bluuebunny/crossref_metadata_2025 huggingface dataset:
P678 Late gadolinium enhancement cardiac magnetic resonance and layer-specific longitudinal strain in treatment naive Anderson Fabry disease
Authors: Esposito R , Sorrentino R , Ponsiglione A , Santoro C , Lembo M , Riccio E , Imbriaco M , Pisani A , Galderisi M
Published: January 2020

Background

In Anderson-Fabry disease (AFD), the accumulation of glycosphingolipids in cardiomyocytes causes inflammation, hypertrophy and interstitial fibrosis which is first limited to the mid-myocardial layers, then spreads to transmural fibrosis. Speckle tracking echocardiography allows the estimation of layer-specific strain, differentiating longitudinal strain (LS) at subendocardium and subepicardium (LSsubendo and LSsubepi, respectively).

Purpose

To investigate the matching of functional and structural abnormalities in newly diagnosed, never treated AFD patients by comparing multi-layer LS and late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR).

Methods

Twenty newly diagnosed, never treated AFD patients (age = 37 ± 13 years; F/M =10/10) and 20 healthy controls, matched for age and sex, underwent comprehensive evaluation of target organs and a standard echo-Doppler exam, including assessment of relative diastolic wall thickness (RWT) and left ventricular mass index (LVMI). Left ventricular hypertrophy (LVH) was defined as LVMi > 47 g/m^2.7 in women and >50 g/m^2.7 in men. Speckle tracking echocardiography derived left ventricular transmural global longitudinal strain (GLS), LSsubendo, LSsubepi and LS gradient (LSsubendo - LSsubpepi) were also determined. CMR sequences including assessment of LGE were also performed.

Results

AFD patients had normal renal function and comparable body mass index, blood pressure, heart rate, ejection fraction and diastolic indices with healthy controls. LVMi (p = 0.006) and RWT (p < 0.02) were greater in AFD patients than in controls. GLS (p = 0.006), LSsubendo (p = 0.005) and LSsubepi (p < 0.001) were lower in AFD patients. By CMR, only four patients (F/M = 3/1), 3 with LVH (75%), exhibited focal LGE, always localized in the midwall. LGE was detected at basal lateral wall in three patients and at the septal insertional points with the right ventricle in the remaining one. AFD patients with LGE had higher LVMi than those without LGE (47.2 ± 11.0 vs. 34.5 ± 11.6 g/m^2.7, p = 0.04). There was no correspondence of LGE with both regional LS and layer specific LS impairment (Figure). However, AFD patients with LGE had higher LS gradient compared to those without LGE (5.8 ± 0.65 vs. 4.8 ± 0.66, p < 0.02).

Conclusions

Treatment naïve AFD patients show a reduction of longitudinal deformation, which involves both subendocardial and subepicardial layers. Patients with LGE present higher LV mass and increased LS gradient, without a correspondence of LGE with both regional and layer specific LS impairment. Accordingly, this impairment might due to myocardial inflammation occurring in the early disease stages more than to myocardial fibrosis itself.

Abstract P678 Figure. Multilayer bull"s eye and LGE-CMR in AFD
P681 Surprise imaging findings in an asymptomatic patient with an ECG suggestive of apical hypertrophic cardiomyopathy
Authors: Cadil D , Calin A , Calin C , Popescu B A
Published: January 2020

We present the case of a 55-year old woman with an unremarkable past medical history, allergic to eggs and cinnamon and without any clinical complaints, who presented for a routine ECG prior to a dental implant procedure.

The ECG revealed signs of left ventricular (LV) hypertrophy with deep negative T waves in V2-V6 (Figure) suggesting apical hypertrophic cardiomyopathy. Her physical exam was unremarkable and a transthoracic echocardiography (TTE) was ordered. The TTE revealed normal LV dimensions, a normal global systolic function of both ventricles, but most remarkably, an isoechoic mass that occupied the whole apex and one third of the LV cavity (Figure), with a maximum thickness of 22 mm and a 2 mm hyperechogenic lining towards the LV, all these findings being suggestive of Loeffler endocarditis.

The routine laboratory tests showed (apart from a slightly increased LDL-cholesterol and normal BNP values) hypereosinophilia: more than 10% of the white blood count.

Chest X-Ray and the abdominal scan showed no signs of pulmonary or hepatic infiltration. Cardiac magnetic resonance imaging was scheduled, but the patient has claustrophobia and was unable to perform the exam.

The aetiological workup included the investigation of allergic, hematologic, as well as parasitic causes of the hypereosinophilic syndrome. Consequently, serological tests for Coxiella, Chlamydia, Echinococcus and Toxocara were all performed. The IgG antibodies for Toxocara canii were found in a very high level, indicating a chronic parasitic infection as a possible cause of the hypereosinophilic syndrome. The hematologic exams were all within normal limits. The endomyocardial biopsy, the gold standard for diagnosis could not be performed for technical reasons.

The first step in the management of hypereosinophilia (HE) is stopping exposure to the trigger, as well as specific treatment- albendazole. The patient received oral anticoagulant treatment in order to prevent thromboembolic complications, which are frequently reported in this clinical setting.

Loeffler’s endocarditis is usually a late cardiac manifestation of the HE syndrome. This is a rare and surprising case of an incidental imaging diagnosis in a totally asymptomatic patient after a routine ECG that was suggestive of hypertrophic cardiomyopathy. The challenge consisted in finding the cause of HE in order to attempt an aetiological treatment. Although the allergic and parasitic causes were most likely, considering the patient’s history, a hematologic malignancy had to be excluded. HE associated with toxocariasis rarely causes cardiac manifestations, but it should not be excluded when the patient has a history of canine exposure. The most fearsome complication in this case is the embolization of the eosinophilic mass, but the prompt management and routine follow-up allow the prevention of a thromboembolic event.

Abstract P681 Figure. ECG and TTE apical views
P690 Pulmonary valve endocarditis complicated with fistula between right ventricle outflow tract and aorta in a patient with patent ductus arteriosus
Authors: Toader D , Craciun Mirescu A , Cocora M , Munteanu O , Mustafa E R , Florescu C , Berceanu M , Popescu M , Cojocaru A , Oprian A
Published: January 2020

Background

The majority of cases of right sided infective endocarditis involve the tricuspid valve. Isolated pulmonary valve (PV) endocarditis is rare. Congenital heart disease are risk factors. Material and methods: We present the case of 36 years old male, without any known cardiovascular disease, who was admitted with signs and symptoms of heart failure, pulmonary embolism and fever. He was evaluated clinically, 12 lead ECG, pulmonary radiography, thoracic computer tomography (CT) scan, transthoracic and transesophageal echocardiography, laboratory investigations. Results: Transthoracic and transesophageal echocardiogram revealed large vegetations located on pulmonary valve, pulmonary regurgitation and dilation of the pulmonary valve, patent ductus arteriosus (PDA) with bidirectional shunt and local complications: fistula between right ventricle outflow tract (RVOT) and aorta, pleural and pericardial effusion. Blood cultures were negative. ECG aspect was right bundle branch block. Radiography and thoracic CT scan revealed pulmonary embolism aspect. The patient was treated with antibiotics and surgical option included debridement of the infected area, vegetation excision with valve replacement, relief of RVOT, fistula closure with pericardial patch and ligature of PDA. Evolution after surgical intervention was good.Conclusions: This presentation reveals a favorable evolution of a patient with infective endocarditis located to pulmonary valve. In most of cases, right heart endocarditis presents with signs and symptoms of respiratory disease and fever; these are due to septic pulmonary embolization. Isolated PV endocarditis still remains a challenging and needs carefully echocardiographic evaluation for a correct diagnosis and risk factors identification.
P703 A breathtaking heart. The loeffler"s endocarditis
Authors: Carcaterra A , Moch S , Sologashvili T , Muller H , Testuz A
Published: January 2020

This is a 72 year-old man known for idiopathic HES with endomyocardial fibrosis and moderate aortic regurgitation, treated with corticosteroids and antithrombotics. Two months prior to admission, he develops progressive exertional dyspnea reaching NYHA 3 class, with concomitant peripheral edema and rise in NT-proBNP. Cardiac transthoracic work-up shows a preserved left ventricular ejection fraction, but more marked dilatation with decrease in left ventricular volume due to a large echodense mass in the apex. The transmitral flow is restrictive, and the aortic regurgitation moderate. In view of this rapid evolution, resection of the left ventricular mass with concomitant aortic valve replacement is performed. Pathology confirmed eosinophilic infiltration.

First described in 1975, hypereosinophilic syndrome (HES) is a rare pathology that is defined as an absolute eosinophil count (>1,5 G/L) in the peripheral blood with eosinophil-mediated organ damage and /or dysfunction. We know three mains categories; primary (or neoplastic), secondary (or reactive) and idiopathic. Cardiac involvement is uncertain and cardiac injury does not clearly correlate with degree of peripheral eosinophilia. Heart tissue damage evolves through three stages (necrotic, intermediate and fibrotic). Endomyocardial fibrosis and eosinophilic myocarditis, also known as "Loeffler’s endocarditis", are major causes of morbidity and mortality among patients with HES. Echocardiography plays a crucial role in initial diagnosis of endomyocardial fibrosis, displaying myocardial wall thickening, signs of restriction (mitral inflow with large E wave and small A wave; E/A ratio greater than 2, short deceleration time less than 150 ms) and intracardiac thrombus (fixed mass embedding left ventricular apex). Valve regurgitation is another possible complication due to entrapment of the chordae tendinae and/or leaflets during the fibrotic stage of this disease. Cardiac MRI is another important diagnostic tool for precising cardiac involvement. Despite of steadily improving noninvasive diagnostic imaging methods, endomyocardial biosy still remains the gold standard exam and ultrasounds work-up is crucial for follow-up.

In conclusion, endomyocardial fibrosis is a rare cause of restrictive cardiomyopathy characterized by echocardiographic sign of elevated filling pressure, progressive endomyocardial thickening, valve regurgitation and possible intracardiac thrombus formation. This case underlines the importance of echocardiography in initial diagnosis and regular follow-up of this type of patients, in order to adapt medical treatment and monitor hemodynamic evolution of the restrictive physiology and of valvular damage.

Abstract P703 Figure. HES-3
P704 Mechanical complications of acute myocardial infarction in the era of early reperfusion therapy: a case report
Authors: Proenca T , Alves Pinto R , Martins Carvalho M , Nunes A , Araujo P M , Torres S , Resende C X , Grilo P D , Dias P , Paiva M , Casanova J , Maciel M J , Macedo F
Published: January 2020

Introduction

Left ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction, and its incidence has decreased with the widespread use of reperfusion therapies. Pseudoaneurysm is the result of a free wall rupture contained by pericardial adherences and mural thrombi, which contain the bleeding and prevent cardiac tamponade.

Clinical Presentation

A 68-year-old woman who had hypertension, diabetes mellitus and chronic kidney disease (caused by diabetic nephropathy) was first admitted with acute myocardial infarction of the inferior wall. Emergent coronary angiography revealed proximal occlusion of the right coronary artery. Primary angioplasty was performed with three stents implantation. However due to transitory no reflow, verapamil, nitrate and intracoronary abciximab were administered with recovery of coronary flow. Patient remained stable, without recurrence of symptoms. Echocardiography, at discharge, showed normal biventricular function and no mechanical complications.

Two months later, the patient was readmitted in the emergency room with constant chest pain, fatigue, prostration and loss of appetite beginning ten days earlier and an episode of syncope. Physical examination revealed fever, cardiac auscultation was rhythmic and without murmurs or pericardial friction rub, and pulmonary auscultation revealed crackles in inferior hemithorax. 12-lead electrocardiogram showed sinus rhythm, Q waves and negative T waves in inferior leads. Blood tests revealed leucocytosis, high sensibility troponin I was 28,8 ng/L and brain natriuretic peptide was 264,9 pg/mL. Chest-X-ray demonstrated enlargement of the cardiac silhouette and echocardiography showed moderate to large pericardial effusion with large amounts of fibrin close to right cardiac chambers and a basal inferior pseudoaneurysm with 23 mm x 24 mm; intracavitary contrast was administered without opacification of pericardial space; biventricular function remained normal.

Patient was promptly admitted on Cardiac Intensive Care Unit with diagnosis of pseudoaneurysm due to myocardial infarction. Therapeutic with ticagrelor was suspended and surgical correction was proposed, after discussion in Heart Team. False aneurysm correction was performed with a bovine pericardial patch without complications, and the patient was discharged asymptomatic eight days later.

Conclusion

Even with lower incidence, pseudoaneurysms remains as a potential life-threatening due to its high risk of rupture. Prompt diagnosis, usually with echocardiography and surgical referral are crucial.

Abstract P704 Figure. Inferior Pseudoaneurysm
P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection
Authors: Castelo A , Silva T , Ramos R , Fiarresga A , Moreira R , Mano T , Ferreira V , Bras P , Ferreira R
Published: January 2020

Introduction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness.

Case report

We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN< 15.6) and CK 874U/l (ULN <168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic.

Discussion and conclusion

The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option.

Abstract P715 Figure. angio-CT
P719 Complex cyanotic congenital heart disease and its complications- it is never too late to treat
Authors: Radu D N , Stoica S , Dorobantu D M , Olaru-Lego G , Buta A S , Platon P , Iosifescu A , Coman I M , Ginghina C , Popescu B A , Enache R
Published: January 2020

Noncardiac complications significantly contribute to the morbidity and mortality of adults with congenital heart disease (CHD), mainly because life expectancy and quality of life for those born with CHD have greatly improved in the last decades. Double-outlet right ventricle (DORV) with a subaortic ventricular septal defect (VSD) associated with subpulmonary stenosis is a complex cyanotic congenital heart disease from the spectrum of tetralogy of Fallot.

We present the case of a young male who was diagnosed at the age of 18 with DORV with subaortic VSD (Figure A), subpulmonary stenosis (Figure C) and mitral valve malformation (anterior leaﬂet cleft (Figure B) and both leaﬂets prolapse) with secondary moderate mitral regurgitation (MR), associated with major aortopulmonary collaterals, without pulmonary hypertension. There was no surgical correction at that moment. At the age of 26 he presented with recurrent hemoptysis and embolisation of bronchial arteries was performed. In the same year, a cerebral MRI showed signs of multiple infratentorial and supratentorial ischemic strokes. One year later, he was diagnosed with brain abscess and otomastoiditis that were surgically managed; multiple microorganisms were isolated from the two sources (M. morganii, K. pneumoniae, P . aeruginosa) and the patient received prolonged antibiotic therapy. Two months later he presented with clinical, biological and echocardiographic signs of infective endocarditis (IE) and blood cultures confirmed the diagnosis of Candida albicans associated mitral valve IE (Figure D, E, F, G). Antifungal therapy was administered for one month, with the complete disappearance of the vegetation, but worsening of the mitral regurgitation and moderate left ventricular systolic dysfunction. Thus, the patient had a clear indication for mitral valve replacement together with complete repair of the cardiac malformation that seemed still feasible as the pulmonary arteries were well developed, there was no pulmonary vascular disease and the systolic function of the RV was normal. Correction of CHD was performed in March 2019 consisting of repair of the DORV (Figure H), mitral valve replacement (33 mm bileaflet mechanical valve) (Figure I), tricuspid valve repair with RVOT remodelling. Postoperative, the patient clinical status improved significantly and transthoracic echocardiography revealed a mild residual subpulmonary stenosis (Figure J) and normally functioning mitral prosthesis.

There are frequent, various complications in the natural history of congenital heart diseases, especially unrepaired. This case illustrates how vicious the circle of complications can get in a case of unrepaired cyanotic cardiac malformation and the difﬁculty of breaking this circle. The correction of CHD is the best prevention method and should be performed whenever it is feasible, even at an adult age.

Abstract P719 Figure.
P728 Left main coronary artery thrombus found in a teenager with Kawasaki disease following cardiac arrest
Authors: Roque H , Monteiro De Sousa D , Bowes M
Published: January 2020

Background

A male teenager presented with an out of hospital cardiac arrest while exercising requiring CPR and DC Cardioversion. Incidentally, he was stung by a wasp minutes before the event.

After being admitted, the patient was intubated, ventilated and treated for anaphylaxis and seizures. The patient had no significant past medical or family history of note. Investigations were performed after the patient was stabilized including 15 lead ECG, 24 hours ECG monitor, Echocardiogram and blood sample for troponins and cardiomyopathy screening. The ECG and 24 Hours ECG were reported as normal. The patient also had an exercise treadmill test which showed ischaemic changes at peak exercise. Cardiomyopathy screening was negative.

Echocardiogram showed globally mildly impaired left ventricular systolic function with no other significant abnormalities.

The patient underwent a cardiac MRI a couple of weeks later which showed an aneurysmal and tortuous proximal left coronary artery with a thrombus and also an aneurysmal mid left circumflex artery. Anticoagulation therapy was initiated, and a Cardioverter Defibrillator was implanted.

Another echo was performed focused on the LV function and visualisation of the coronary arteries. This confirmed the cardiac MRI findings, demonstrating two coronary artery aneurysms and a filling defect suggestive of thrombus in the more distal of the two aneurysms.

Due to the lack of evidence of any other potential condition, a diagnosis of Kawasaki disease was made and anticoagulation therapy was continued.

Conclusion

Although Kawasaki disease (KD) has been investigated for over four decades, its cause is still unknown. Current understanding of the immune system response indicates response to a classic antigen, that in most patients is protective against future exposure (1).

KD is an acute, self-limited vasculitis that affects young children. In a significant proportion of patients, it can originate coronary artery abnormalities, predominantly if the diagnosis is not achieved or treatment gets delayed. In the course of acute illness, the vascular architecture is destroyed by a necrotizing arteritis, causing hydrostatic pressure and leading to aneurysms in the affected areas (2).

The imaging modality preferred for assessment of myocardial function and detection of coronary artery abnormalities is Echocardiography (2).

In this case, given the unusual presentation of cardiac arrest and the diagnosis of KD we recommend a thorough assessment of the coronary arteries in echocardiography routinely.

Abstract P728 Figure.
P734 Feasibility and accuracy of the new automated software dynamic heart model in an unselected population
Authors: Manfredonia L , Fusini L , Muratori M , Tamborini G , Gripari P , Mantegazza V , Volpato V , Italiano G , Lombardo A , Crea F , Pepi M
Published: January 2020

Objective

Preliminary studies showed the accuracy of machine learning based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes. We aimed to evaluate the feasibility and accuracy of this new Dynamic Heart Model (DHM) software in an unselected population undergoing transthoracic echocardiography (TTE). Methods. We enrolled 91 consecutive unselected patients (80% in sinus rhythm) referred for clinically indicated 2D TTE, who also underwent single 3D TTE image acquisition from the apical 4-chamber view. 2D images were analyzed to measure ejection fraction, LV and LA volumes; 3D images were analyzed using Dynamic Heart Model (DHM) software (Philips Healthcare), which automatically measures chamber volumes throughout the cardiac cycle, resulting in LV and LA volume-time curves. Average time of analysis, feasibility, image quality were recorded and results compared between the 2D and 3D techniques. Results. Quality of the 91 2D TTE images was graded as poor (N = 13), satisfactory (N = 45) and good (N = 33). The use of DHM was feasible in 79/91 cases (87%). The remaining 12 datasets could not be analyzed because of poor images (N = 10) or incorrect automated border detection (N = 2): in these cases, the software did not accurately identify endocardial borders due to LV cavity near obliteration or extreme LA enlargement. When feasible, the boundary position was considered accurate in 61/79 patients (77%), while minor manual correction of the LV/LA borders was needed in the remaining cases. In only 1 case the reconstruction was considered unreliable because it needed major corrections. The overall time required to obtain DHM data was approximately 45 seconds. In all cases in which DHM was used, not only shapes of LV and LA were very well defined, but also functional curves were physiologically plausible. Even in the 13 patients in whom the 2D image was suboptimal, the DHM was not only feasible but also accurate endocardial boundaries in 8 cases, without (N = 5) or with only minimal manual corrections (N = 3). As expected, 3D LV volumes were slightly hige than 2D ones ( EDV 153.9 ± 59.8 vs 121.4 ± 47.3 mL, respectively), while LV EF and LA volumes were similar (EF 58.8 ± 11.8 vs 59 ± 11.8% and LA volume 92 ± 39.3 vs 83.4 ± 32.1 mL, respectively). Conclusions. The new DHM software is quick, feasible and accurate in the majority of unselected patients, including those with suboptimal 2D images or in atrial fibrillation. Introduction of this automated analysis into clinical practice can reduce examination time, while providing reliable information not only on volumes but also on function of the left heart chambers.
P737 Left ventricular hemodynamic forces: towards establishing reference values for healthy adults
Authors: Capuano F , Cocchia R , Ferrara F , Lanero S , Russo V , Ranieri B , Contaldi C , Sepe C , Mirto G , Pedrizzetti G , Bossone E
Published: January 2020

Introduction

Left ventricular hemodynamic forces (LV-HDF) have been recently demonstrated to be promising markers of sub-clinical dysfunction and potential predictors of disease outcome. However, there is a lack of reference values in healthy subjects. Knowledge of physiologic ranges is mandatory towards the use of LV-HDF-based indices for disease assessment in future clinical applications.

Purpose

Aim of the current study is to define the normal reference values for LV-HDF parameters in a large cohort of healthy adults. Here we present preliminary results for the initial set of enrolled subjects.

Methods

We enrolled 82 healthy subjects [mean age 44 ± 13.2 years (range 18-88), 41 men]. All participants underwent standard transthoracic echocardiography (TTE) examination, as recommended by current guidelines, including apical two-, three- and four-chamber windows, acquired at a frame rate above 40 Hz. These were then analyzed by tri-plane tissue tracking, measuring LV volume and LV ejection fraction (EF) as reference parameters. The same tracking method was used to evaluate the global hemodynamic force by a novel mathematical calculation technique applied to the three-dimensional endocardial contour. Physical-based LV-HDF parameters were then extracted for clinical application; these included the amplitude (root mean square) of the longitudinal and transversal force components (FL and FT) and their alignment angle relative to the LV axis. Parameters were computed as average over the whole cardiac cycle as well as limited to the systolic phase. Forces were normalized with LV volume to reduce variability with LV dimension, and divided by specific weight to yield a dimensionless measure.

Results

Mean EF was 63 ± 9%. Whole cycle LV-HDF parameters were: FL = 16.0 ± 5.6%, FT = 2.3 ± 0.8%, with significant longitudinal alignment FT/FL = 0.15 ± 0.04, angle = 13.0°±3.1°. Systolic HDF parameters were: FL = 22.7 ± 8.2%, FT = 2.9 ± 1.1%, with longitudinal alignment FT/FL = 0.13 ± 0.04, angle = 11.2°±3.1°. Importantly, dimensionless physical-based LV-HDF parameters showed no significant variation with age, gender or BSA.

Conclusions

We report the physiologic range of LV-HDF parameters measured by TTE. Knowledge of age- and gender-specific reference values, for a combination of standard, mechanical and hemodynamic indices, can improve the global assessment of the LV function and may help to detect sub-clinical stages of LV dysfunction.
P740 Right ventricular function evaluated by conventional echocardiography and strain imaging: study in young adults born preterm with and without lung disease
Authors: Bolander V , Maret E , Um Bergstrom P , Skold M , Eriksson M J
Published: January 2020

Funding Acknowledgements

Stockholms

Background

In young adults born preterm, particularly those with bronchopulmonary dysplasia (BPD), chronic respiratory dysfunction is seen even later in Life, and may lead to pulmonary hypertension and right ventricular (RV) dysfunction. Little is known on RV function in young adult patients with BPD in comparison to healthy Controls . RV strain imaging based on 2D speckle tracking echocardiography (ECHO) allows analysis of myocardial deformation and may improve the assessment of RV function.

Aims

The purpose of this study was to evaluate RV function using conventional ECHO parameters and 2D-strain in young adults born preterm and with and without BPD, and in healthy controls.

Methods

43 patients born preterm (21 with BPD and 22 without BPD) and 20 healthy age-matched Controls with mean age 23 +/- 1.7 y. RV size and function were assessed using conventional parameters (RV diameters, fractional area change (FAC%), tricuspid annular plane systolic excursion (TAPSE), peak systolic velocity of tricuspid annulus (PSV), RV myocardial performance index (MPI)) and 2D-strain of the RV free-wall and Total (free-wall and septum).

Results

No significant differences were found between the groups in the RV size, RV 2D-strain free-wall or Total, TAPSE or FAC%. Only RV MPI differed significantly between groups, however all values were within normal range (Table 1). There were significant correlations between RV 2D-strain and TAPSE, PSV and RV MPI and, but no correlation between RV 2-D strain and FAC%. RV free-wall strain was higher than RV total strain in all Groups.

Conclusion

RV function in young patients born preterm, with BPD did not differ significantly from the controls and the subjects born preterm with normal lung function. 2D-strain for RV evaluation was within normal range, suggesting that cardiac complications are rare in young BPD patients. RV MPI combining systolic and diastolic function variables may be a more sensitive measure to distinguish between BPD patients and other groups.

Variables Controls mean (SD) without BPD mean (SD) with BPD mean (SD) p = value FAC, % 44 (4.4) 46 (5.6) 48 (5.7) 0.1 TAPSE, mm 23 (3.5) 24 (3.8) 25 (4.2) 0.25 RV MPI 0.2 (0.06) 0.3 (0.09) 0.4 (0.1) <0.05 RV strain Total. % -22 (2.5) -22 (3.3) -22 (2.5) 0.8 RV strain free wall, % -29 (5.6) -27 (4.3) -28 (4.7) 0.57 PSV, cm/s 15 (2.3) 14 (2.0) 15 (2.2) 0.26 Differences in right ventricular (RV) function between the study groups, (BPD – bronchopulmonary dysplasia).
P743 Right ventricular function is important for exercise capacity in patients at risk of heart failure
Authors: Kikuchi S , Kitada S , Wakami K , Goto T , Sugiura T , Seo Y , Ohte N
Published: January 2020

Background and Purpose

It is important to evaluate exercise capacity to detect the development of heart failure (HF) in patients with heart disease. The pathology of exercise capacity is multi-factorial, and cardiac function is recognized as one of the most important determinants. However, the correlation between right ventricular (RV) function and exercise capacity is not fully understood in the subjects without HF. Therefore, we assessed the relationship between RV function and exercise capacity, both in patients with HF (HF+) and in patients with heart disease but not developed HF (HF-).

Methods

Two hundred and fifty-two patients with heart disease who underwent both Doppler echocardiography at rest and cardio-pulmonary exercise testing (CPET) for the assessment of heart function were enrolled (HF+: n = 142, HF-: n = 110). We measured left ventricular ejection fraction (LVEF), peak early diastolic transmitral flow velocity (E), peak late diastolic transmitral flow velocity (A), early diastolic mitral annular velocity (e’), left atrial volume (LAV), and tricuspid annular plane systolic excursion (TAPSE) by echocardiography. After echocardiographic examination, symptom-limited exercise testing was performed with simultaneous respiratory gas analysis, and peak oxygen consumption (pVO2) was determined. Blood examination including hemoglobin (Hb) and brain natriuretic peptide (BNP) was done on the same day.

Results

There were significant relationships between pVO2 and LVEF (r = 0.16, p = 0.005), e" (r = 0.51, p < 0.0001), E/e" (r=-0.47, p < 0.0001), LAV (r=-0.21, p = 0.0002), and TAPSE (r = 0.33, p < 0.0001) in the whole subjects. In the multiple regression analyses, age, Hb, E/e" and TAPSE were selected as significant determinants for pVO2 both in HF+ (R²=0.39, p < 0.0001) and HF- (R²=0.33, p < 0.0001).

Conclusion

RV function is the prime determinant of exercise capacity in patients at risk of HF, as well as in patients with HF.

Abstract P743 Figure.
P754 Severe aortic stenosis with preserved ejection prognostic differences according to flow status and gradient fraction: a Spanish multicentre study
Authors: Galian-Gay L , Escalona Silva R A , Ferrer-Sistach E , Mitroi C , Mingo S , Saura D , Vidal B , Moral S , Calvo F , Sanchez-Sanchez V , Gonzalez A , Guzman G , Noris Mora M , Arnau Vives M A , Evangelista A
Published: January 2020

Background and objectives

Low-flow low-gradient (LFLG) aortic stenosis portends bad prognosis in different series. The objective of this study was to evaluate the evolution of this entity in our country.

Methods

We included 1394 consecutive patients evaluated between 2008-2016 with severe AS (AVA <1 cm²) and ejection fraction> 50% from 14 Spanish centres. The results (aortic valve intervention and mortality) were compared using the Kaplan-Meier survival analysis.

Results

Three groups based on gradient and flow status were established (high gradient: HG, normal flow under gradient: NFLG, low gradient low flow: LFLG). No significant demographic or clinical differences between groups were observed. After a follow-up of 61.52 months (IQR 43.5-86.5), 551 (73.8%) HG, 268 (35.4%) with NFLG and 81 (57.9%) LFLG received intervention, with a later surgery/TAVI indication in the LFLG group compared with HG group (p = 0.001) (Figure 1). The analysis of the Kaplan-Meier mortality curves showed no significant differences.

Conclusions

Patients with LFLG aortic stenosis with normal ejection fraction received less and later aortic valve intervention than the HG group with no significant differences in mortality.

Abstract P754 Figure. Time to surgery
P756 Paradoxycal restricted motion in diastole associated to mitral valve prolapse/dystrophy: a frequent finding
Authors: Le Tourneau T , Cueff C , Marrec M , Piriou N , Capoulade R , Le Scouarnec S , Merot J , Schott J J
Published: January 2020

Funding Acknowledgements

PHRCI mitral 2012

Background

Filamin-A mitral valve prolapse/dystrophy (FLNA-MVP) phenotype associates moderate MVP and a paradoxical restricted motion in diastole.

Purpose

We aimed to assess the association of MVP with restricted motion in diastole in MVP patients (restricted MVP).

Methods

We prospectively enrolled 433 MVP probands (57 ± 16 years). Patients underwent a clinical examination and a comprehensive echocardiographic analysis of mitral valve apparatus.

Results Among the 433 probands, 27 (6.2%, 95% CI 3.9-8.5) had both a MVP and a doming aspect in diastole. Patients with restricted MVP exhibited shorter posterior chordae tendinaes (24.8 ± 6.3 vs 27.2 ± 5.9 mm, P = 0.037), and a shorter distance between papillary muscle (PM) tips and mitral annulus (anterior PM: P = 0.0001; posterior PM: P = 0.009). Anterior mitral valve leaflet was lengthened (15.5 ± 2.4 vs 14.3 ± 2.6 mm/m², P = 0.018), but leaflet thickness, leaflet prolapse, and mitral valve annulus did not differ between the 2 groups. Bicuspid aortic valve was more frequent in patients with restricted phenotype (14.8 vs 2.9%, P < 0.05). Familial recurrence of restricted MVP was identified even in the absence of Filamin-A mutation.

Conclusion

Restricted MVP is a quite frequent finding in MVP patients and is associated with PM tips location closer to mitral annulus. Restricted MVP can be regarded as a third type of MVP beside myxomatous Barlow disease and fibro-elastic deficiency MVP.
P757 Left atrial contractile function improves shortly after transcatheter aortic valve replacement. A speckle tracking echocardiography study
Authors: Calin A , Cadil D , Parasca C , Mateescu A , Rosca M , Beladan C C , Enache R , Ginghina C , Deleanu D , Chioncel O , Iliescu V , Popescu B A
Published: January 2020

Background

Transcatheter aortic valve replacement (TAVR) reverses LV remodeling and improves overall cardiac function, but data regarding its effect on left atrial (LA) function is scarce. Our aim was to evaluate the short-term effect of TAVR on LA myocardial deformation parameters and the relationship between the improvement of LA function and baseline echocardiographic parameters.

Methods

Fourty-eight consecutive pts (75 ± 6 yrs, 28 men) considered to be at increased risk for surgical aortic valve replacement were enrolled and examined before and 30 days after TAVR. All pts underwent a comprehensive echocardiogram, including speckle tracking echocardiography (STE) for deformation analysis. Longitudinal LA strain parameters were assessed from the apical 4-chamber view. Peak values of global longitudinal LA strain (LAε) and LA systolic strain rate (SSr, reservoir function) and early diastolic strain rate (ESr, conduit function) were measured in all. Contractile LA function (late diastolic strain rate, ASr) was assessed in patients in sinus rhythm (39 pts).

Results

Compared with baseline, the mean indexed LV mass was significantly reduced after TAVR (141 ± 26 vs 160 ± 37 g/m2, p = 0.009) but the mean increase in LVEF was not statistically significant (51 ± 14% vs 47 ± 15%, p = 0.2). There was a significant reduction in systolic pulmonary pressure after TAVR (34 ± 12 vs 42 ± 13, p = 0.004). Although there was no significant decrease in indexed LA volume (51 ± 22 vs 56 ± 20 ml/m2, p = 0.3), the contractile LA function significantly improved 30-days after TAVR (mean ASr, -1.1 ± 0.5 vs -0.8 ± 0.4 %, p = 0.02). There was a tendency of improvement in global longitudinal LA strain (15 ± 7 vs 12 ± 6%, p = 0.06) and global longitudinal LV strain (-13 ± 4 vs -11 ± 5%, p = 0.06) as well. Parameters of LV diastolic function, including TDI derived e’ and E/e’ ratios were not significantly improved 30 days after TAVI. While LA volumes and function parameters were not significantly different between genders at baseline, the improvement of LA function was more frequently found in male pts (p = 0.05). There were no significant correlations between the improvement of LA function parameters and baseline echocardiographic parameters in our study group. The only predictor of LA booster function improvement was the baseline value of ASr (p = 0.01).

Conclusions

TAVR is associated with a significant recovery of LA function as assessed by STE, suggesting a reverse cavity remodeling. This was accompanied by a significant reduction in LV mass and systolic pulmonary pressure. Men seem to show a more significant improvement in LA contractile function, suggesting a gender-related LA response to chronic afterload reduction.
P758 Should ECHO measurements be indexed to ideal BSA or actual BSA?
Authors: Cases M , Zhu T , Jurt U , Brouillard D , Matangi M
Published: January 2020

INTRODUCTION

A patient with aortic stenosis with an AVA of 1.22 cm2 who stands 5’ 6" and weighs 145 lb has a BSA of 1.76m2 (AV area index = 0.69 cm2/m2). If the same patient weighs 200 lbs, the BSA increases to 2.09 m2 (AV area index 0.58 cm2/m2). Their calculated AV area index therefore changes from the moderate range to the severe range.

PURPOSE

To determine from our ECHO database the effect the current obesity epidemic has on all ECHO variables that are indexed to BSA.

METHODS

Our ECHO database was searched for all patients with the required data variables, gender, age, height (cm)and body weight (kg) were required. Duplicate patients with multiple ECHO studies were removed, only the first ECHO entry being included. Obvious data entry errors were removed (e.g. height 1866 cm, or weight 8.6 kg). Ideal weight was calculated using the Devine formula, ideal weight = Constant + 2.3x[height in inches-60], where constant= 50kg in males and 45.5kg in females. Body surface area in m2 was calculated = [√(height in cm x weight in Kg)/3600]. The paired t-test was used to determine differences between means. A p value of <0.05 was considered significant.

RESULTS

There were 47,761 ECHO studies entered into the database, of which 46,605 (98%) had all the required fields completed. Once duplicates were removed (-15,903) and erroneous data deleted (-158, 0.33%), 30,536 remained. There were 16,160 females aged 58.7 ± 19.2 years, with a mean height of 161.7 ± 7.2cm and 14,376 males aged 59.8 ± 19.2 years, with a mean height of 176.7 ± 7.6 cm. There were statistically significant differences in both men and women between actual and ideal weight and actual and ideal BSA, see Table 1.

CONLUSIONS. For all ECHO measurements where the value is frequently indexed a decision needs to be made to either use the actual BSA or the ideal BSA. It may be more practical to use the ideal BSA which will remain consistent throughout follow up. Using our data any such measurement for females could be multiplied by 1.16 and for males 1.11 (i.e. actual BSA/ideal BSA). It is disappointing to find that, on average, females are 20 kilograms and males 18 kilograms above their ideal weight.

Table 1. Weight females (kg) Weight males (kg) BSA females (m2) BSA males (m2) Number. 16,160 14,376 16,160 14,376 Actual. 73.2 ± 18.9 89.1 ± 19.3 1.80 ± 0.24 2.08 ± 0.24 Ideal. 53.4 ± 6.5 71.4 ± 6.9 1.55 ± 0.13 1.87 ± 0.3 P value. <0.0001 <0.0001 <0.0001 <0.0001 BSA = Body surface area.
P760 Stress echocardiography testing of a novel trans annular mitral bridge implantation for mitral regurgitation
Authors: Benesova M , Subramanian V A , Cerny S
Published: January 2020

Objectives

Indirect reduction of septal- lateral diameter (SLD) by circumferential cinching of the annulus with ring annuloplasty (RA) is the standard part of mitral valve repair surgery. Direct SLD reduction without circumferential annular cinching by a novel trans-annular Mitral Bridge with an infra-annular curvature has been used for functional mitral regurgitation (FMR) as a sole procedure and for mitral valve prolapse (MVP)as a part of valve repair. The aim of this study was to assess the functional and hemodynamic outcomes at rest and exercise at 2 yr. follow up in the patients with this novel type of annuloplasty.

Methods

30 of 34 patients with FMR who had trans annular Mitral Bridge as the sole treatment of their MR and 5 of 8 patients with MVP in a prospective trial underwent at 2yr F/U bicycle ergometer exercise echocardiography on a special semi-recumbent bicycle. Mitral regurgitation, mitral peak and mean gradient, mitral valve area, systolic pulmonary arterial pressure, systolic function of the left ventricle were assessed at rest and peak exercise.

Results

Mitral regurgitation was 0.3 ± 0.5 at rest and 0.4 ± 0.5 at peak exercise (p = 0.264). The resting mean mitral gradient was 2.3 ± 0.9 mmHg and peak 4.6 ± 1.9 mmHg (p <.0001) and valve area was at rest 3.5 ± 0.7cm2 and at peak 3.9 ± 0.9 cm2 (p = 0.026). Pulmonary systolic arterial pressure was 25.8 ± 17 at rest and 36.9 ± 21.8 at peak exercise (P = 0.012). LVEF was 60,4± 10.5 at rest and at peak 66,4± 12.5 (p <.0001).

Conclusion

Trans annular Mitral Bridge as a alternative to standard annuloplasty ring is effective. At 2 yr follow up there was only trace mitral regurgitation and no mitral stenosis. The stress test verified the durability of the mitral repair both in FMR and MVP. There was no mitral stenosis and no mitral regurgitation at exercise. The raise of the mean mitral gradient was statistically important, but the values remained within the normal range. The raise of gradients is in correlation with the presence of cardiac reserve and increased LVEF. There were no signs of pulmonary hypertension caused by the stress.

Abstract P760 Figure. Mitral Bridge
P763 Asymptomatic severe organic mitral regurgitation: Does the anatomic substrate affect the functional response to supine ergometry?
Authors: Armenis I , Kontonika M , Marinou M , Motsi A , Athanassopoulos G
Published: January 2020

Asymptomatic severe mitral regurgitation (MR) remains a grey zone in decision making for intervention. The predictive role of left ventricular (LV) functional reserve remains uncertain and the potential role of the anatomical substrate has not been elucidated.

Aim of the study was to compare the LV function and hemodynamic changes during supine ergometry (Ex) in asymptomatic severe MR between myxomatous (Myx) and degenerative (Deg) substrate.

Methods

32 patients with Deg (male M/female F = 15/17) and 19 with MyxS (M/F = 7/12) were studied at rest (R) and Ex.

We estimated

heart rate (HR), rate-pressure product (HRxBP), LV endsystolic (LVESV)- enddiastolic volume (LVEDV), ejection fraction (EF), LV longitudinal strain (GLS), transmitral E wave (E), ratio E/e, peak tricuspid gradient (TrPG). To adjust for a potential volume effect on GLS, GLS was normalized to volumes and respective ratios were considered (GLS/LVESV, GLS/LVEDV). Parameters were measured at R and Ex and % changes were calculated : %d (Ex-R).

Results

Myx and Deg had similar chronotropic reserve and HR-BP. Myx were younger, and during Ex they had a greater LVEDV, a greater EF. a smaller E/e, and a smaller TrPG compared with Deg.

Myx group, despite having a better GLS both at R and Ex, revealed a smaller % GLS improvement from R to Ex (15% vs 32%). The normalized GLS/LVESV and GLS/LVEDV were similar at R between Myx and Deg, but they showed a smaller improvement during Ex in Myx. (table-results)

Conclusion

Despite similar severity of MR, asymptomatic patients with MyxS revealed a different dynamic profile during Ex compared with Deg. The underlying MV substrate in organic MR might be related with a different LV adaptation to volume loading combined with subsequent uneven stress induced hemodynamic response.

The disparities found might have implications both in the nature history of MR as well as in the decision making for intervention.

RESULTS Parameter DegS MyxS p Age(years) 65 ± 11 44 ± 12 <0. 001 LVEDV Ex (ml) 85 + 32 117 ± 41 =0. 007 EF Ex(%) 65 + 7 69 ± 8 =0. 05 GLS R(%) -17.6 ± 6.8 -22.2 ± 4.3 =0. 04 GLS Ex(%) -22 ± 4 -25.0 ± 5.7 =0. 05 % d (Ex-R) LV strain/endsystolic volume 0.84 ± 0.4 -0.54 ± 0.5 =0. 05 E/e" Ex 16.7 ± 8.8 9.7 ± 2.2 =0. 004 TrPG Ex(mmHg) 59 ± 11 44 ± 11 =0. 0001