male patients and the estimated rate of sufficient image quality throughout the entire test is currently around 60%. We are hoping, that gaining more experience with the product could increase the success rate on exercise tests.

Abstract P1398 Figure. Treadmill and ergometer stress test
P1401 The prognostic value of the reduction of coronary flow velocity reserve in non-ischemic heart failure patients
Authors: Borguezan Daros C , Ciampi Q , Zanella H , Cortigiani L , Gaibazzi N , Rigo F , De Castro E Silva Pretto J L , Djordjevic-Dikic A , Amor M , Merlo P M , Citro R , Colonna P , Lowenstein J , Torres M A R , Picano E
Published: January 2020

OnBehalf

Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging

Background

Coronary microvascular abnormalities determining a reduction of coronary flow velocity reserve (CFVR) have been described in patients (pts) with non-ischemic heart failure (HF).

Aim

To assess the prognostic value of CFVR in HF.

Methods

In a prospective, observational, multicenter study, we recruited 333 pts with angiographically normal coronary arteries: 105 patients with HF and preserved (>50%) ejection fraction (HFpEF); 71 with HF and mid-range (40-50%) ejection fraction (HFmrEF); 157 with HF and reduced (<40%) ejection fraction (HFrEF). All patients underwent vasodilator SE with dipyridamole (0.84 mg/kg) in 10 accredited laboratories of 5 countries (Argentina, Brazil, Italy, Mexico, Serbia). CFVR was calculated as the stress/rest ratio of diastolic peak flow velocity pulsed wave-Doppler assessment of LAD flow. In all patients we also assessed left ventricular contractile reserve (LVCR) based on force (systolic blood pressure/end-systolic volume) Abnormal cutoff values were ≤2.0 for CFVR and ≤1.1 for LVCR. All pts were followed-up.

Results

After a median follow-up time of 15 months, 78 events occurred: 36 hospital admissions for acute decompensated heart failure, 23 deaths, 16 worsening in NYHA functional class, 2 stroke and 1 late revascularization. Event-free survival was best in patients with preserved CFVR and LVCR and worst in pts with reduced CFVR and impaired LVCR, with intermediate values for patients with either one (CFVR or LVCR) abnormal results: see figure. A preserved CFVR was associated with a better 24-month event-free survival than reduced CFVR in a subset analysis in pts with HFpEF (HR = 16.2, 95% CI, 1.8-145.1, p = 0.001) and in HFrEF (HR = 3.06, 95% CI, 1.6-5.6, p < 0.001). A multivariable analysis in the overall group of HF pts identified a reduced CFVR as the only independent predictor of event-free survival (HR = 3.455,95% CI 1.723-6.929).

Conclusions

A reduction in CFVR identifies a high risk subset in HF patients, outlining a shared role of coronary microvascular abnormalities as a marker and potential therapeutic target of HF, independently of underlying EF.

Abstract P1401 Figure. Event-free survival based on CFVR-LVCR
P1410 Right ventricle to pulmonary circulation coupling is primarily defined by the circumferential right ventricle function
Authors: Bandera F , D"alesio G , Ghizzardi G , Losito M , Boveri S , Alfonzetti E , Guazzi M
Published: January 2020

Background

Right ventricle to pulmonary circulation (RV-PC) coupling plays a pivotal role during the physical effort. The RV-PC uncoupling can be easily identified by the TAPSE/SPAP ratio, a prognostic marker based on RV longitudinal function and its afterload (SPAP).We sought to explore the relationship between the functional capacity (peak VO2 and VE/VCO2) and the RV-PC coupling, using both a standard and 3D-based echocardiographic assessment of RV.

Methods

eighty-seven patients (age 72 ± 10 years; LV EF 53 ± 15%) underwent rest echocardiography with 3D RV assessment and cardiopulmonary exercise test. RV EF was measured using the 4D RV TomTec software. The 3D mesh of the RV model was post-processed using a custom developed software. This provided longitudinal (EFlong) and circumferential (EFcirc) components of EF. RV-PC coupling was assessed with the TAPSE/SPAP ratio and with similar parameters obtained by using 3D components of RV systolic function over SPAP (EF/SPAP, EFlong/SPAP and EFcirc/SPAP ratio). All variables were correlated with peakVO2 and VE/VCO2.

Results

Correlations between peakVO2 and TAPSE (0.409, p = 0.006), SPAP (-0.597, p < 0.001), RV EF (0.555, p < 0.001), RV EFlong (0.327, p = 0.03), RV EFcirc (0.587, p < 0.001) were modest, while TAPSE/SPAP (0.641, p < 0.001), EF/SPAP (0.751, p < 0.001), EFlong/SPAP (0.610, p < 0.001) and EFcirc/SPAP (0.775, p < 0.001) showed stronger correlations. VE/VCO2 showed a similar relationships although the correlations were weaker [TAPSE (-0.523, p <0.001), SPAP (0.617, p < 0.001), RV EF (-0.412, p = 0.006), RV EFlong (-0.232, p = 0.129), RV EFcirc (-0.454, p = 0.002), TAPSE/SPAP (-0.561, p < 0.001), EF/SPAP (-0.516, p = 0.001), EFlong/SPAP (-0.429, p = 0.008) and EFcirc/SPAP (-0.541, p < 0.001)].

Conclusions

RV-PC coupling is associated with both peak VO2 and VE/VCO2. The use of 3D-derived markers of RV-PC coupling showed a better correlation with the peak VO2, while there were no differences for VE/VCO2. The circumferential component of RV systolic function seems to emerge as a dominant determinant of RV-PC coupling, as well as of functional capacity.
P1415 Obesity and epicardial fat in a Spanish infant population by echocardiography
Authors: Aristizabal Duque C H , Fernandez Cabeza J , Blancas Sanchez I M , Ruiz Ortiz M , Delgado Ortega M , Rodriguez Almodovar A , Pan Alvarez Osorio M , Romo Pena E , Fonseca Del Pozo F J , Romero Sardana M , Mesa Rubio D
Published: January 2020

Introduction

Childhood obesity is currently a mayor public health problem. There is a direct relationship between a high body mass index with a higher cardiovascular morbimortality. Among child population 4 out of 10 individuals are overweight, the prevalence of overweight is 26 per cent and the prevalence of obesity is 12,6 per cent. The epicardial fat is a heart visceral adiposity index, may play a role in the coronary atherosclerosis pathogenesis, a chronic inflammatory disease and in heart disease. The rise in the epicardial fat is considered as a target organ injure in child population.

Aims

To know the relationship between childhood obesity and echocardiographic parameters of epicardial fat, as a target organ injure among the child Mediterranean population.

Methods

Randomly, we selected a sample of children and adolescents of primary and secondary education, in a rural town of 2864 inhabitants of southern Spain. We include children between 6-17 years. We performed transthoracic echocardiography, with measurements of 2D epicardial fat, in systole in parasternal long axis (PLA) and parasternal short axis (PSA), taking the measure as the average of 3 measurements in consecutive beats.

Results

We studied a total of 212 children (10.9 ± 3.0 years and 51.9% males), 45 (21.3% were obese), of which 7.2% were diagnosed with hypertension (HBP), 5.1% with metabolic syndrome and 5.3% as prediabetic. The thickness of the epicardial fat in PLA was related to Obesity 2.2 ± 0.7 mm vs 1.75 ± 0.5 mm p (<0.001); HBP 2.16 ± 0.9 mm vs. 1.86 ± 0.5 mm (P <0.05); Metabolic syndrome 2.23 ± 0.8 mm vs 1.81 ± 0.5 mm (P <0.05), in PSA: Obesity 2.36 ± 0.7 mm vs 1.78 ± 0.6 mm p (<0.001); HBP 2.31 ± 0.6 mm vs 1.88 ± 0.6 mm (P <0.05); Metabolic syndrome 2.43 ± 0.8 mm vs 1.87 ± 0.6 mm (P <0.01) and overall combining PLA and PSA views: Obesity 2.27 ± 0.7 mm vs 1.76 ± 0.5 mm p (<0.001); HBP 2.23 ± 0.7 mm vs 1.85 ± 0.5 mm (P <0.05); Metabolic syndrome 2.23 ± 0.7 mm vs 1.84 ± 0.5 mm (P <0.01).

Conclusion

In a random Spanish pediatric population correlation is found by echocardiography of the thickness of epicardial fat with obesity, HBP and metabolic syndrome. Being this a rapid test, non-invasive and without ionizing radiation.
P1417 Acceptability of a virtual reality system for examination of congenital heart disease patients
Authors: Wheeler G , Deng S , Pushparajah K , Schnabel J A , Simpson J M , Gomez A
Published: January 2020

Funding Acknowledgements

Work supported by the NIHR i4i funded 3D Heart project [II-LA-0716-20001]

Background/Introduction

Virtual Reality (VR) has recently gained great interest for examining 3D images from congenital heart disease (CHD) patients. Currently, 3D printed models of the heart may be used for particularly complex cases. These have been found to be intuitive and to positively impact clinical decision-making. Although positively received, such printed models must be segmented from the image data, generally only CT/MR may be used, the prints are static, and models do not allow for cropping / slicing or easy manipulation. Our VR system is designed to address these issues, as well as providing a simple interface compared to standard software. Building such a VR system, one with intuitive interaction which is clinically useful, requires studying user acceptance and requirements.

Purpose: We evaluate the usability of our VR system

can a prototype VR system be easily learned and used by clinicians unfamiliar with VR.

Method

We tested a VR system which can display 3D echo images and enables the user to interact with them, for instance by translating, rotating and cropping. Our system is tested on a transoesophageal echocardiogram from a patient with aortic valve disease. 13 clinicians evaluated the system including 5 imaging cardiologists, 5 physiologists, 2 surgeons and an interventionist, with their clinical experience ranging from trainee to more than 5 years’ of experience. None had used VR regularly in the past. After a brief training session, they were asked to place three anatomical landmarks and identify a particular cardiac view. They then completed a questionnaire on system ease of learning and image manipulation.

Results: Results are shown in the figure below. Learning to use the system was perceived as easy for all but one participant, who rated it as ‘Somewhat difficult’. However, once trained, all users found the system easy to use. Participants found the interaction, where objects in the scene are picked up using the controller and then track the controller’s motion in a 1:1 way, to be particularly easy to learn and use.

Conclusion

Our VR system was accepted by the vast majority of clinicians, both for ease of learning and use. Intuitiveness and the ability to interact with images in a natural way were highlighted as most useful - suggesting that such a system could become accepted for routine clinical use in the future.

Abstract P1417 Figure. VR system evaluation participant feedbac
P1421 Patients with severe aortic regurgitation showed systolic dysfunction and increased stroke work despite preserved EF; clues for reconsidering optimal time point of surgery
Authors: Reil J C , Reil G-H , Borer J S , Hecker N , Aboud A , Schaefers H-S , Langer H F , Sievers H-H , Ensminger S
Published: January 2020

Background

Current guidelines recommend surgery in patients with severe aortic regurgitation (AR) with clinical symptoms or subnormal ejection fraction (EF). Furthermore, surgery should be considered in patients with severe AR, preserved EF and increased left ventricular diameters (LVEDD >70mm, LVESD >50mm). The aim of the study was to investigate LV systolic function as well as mechanical energetics using non-invasive pressure-volume- and strain analysis in patients with severe AR and preserved EF as well as moderately dilated ventricles (LVEDD <70mm).

Methods and Results

Echocardiographic strain and single beat pressure-volume analyses were performed in patients with severe AR and moderately increased ventricular size (LVEDD < 70mm, EF >50% n = 39) as well as healthy, age-matched controls (n = 20) using echo-derived volume and arm-cuff blood pressure measurements. Load independent parameters of systolic contractile function like end-systolic elastance (Ees) and end-systolic volume at 100mmHg (ESV100) were calculated as well as stroke work ((SW) and total pressure volume area (PVA = SW + potential energy). Patients with AR demonstrated significant depression of systolic function beyond ejection fraction: global longitudinal strain was reduced compared to controls (-16 ±2.5% vs. -21.5 ±2%; p < 0.001). Accordingly load independent parameters of LV contractility like Ees (1.5mmHg/ml ±0.7 vs. 2.25mmHg/ml ±0.7; p < 0.001), ESV100 (65.7ml ±19.4 vs. 42.4ml ±19.8; p < 0.05) were reduced despite comparable ejection fractions (EF: 0.56% ±0.05 vs. 0.60% ±0.07 p = 0,10). End-diastolic volume of AR patients was markedly elevated (236ml ±90 vs. 136ml ±30; p < 0.001), while PVA (20470mmHg x ml ±10400 vs. 11907mmHg x ml ±2877; p < 0.01) and stroke work (13200mmHg x ml ±5700 vs. 7606 mmHG x ml ±2048; p< 0.01) were markedly elevated indicating waste of energy.

Conclusion

Patients with severe AR and moderately enhanced LV showed depressed values of contractility and waste of energy using more advanced parameters of LV systolic function although EF was preserved. The data may demonstrate that surgery is performed too late in many of those patients and may give clues for reconsidering guidelines to meet the optimal time point of surgery.

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P1423 Significantly higher 1-year mortality rate in patients undergoing TAVR with higher right ventricular volumes, as calculated by pre-procedural CT angiography
Authors: Maret E , Rozenbaum Z , Lax L , Shmilovich H , Finkelstein A , Steinvil A , Halkin A , Banai S , Cohen D , Topilsky Y , Berliner S , Fleischmann D , Aviram G
Published: January 2020

Background

Cardiac gated computed tomography angiography (CCTA) is the mandatory pre-interventional imaging planning procedure in patients eligible for trans-catheter valve implantation (TAVR). Automated analysis of the cardiac chambers" volumes including the right ventricle (RV), can be obtained from the CCTA and thus contribute to patient selection.

Objectives

To assess the prognostic implications of increased RV volume using a fast automated volumetric analysis software on preprocedural CCTA data among patients undergoing TAVR.

Methods

CCTA of patients who underwent TAVR at two medical centers – Stanford University Medical Center (California, USA) and Tel Aviv Medical Center (Israel) – between 2013 and 2016 were analyzed by an automatic four chamber volumetric analysis (4CVA) software, and grouped according to their RV volume index, into those with the largest RV (upper 5th percentile of RV volume index (>120 ml/m2; n = 16) versus those within the 95th percentile lower volumes index (≤120 ml/m2; n = 307). Differences in baseline characteristics between the groups were adjusted for with a propensity score. The risk for one year mortality following the TAVR was compared between the two groups.

Results

In total 323 patients were included. There were no major differences in background and demographic characteristics between the study groups. A significantly higher 1-year mortality rate was found for patients with large RV (31.3% vs. 7.5%, p = 0.008). After adjustment for clinical characteristics, patients with RV volume index >120 ml/m2 were at almost a 5 times higher risk for 1-year mortality compared to patients with smaller RV (HR 4.9, 95% CI 1.8-13.1, p = 0.002). The addition of echocardiographic parameters to the propensity score did not eliminate the significance of RV volume index >120 ml/m2 as an independent predictor for mortality at 1-year. An analysis of RV as a continuous variable demonstrated that the risk for 1-year mortality increased by 2% for every 1 ml/m2 RV volume enlargement (p = 0.013).

Conclusions

Cardiac volumetric data by CCTA performed for procedural planning may help predict outcome in patients undergoing TAVR.

Abstract P1423 Figure. Cox survival curves according to RVi
P1425 Association between severity of mitral regurgitation and right ventricular function in patients with moderate to severe mitral regurgitation assessed by invasive hemodynamics measurements
Authors: Omar M
Published: January 2020

Funding Acknowledgements

-

Background

Primary mitral regurgitation (MR) will cause volume overload to the left ventricle (LV) but due to systolic reguritant flow the pulmonary circulation will be affected often leading to post-capillary pulmonary hypertension and thus increased afterload to the right heart. As a consequence right ventricular (RV) dysfunction may be a consequence of MR.

Purpose

To assess the association between RV function assessed with cardiac magnetic resonance imaging (CMRI) and hemodynamics at rest and during exercise in ambulatory patients with primary mitral regurgitation (MR).

Methods

In an observational study, patients with significant primary MR with effective regurgitant orifice ≥0.30 cm2 and LV ejection fraction >60% were examined with right heart catheterization during rest and exercise and CMRI at rest. Patients were examined in semi-supine position (30 degree). From right heart catheterization pulmonary artery systolic pressure (PAPs) was measured, where RV stroke work index (RVSWI = 0.0136*(mean pulmonary artery pressure – right atrial pressure *stroke volume index) and pulmonary artery compliance (PAC= stroke volume / (PAPsystolic – PAPdiastolic)) was calculated. Patients were dichotomized according to effective regurgitant orifice (ERO) (≤0.4 cm2).

Results

The two groups (total n = 46) have same baseline characters with no significant differences. In both groups resting RVEF was normal and no difference in RV stroke volume was seen between the groups at rest or with exercise. However RVSWi was significantly higher in patients with ERO > 0.4, (rest p = 0.0039, exercise p = 0.01), Figure. The increase in RVSWi was driven by increased sPAP and where significantly in ERO > 0.4 at rest at during exercise (rest p = 0.00027, exercise p = 0.0352). At rest PAC was significantly higher in ERO above 0.4, but during exercise no differences was found in the two groups. RVEF at rest measured by CMRI showed no correlation with RVSWi in the two groups (r = 0.11, p = 0.45)

Conclusion

In ambulatory patients with mitral regurgitation above 0.4 cm2, RVSW is associated with an increased right ventricle workload and contractility at rest and during exercise which especially is driven by increased post capillary pressure whereas pulmonary arterial compliance only is mildly affected.

Abstract P1425 Figure. Ventricle function at rest/exercise
P1426 Non-cardiac sourses of thromboembolic complications in atrial fibrillation
Authors: Germanova O , Germanov A
Published: January 2020

Background

Thromboischemic stroke is a significant medical problem. The most dangerous arrhythmia that causes the thromboembolism is atrial fibrillation. The source of thrombus mostly located in left atrium appendage or apex of left ventricle. But there’re a lot of cases of thromboischemic stroke in patients with atrial fibrillation without any intra-heart thrombus.

Purpose

To study the possibility of thromboembolic complications in patients with permanent form of atrial fibrillation without intra-heart thrombus.

Materials and methods

We included 48 patients with permanent form of atrial fibrillation. Mediana age - 68 ± 4,6 y.o. 32 (66,7%) were men and 16 (33,3%) women. All patients were performed 24-hours ECG monitoring to verify the atrial fibrillation. 34 (70,8%) were regularly took warfarin or NOACs to prevent the thromboembolic complications. We used CHADS-2 scale to make the prognosis of 1-year thromboembolic complications. 0 points - 0 (0%) patients, 1 point - 1 (2,1%), 2 points - 2 (4,2%), 3 points - 8 (16,6%), 4 points - 7 (14,5%), 5 points - 18 (37,5%), 6 points - 12 (25,1%). All patients were made transesophageal echocardiography. Only 3 (6,2%) of them had intra-heart thrombus. Intra-arterial blood flow we measured with Doppler-ultrasound. Most of patients – 39 (81,3%) had atherosclerotic plaques of internal carotid artery on one or both sides. In 22 (45,8%) patients were the signs of non-stability of plaques (heterogenic structure, rough surface). We valued the arterial wall kinetic parameters with sphygmography: speed, acceleration, power, work. We analyzed these parameters in different cardiocycles.

Results

We observed the following patterns:

1. If longer was the pause between cardiocycles in atrial fibrillation then more increase of biomechanical and kinetic parameters was observed.

2. The secondary hemodynamic arterial hypertension at the moments after long pause between cardiocycles. The longest duration of it was observed in bradysystolic atrial fibrillation (up to 38% of time).

3. In patients with hemodynamically important stenosis (about 70%) of internal carotid artery the speed after the long pause in atrial fibrillation is rising up to 4-4,5 meters per second. In comparison with sinus rhythm it is about 2,3 meters per second. Such rising of speed can cause the plaque integrity damage of parietal thrombus fragmentation.

4. Increased arterial wall deformation. The increased biomechanical parameters cause the appearance of additional waves, stand waves that may cause non-stability of plaques with further thromboembolism.

5. During the 1-year observation thromboembolic comlications appeared in 11 (22,9%) patients.

Conclusion

The source of thromboembolic complications can be non-cardiac in patients with multi-focus atherosclerosis and non-stable plaques.
P1428 Mortality in non-ischemic cardiomyopathy is low and close to the general population
Authors: Melichova D , Nguyen T M , Salte I M , Klaebo L G , Sjoli B , Karlsen S , Dahlslett T , Leren I S , Edvardsen T , Brunvand H , Haugaa K H
Published: January 2020

Funding Acknowledgements

South Eastern Norway regional health authority

Background

Patients with non-ischemic dilated cardiomyopathy (NDCM) have lower mortality compared to patients with ischemic cardiomyopathy (ICM). Recent reports suggest less benefit of a primary prophylactic implantable cardioverter defibrillator (ICD) in NDCM.

Purpose

We aimed to investigate mortality rate and appropriate ICD therapy in a consecutive cohort of patients with NDCM and ICM.

Methods

In this prospective multi-center study, we consecutively included NDCM and ICM patients with left ventricular ejection fraction (LVEF) < 40% from July 2014 to January 2018. ICM or NDCM classification was based on coronary angiography. Echocardiography was performed at inclusion and LVEF and global longitudinal strain (GLS) were assessed. All-cause mortality and primary prevention ICD therapies were recorded during follow-up.

Results

We included 290 patients (67 ± 13 years old, 74% males), 207 with ICM and 83 with NDCM. At inclusion LVEF was 31 ± 6% and GLS -10.5 ± -3.3%. Patients with ICM were older (68 ± 12 years vs. 63 ± 15 years, p < 0.01), had better LVEF (32 ± 6% vs. 28 ± 7%, p < 0.01), and shorter QRS duration (106 ± 23 ms vs. 122 ± 28 ms, p < 0.01). A primary prevention ICD was implanted in 18 (9%) ICM patients and in 21 (25%) NDCM patients (p < 0.001).

During 22 ±12 months follow up, all-cause mortality was 27 (9%) in the entire population. In patients with ICM 1/18 (6%) received appropriate shock from their primary prevention ICD compared to 3/21 (14%) NDCM patients. Mortality was more frequent in ICM; 26/207 (13%) compared to 1/83 (1.2%) in NDCM (Log rank p < 0.01). All-cause mortality or appropriate ICD shock was more frequent in ICM compared to NDCM (27 (13%) vs. 4 (5%) log rank p = 0.02) (Figure). Assuming the arrhythmias treated by the ICD shocks would have been lethal, annual mortality of 2.5% in the NDCM population was only slightly higher compared to the age matched general population (1% annual mortality) (blue line).

Conclusion

Patients with NDCM had better survival, and in general a lower event rate, compared to patients with ICM. However, subgroups of NDCM patients may benefit from their primary prophylactic ICD and further studies should investigate the need of primary prevention ICD in patients with NDCM.

Abstract P1428 Figure.
P1432 Heart failure subgroups according to left ventricular ejection fraction A latent class analysis
Authors: Morbach C , Henneges C , Sahiti F , Breunig M , Cejka V , Ertl G , Frantz S , Angermann C E , Stoerk S
Published: January 2020

Funding Acknowledgements

German Research Foundation (BMBF 01EO1004 and 01EO1504)

OnBehalf

AHF

Background & Aims Heart failure (HF) is classified according to left ventricular (LV) ejection fraction (EF) into heart failure with reduced (HFrEF) and heart failure with preserved EF (HFpEF). In 2016, a third subgroup, heart failure with mid-range EF (HFmrEF), has been introduced by the ESC. We aimed to identify the number of naturally occurring heart failure subgroups according to LVEF using latent class analysis.

Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for acute heart failure (AHF). Echocardiography was performed within 72 hours prior to discharge. We first estimated the distribution of LVEF using histogram and kernel density estimation methods (bandwidth was selected by biased cross-validation). We then fitted Gaussian Mixture Models with increasing number of components to the data. To select the optimal number of components we calculated the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC). The minimum of each criterion suggests the optimal number of components for the final model. The BIC requires more data to select more components than the AIC and hence is more conservative. Finally, for each criterion the optimal model was determined.

Results Out of 629 patients, 585 (93%) patients received echocardiography and in 498 (79.2%) the LVEF could be calculated using Simpson´s biplane or monoplane method.

The BIC suggested two (panel B), the AIC three components (panel A). In the two-component model, mean ± SD LVEF values were 60.2 ± 8.7% and 30.8 ± 9.6%, thus covering 56% and 44% of patients, respectively (panel D). In the three-component model, respective LVEF values were 64.9 ± 6.2%, 50.2 ± 6.9%, and 28.4 ± 8.1%, thus covering 35%, 27%, and 38% of patients (panel C).

Conclusions Our analysis suggests that LVEF in patients with AHF is not a continuum, but clusters in two or three subgroups. In line with the HFrEF and HFpEF classification, the more conservative model suggested two subgroups of LVEF. The less restrictive model allowed for a third subgroup, compatible with HFmrEF. Future analyses will better characterize the identified subgroups.

Abstract P1432 Figure
P1434 Evolution of coronary wall shear stress following implantation of bioabsorbable vascular scaffolds - first results of a 1-year follow-up pilot study
Authors: Benedek T , Ferent I , Benedek A , Cernica D , Nita C , Puiu A , Itu L , Rapaka S , Puneet S , Benedek I S
Published: January 2020

Funding Acknowledgements

This research has been funded by the research grant PlaqueImage, contract number 26/01.09.2016, SMIS code 103544, Project funded by the European Union

Aims

Coronary shear stress (CSS) has been recently recognized to play a significant role in coronary plaque progression and vulnerabilisation. However, the evolution of CSS after implantation of different types of coronary stents is still under investigation. The aim of this study was to assess the evolution of the CSS along the coronary lesions following implantation of bioabsorbable vascular scaffolds (BVS), to determine the impact of BVS on coronary flow haemodynamics.

Methods and results

This was a single center prospective pilot study which enrolled 15 patients (aged 58.35 +/- 7.79 years, 13 males) with coronary artery disease undergoing BVS implantation in a major epicardial vessel. In all patients, angio CT scanning (Siemens Somatom Sensation scanner, Erlangen, Germany) was performed prior to the BVS implantation and repeated after 12 months. Lumen information was extracted from the vessels of interest and coronary rest hemodynamics, including CSS, were calculated using a computational fluid dynamics solver. All shear stress calculations were performed at baseline and repeated after 1 year. Average CSS was determined proximally, distally, and at the level of the minimal lumen area (MLA). Average CSS along the stented segment significantly decreased after BVS implantation, from 2.87 +/- 1.64 Pa at baseline to 1.9 +/- 0.49 at 1 year (p = 0.0001). Maximum CSS along the segment also exhibited a significant decrease, from 11.78 +/- 10.06 Pa to 6.35 +/- 3.08 Pa (p = 0.0009). Proximally to the MLA, CSS significantly decreased after BVS implantation, from 3.39 +/- 1.93 Pa at baseline to 1.91 +/- 0.68 Pa at 1 year (p <0.0001). However, this decrease in CSS was not significant distally to the MLA (1.3 +/- 0.72 Pa vs 1.59 +/- 0.65 Pa, p = 0.9).

Conclusions

Implantation of BVS leads to a significant decrease of CSS after 1 year, especially within coronary segments located proximally to the stenosis. This underlines the role of BVS in re-establishing a physiological pattern of coronary flow in diseased coronary vessels. The feature (mentioned herein) is not commercially available. Due to regulatory reasons its future availability cannot be guaranteed.