bluuebunny/crossref_metadata_2025 huggingface dataset:
46 Classic or new echocardiographic parameters in the evaluation of the right ventricular function after tricuspid valve surgery?
Authors: Segura Rodriguez D , Torres-Quintero L , Rodriguez-Torres D J , Moreno-Escobar E , Garcia-Orta R
Published: January 2020

Background

Tricuspid valve regurgitation(TR) is frequent in patients undergoing to valvular heart disease surgery, particularly joined to mitral valve surgery. Classically, it was considered that left valve disease surgery would regress the TR without requiring any surgery on it, which has not been confirmed during follow-up. There is no consensus about which tricuspid lesions need to be operated neither which is the best surgical technique.

Purpose

In this study, we have evaluated the right ventricle(RV) function by advanced transthoracic echocardiography before to surgery and three months later.

Methods

Prospective cohort including 43 patients with valve surgical indication and some degree of tricuspid insufficiency. An advanced echocardiographic study was performed to determine the RV function measured by the following variables: basal diameter, Tricuspid Annular Plane Systolic Excursion(TAPSE), end-systolic RV area, fractional area change(FAC), systolic tricuspid valve lateral annular velocities by tissue Doppler(s’) and global longitudinal strain(GLS). Variables were tested to normality with Kolmogorov-Smirnoff test. Wilcoxon test was performed in order to compare measures previous and after surgery.

Results

43 patients were analysed. Mean age 64.7 ± 8.3 years, 31(72.1%) were female, 36 patients(83.7%) with functional TR which was associated to a left valvulopathy in 31(72.4%)cases. 17 patients(39.5%) had severe TR, 19 patients(44.2%) had moderate TR and 7 patients(16.3%) had mild TR. Twelve patients(27.9%) had isolated tricuspid surgery. The most frequent TR surgery was simple annuloplasty with 27 patients (62.8%). The classic RV echocardiographic parameters at initial evaluation and three months after surgery showed the following values respectively:Mean RV basal diameter was 48.3 ± 8.0mm vs. 41.7 ± 4.7 mm(p < 0.001), TAPSE was 19.0 ± 4.4mm vs. 15.7 ± 3.4mm (p < 0.001), peak systolic lateral annular velocity (s") was 0.12 ± 0.11cm/s vs. 0.11± 0.14cm/s(p = 0.001), FAC was 39.2 ± 13.2% vs. 38.2 ± 11.8%(p = Not significant), end-systolic RV area was 15.8 ± 10.2cm² vs. 14.4 ± 4.0cm²(p = Not significant). Nonetheless, there had not worsening in RV function based on myocardial deformation, with no significant differences between RV GLS(-20.0 ± 5.4% vs. -19.6 ± 4.9%; p = Not significant).

Conclusions

In our sample, 3 months post-surgery, the classic echocardiographic parameters based on the translational motion of the heart showed worsening of RV function. The parameters based on myocardial deformation do not show changes in RV function post-surgery, being better indicators of RV function in recently operated patients. These differences could be explain because tricuspid surgery is focus on the annulus that affects its motion while it does not affect to the global RV myocardial function evaluated by GLS.
47 Identification of threshold values to define right chamber enlargement consistent with severe tricuspid regurgitation
Authors: Previtero M , Bottigliengo D , Guta A C , Ochoa-Jimenez R C , Figliozzi S , Palermo C , Baritussio A , Cecchetto A , Aruta P , Iliceto S , Badano L P , Muraru D
Published: January 2020

Background

Right ventricle (RV), tricuspid anulus (TA) and right atrium (RA) dilatation, are listed among the supportive signs to grade severe tricuspid regurgitation (TR) according to current EACVI and ESC guidelines. However, at present, there is no cut-off value to define RV, RA and TA dilatation associated to severe TR.

Purpose

Accordingly, we sought to identify the threshold values of RV, RA and TA size associated to severe TR.

Methods

302 patients (59 ± 13 years, 54 % women) with functional TR underwent three- (3D) and two-dimensional (2D) echocardiography to obtain: 3D RV end diastolic volume (RVEDVi) indexed for body surface area (BSA), 3D RV end systolic volume indexed for BSA (RVESVi), 3D RA max volume indexed for BSA (3DRAi), 2D RA systolic volume indexed for BSA (3DRAi), 2D RV basal diameter (2DRVd), 2D RV basal diameter indexed for BSA (2DRVdi), 2D TA measured in the apical 4-chamber view and 2D TA measured in the apical 4-chamber view indexed for BSA. To identify the threshold values of the parameters that discriminate patients with right chamber enlargement associated to severe TR, we selected the probability which returns the best sum of sensitivity and specificity on the ROC curve of the model.

Results

According to EACVI multiparametric approach, 50/302 pts (17%) were found to have severe TR. As shown in Figure, 3DRAi > 45 ml/m2 and 2DRAi > 45 ml/m2 identified patients with RA enlargement associated to severe TR. RVEDVi and RVESVi did not show any predictive value for severe TR. Conversely, 2DRVd > 52 mm (or >30 mm/m2) was associated to severe TR. 2DTA > 42 mm ( or >24 mm/m2) was the selected threshold value for TA dilatation.

Conclusions

Our study provided the threshold values to define the right chamber and TA dilatation associated to severe TR. Implementation of those values in current guidelines can help clinicians to improve their accuracy to identify patients with severe TR.

Abstract 47 Figure.
104 Left ventricular stroke volume differences among echocardiographic methods in healthy adults from the World Alliance of Societies of Echocardiography (WASE) Normal Values Study
Authors: Miyoshi T , Addetia K , Blitz A , Lang R , Asch F
Published: January 2020

Funding Acknowledgements

WASE Normal Values Study is sponsored by American Society Echocardiography Foundation.

OnBehalf

the WASE Investigators

Background

Left ventricular (LV) stroke volume (SV) can be determined by multiple ultrasound methods, including Doppler, two- (2D) and three-dimensional (3D) echocardiography. However, how methods compare to each other is not well understood. In this report from the WASE study, we aim to examine and compare normal reference ranges for SV and SV index (SVI) obtained from healthy adults by Doppler, 2D Simpson’s and 3D methods.

Methods

WASE Normal Values Study is a multinational, observational, cross-sectional study. Individuals free from known cardiac, lung and renal disease were prospectively enrolled with even distribution among age groups and gender. Doppler, 2D and 3D datasets were acquired at the enrolling centers, following a standardized protocol. LV SV was measured by three methods: Doppler (LV outflow tract diameter and velocity time integral), 2D biplane Simpson’s rule and 3D volume method. SV was indexed by body surface area (SVI). All measurements were analyzed (TOMTEC) in two core laboratories (for 2D and 3D) following ASE Guidelines. Methods were compared by Friedman test and Bland-Altman analysis.

Results

As of May 2019, 646 cases have been analyzed in both 2D and 3D datasets. In this population, age was 45 ± 16 years old (range 18-85) and body surface area was 1.76 ± 0.22 m² (range 0.95-2.44). LV EF by 2D Simpson’s rule and 3D method were 63.2 ± 2.9 and 62.3 ± 5.0 %, respectively (p < 0.0001, Wilcoxon test). SVI by Doppler, 2D and 3D were 39.6 ± 7.6, 33.8 ± 6.5 and 41.0 ± 9.4 ml/m², respectively. There were significant differences between the three methods (p < 0.0001, Friedman test). 2D underestimated SVI compared to Doppler by 14.6% (mean of differences 5.8 ml/m², p < 0.0001) and 3D by 17.6% (7.2 ml/m², p < 0.001). The difference between Doppler and 3D was smaller (3.4% lower by Doppler) but still statistically significant (1.4 ml/m², p = 0.0008). The results are shown in the figure.

Conclusions

Comparing 3 modalities in a large population of healthy individuals, SV and SVI are underestimated by 2D Simpson’s method. Given the large differences, combining 2D and Doppler or 3D measurements for hemodynamic calculations (such as regurgitant volumes and fraction) should be done with caution.

Abstract 104 Figure.
106 Mitral annulus calcification: potential indicator of vascular disease and higher thromboembolic risk
Authors: Radu S , Al Shurbaji S , Mircea G , Ouatu A , Tanase D M , Floria M
Published: January 2020

Background

In CHA2DS2-VASc thromboembolic risk score, vascular diseases (V) include either prior myocardial infarction, peripheral arterial disease or aortic plaque, summarizing the patient’s atherosclerotic burden. Despite this, thromboembolic risk scores used in atrial fibrillation (AF) patients do not include mitral annular calcification (MAC) as a potential indicator of vascular disease.

Purpose

This case-control study retrospectively assessed the relationship between MAC and thromboembolic risk scores (CHADS2 and CHA2DS2-VASc) in non-valvular AF patients (paroxysmal and non-paroxysmal).

Methods

We compared thromboembolic risk scores value, clinical and transthoracic echocardiographic data in AF patients with and without MAC. The presence and severity of MAC was assessed in parasternal short axis and apical four chamber views. It was qualitatively defined as either mild, moderate or severe based on echodensity and extension in mitral annulus ring. MAC of > 4mm thickness was also considered severe.

Results

We included 103 patients: mean age 72.6 ± 9.9 years, 44.7% male, 83.5% hypertensive, 30.1% diabetic, 79.6% with heart failure, 40.8% were in atrial fibrillation and 7.8% had a history of stroke/transient ischemic stroke. We identified MAC in 50.5% patients: 15.7% severe, 50.3% moderate, 34% mild. Mean CHADS2 and CHA2DS2-VASc were 2,56 ± 1.213 and 4.57 ± 1.61, respectively. In MAC patients, both scores tended to increase with a mean of 2,88 ± 1,114, p = 0.003 and 5,211 ± 1,51, p < 0.001 as compared with control (2,23 ± 1,06 and 3,92 ± 1,46), respectively. The presence of MAC was a risk factor for vascular disease (OR = 2,47, χ2 = 34,32, p < 0,001). Moreover, the AUC for CHA2DS2-VASc, CHADS2, and MAC was 0.73 (95% CI, 0.63-0.82) and 0.65 (95% CI, 0.54-0.75), respectively. Both scores showed higher AUC in women: 0.79 (95% CI, 0.67-0.91) for CHA2DS2-VASc and 0.68 (95% CI, 0.54-0.82) for CHADS2. Left ventricular ejection fraction (LVEF) negatively correlated with the presence of MAC (r=-0.254, p = 0.01). Sinus rhythm patients with MAC showed significantly decreased LVEF as compared to those without MAC (55.73 ± 12.3% vs 46.96 ± 14.5 %, p = 0.013). The difference was not significant in AF patients (46.83 ± 10.6% vs 45.92 ± 11.59, p= 0.79).

Conclusion

The presence of MAC, irrespective of severity, correlates very well with both vascular disease and thromboembolic risk scores. Therefore, we consider that MAC might be a potential indicator of vascular disease and of higher thromboembolic risk. This study raises the question whether inclusion of MAC in thromboembolic risk scores as an indicator of vascular disease (V) might increase their predictive value.
158 Myocardial work exposes afterload-dependent changes in strain
Authors: Sletten O J , Aalen J , Khan F H , Larsen C K , Inoue K , Remme E W , Hisdal J , Smiseth O A , Skulstad H
Published: January 2020

Funding Acknowledgements

Norwegian Health Association

Background

Global longitudinal strain (GLS) is used for detection of subclinical left ventricular (LV) dysfunction, for example when screening for chemotherapy-induced cardiotoxicity. A relative percentage reduction in GLS ≥8% is considered abnormal. However, as GLS is load-dependent, modest increases in afterload can potentially prove sufficient to cause clinical implication. In contrast, global myocardial work (GMW) which incorporates afterload, may be more accurate in detecting LV-dysfunction.

Purpose

We investigated the effect of increased afterload on GLS, and if GMW may be a more accurate parameter of myocardial function during increased afterload.

Methods

In 20 healthy individuals (age 49 ± 11 years (mean ± SD), 10 men), blood pressure was increased by a 3 minute arithmetic mental stress test. GLS was measured by speckle tracking echocardiography and LV ejection fraction (EF) by biplane Simpson. GMW was calculated from LV pressure-strain analysis using a non-invasive estimate for LV pressure (LVP).

Results

During the afterload-elevation, systolic blood pressure increased by 25 ± 16 mmHg (p < 0.01), and heart rate by 16 ± 13 bpm (p < 0.01). This was followed by a decrease in EF from 62 ± 5 to 59 ± 5% (p < 0.01) and GLS from 21.9 ± 2.2 to 20.8 ± 2.0% (p < 0.01). In contrast, GMW increased from 2052 ± 278 to 2382 ± 388 mmHg·% (p < 0.01). In 5 of 20 (25%) individuals, the relative percentage reduction of GLS was >8%, despite an increase in GMW. The figure shows an individual example during rest and afterload-elevation, where an increase in systolic blood pressure of 16 mmHg was associated with a 9% relative percentage reduction in GLS, but a small increase in GMW as illustrated by the loop areas.

Conclusions

This study demonstrated that a modest increase in afterload can result in significant reduction in GLS, that may lead to overdiagnosis of LV-dysfunction. GMW did not decrease, suggesting it has a better specificity in patients at risk for subclinical LV dysfunction. Future studies should investigate if GMW is more accurate than strain in detecting LV-dysfunction.

Abstract 158 Figure.
P182 Bleeding complications in a rendu-osler-weber syndrome patient with atrial fibrillation - challenging serial transoesophageal echocardiography
Authors: Branco Mano T , Moura Branco L , Ramos R , Fiarresga A , Timoteo A T , Galrinho A , Abreu J , Castro L , Duarte Silva N , Ilhao Moreira R , Valentim Goncalves A , Cruz Ferreira R
Published: January 2020

Rendu-Osler-Weber (ROW) syndrome or hereditary hemorrhagic telangiectasia is a rare autossomic dominant disease characterized by vascular dysplasia involving multiple systems and associated with an increased bleeding risk. The presence of atrial fibrillation in this population becomes a challenge, regarding the evaluation of bleeding and thrombotic risks and the best approach for the patient management.

A 72 years-old female with ROW syndrome, atrial fibrillation and a CHA2DS2-VASc risk score of four, was admitted to our hospital for left atrial appendage (LAA) closure after a period of novel oral anticoagulation crowed with multiple haemorrhagic events and blood transfusions. After the implantation of a Watchman LAA number 33 closure device (Image 1A), and because of the concomitant diagnose of chronic pulmonary embolism, she was restarted on anticoagulation therapy in lower doses, with initial tolerance. For evaluation of LAA closure device during follow-up, after an unsuccessful attempt of transoesophageal echocardiography (TEE) because of severe epistaxis subsequent to oropharyngeal anaesthesia, the patient underwent a Cardiac Computed Tomography (CT) that showed a moderate peri-device leak (4.4x11mm, 0.73cm2) – (Image 1B). For better characterization, the patient underwent a new attempt of TEE with the support of an anaesthesiologist and the need of local vasoconstrictor agents and tranexamic acid for epistaxis and oropharyngeal bleeding control. TEE confirmed a moderate posterior device-leak (7.1mm) with absence of cavitary thrombus (Image 1C). After a year of anticoagulation with new significant bleeding events, TEE was repeated with the anaesthetic and pharmacologic preparation. This TEE showed a decrease in peri-device leak (<5mm wide – Image 1D), which was fundamental for supporting the multidisciplinary team decision of interruption of anticoagulation therapy. With this case we want to highlight the challenging decisions regarding patients with ROW syndrome and atrial fibrillation. Specifically, we must be alert about possible complications in trying to perform TEE in this population, once the frequent occurrence of telangiectasias in the oropharynges that may occur, as in this patient.

Abstract P182 Figure. Image 1
P186 In search of lost time
Authors: Ureche C , Ailoaei Ș , Tapoi L , Clement A , Boca S , Cazacu A , Grecu M , Sascau R , Statescu C
Published: January 2020

Arrhythmogenic right ventricular dysplasia (ARVD) is one of the most difficult to diagnose and manage of the cardiomyopathies. Physical exercise can be a contributing factor and may accelerate the progression of the disease.

We present the case of a 49-year-old, a former professional football player, with a history of cardiac arrest in 2011 by ventricular tachycardia (VT) (normal coronary arteries). Between 2011 and 2019 the patient didn"t present for reevaluation and resumed endurance sports activity in spite of doctor recommendation. In 2019 he was directed to our clinic for a syncope followed by constrictive anterior chest pain and palpitations, the clinical expression of a VT with LBBB morphology and inferior axis, most likely originated in the RVOT, for which cardioversion was required. Upon admission, the patient was hemodynamically and respiratory stable, at sinus rhythm 60/min with left anterior hemiblock and negative T waves in V1-V2. Biologically, myocardial and hepatic cytolysis enzymes were within normal limits, with mild hypokalemia. Echocardiography showed significant dilatation of RV and RVOT with RV dysfunction (TAPSE 16 mm, FAC 20%, s" 8.6 cm/s). LV was nondilated, with normal systolic function and kinetic, but with trabeculation of the apex. To confirm the diagnosis of ARVD, cardiac MRI was performed and confirmed fat infiltration in the RV free wall with biventricular involvement. Given the high arrhythmic risk (two resuscitated VT episodes, syncope), a two-chamber ICD was implanted, without immediate post-procedural complications.

In the second postprocedural day, the patient suddenly installed important epigastric pain with thoracic irradiation. The ECG showed sensing and pacing malfunction and radioscopy showed evidence of ventricular probe displacement. The echocardiography confirmed the myocardial perforation. Emergency surgery by median thoracotomy was performed, with successful extraction of the electrode and myocardial suture. Postoperative progression was favorable under treatment with beta-blocker and amiodarone. A subcutaneous ICD will be implanted as soon as available.

In conclusion, this case is a very particular one. First of all, we’ve documented two distinct phases in the evolution of the ARVD (electrical phase – 2011 and structural phase - 2019). Moreover, by resuming endurance sports activity and in concordance with the literature data, we can only assume that the progression of the disease was accelerated and the arrhythmic risk was greater. Complications related to probe stability are common in this population, but myocardial perforation is a very rare and dangerous one. The therapeutic management of patients with ARVD has evolved over the years and continues to be an important challenge. To further improve risk stratification and treatment of patients, more information is needed on the natural history, long-term prognosis, and risk assessment.

Abstract P186 Figure. Echocardiografic and MRI aspect
P187 Multimodality in tuberculous constrictive pericarditis
Authors: Leite De Barros Filho A , Moreira H T , Santos M K , Schmidt A , Santana R C , Rodrigues A J , Maciel B C , Marin-Neto J A , Romano M M D
Published: January 2020

CASE PRESENTATION

K.C.P., a 26 y.o. female, presenting dizziness and progressive dyspnea since 9 months ago. Physical examination showed hepatomegaly at 2 centimeters below the right inferior costal border, but without edema, cardiac murmurs or other findings. Electrocardiogram showed atria overload and diffuse ventricular repolarization abnormality. Chest X-ray revealed normal sized cardiac silhouette but with signs of pericardial calcification. Transthoracic echocardiogram revealed: enlargement of both atria, no signs of myocardial left ventricular (LV) hypertrophy; dilated inferior vena cava with minimal respiratory variation; septal bounce; septal e´= 17.20 cm/s, lateral e´= 6.09 cm/s; E/e" septal ratio = 3.9; E deceleration time = 144 ms; thickening and hyper-refringence of the pericardium with calcification adjacent to the lateral and inferior walls of the LV and the free wall of the right ventricle. For evaluation of thickness and extent of pericardial involvement, computed tomography (CT) was performed, showing gross calcifications of the pericardium, mainly in basal and lower portions, without pericardial effusion. Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement revealed areas suggestive of active inflammation adjacent to the basal wall of the LV. With this evidence of active inflammatory activity, the patient was treated empirically against the etiologic agent for tuberculosis. Because of progressively severe edema and dyspnea pericardiectomy was warranted providing relief of symptoms. DISCUSSION: The echocardiogram is the initial image exam for diagnosis and monitoring of pericardial conditions. It is a widely available, low-cost method that does not use ionizing radiation and allows a complete morphological and functional evaluation of the heart. However, in up to 20% of cases, pericardial thickening may not be detectable at echocardiography. CT allows a more accurate assessment of pericardial thickening, while CMR allows detection of active inflammatory process. CONCLUSION: A typical and illustrative clinical case of constrictive pericarditis is presented, where the multimodality of cardiac imaging was decisive for the diagnostic and therapeutic delineation.
P188 Coronary fistula
Authors: Kangelidis I , Spiromitros G
Published: January 2020

Background

A coronary arterial fistula is a connection between one or more of the coronary arteries and a cardiac chamber or great vessel. Most of these fistulas are congenital in origin and remain asymptomatic until the second or third decade of life. After this period, patients may present with symptoms of easy fatigue, myocardial infarction, atrial arrhythmias or heart failure. Also, coronary steal syndrome could be observed, leading to myocardial ischemia of the cardiac wall which is supplied with blood by the corresponding artery.

Case

We present a 50-year-old female who was submitted to ED with palpitations. From her medical history, she suffered from arterial hypertension and dyslipidemia. The clinical evaluation revealed a continuous murmur that could be heard mainly at Aortic Valve point. The only abnormal finding from blood exam was troponin: 288 pg/ml. Admission ECG was consistent with supraventricular tachycardia and the patient was treated with intravenous solution of adenosine. Bedside echocardiography revealed an abnormal flow coming out from the aortic root, next to the right coronary casp. Transesophageal echocardiography confirmed the previous findings. The main differential diagnosis includes patent ductus arteriosus, ruptured sinus of Valsalva aneurysm, aortopulmonary window and coronary arterial fistula although other congenital arteriovenous shunts need to be excluded. For further evaluation, the patient underwent cardiac MRI which revealed right atrial enlargement and dilatation of proximal right coronary artery, from which a dilated arterial branch originates and passes between the aortic root and the right atrium. All these could be attributed to the presence of an arterial fistula. Thus, the patient went on to have CT coronary angiography which confirmed the hypothesis. In particular, CT angiography depicted a fistula between the right coronary sinus and the posterior wall of right atrium.

Conclusion

This case highlights the use of CT coronary as robust tool for investigating the origin, course and drainage site of a coronary arterial fistula.

Abstract P188 Figure. FISTULA
P193 Echocardiographic prognosis score and stratification of the risk of major cardiovascular events after acute coronary syndrome
Authors: Menzou F , Laraba N , Ait Ali M , Krim M
Published: January 2020

Introduction

The stratification of the risk of a major cardiovascular event after an acute coronary syndrome by doppler echocardiography provides prognostic support to the different clinical models and allows a non-invasive evaluation of the risk, independent of comorbidities. The echo-score provides a better definition of the categories of high-risk and intermediate patients for whom a more aggressive approach improves outcomes.

Purpose

The aim of our study is to identify the echocardiographic parameters predictive of major cardiovascular events in the acute phase and after six months of follow-up of an acute coronary syndrome

Methods

To identify the echocardiographic parameters associated with major cardiovascular event, we recruited 302 patients in intensive care unit of cardiology for acute coronary syndrome consecutively on admission. Patients were assessed by clinical risk scores (GRACE, TIMI, CRUSADE) and resting echocardiography,

Results

We have 181 patients with major cardiovascular event. After studying the survival curves, univariate and multivariate analysis, acute coronary events echoscore (HR 1,95 ; p < 0,0001), has four echocardiographic variables (VG-Simpson - biplane ejection fraction, VD-surface - Simpson shortening fraction, M-strain longitudinal total deformation and pulmonary ultrasonic comet). Its discrimination capacity (AUC= 0,85) greater than that of the scores clinical prognosis, (GRACE; AUC = 0,72, TIMI; AUC = 0,71, HR 1,33; p < 0,0001) and (CRUSADE; AUC = 0,76; HR 1,03; p = 0,005)

Conclusion

The developed echocardiographic model could prove very useful in the decision-making process and optimization of the therapeutic strategy in some high-risk patients with acute coronary syndromes following an invasive strategy. It is appropriate for expert interpretation, yet relatively simple because it contains only four echocardiographic variables as predictors, (score 4 points for low risk with a probability of major cardiovascular event 3.4%, up to 16 points for risk high with a probability of 15.1%)
P198 Long-term outcomes after mitraclip implantation
Authors: Dias Ferreira Reis J P , Moura Branco L , Almeida Morais L , Ilhao Moreira R , Rio P , Galrinho A , Fiarresga A , Cacela D , Ferreira R
Published: January 2020

Background

Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies.

Purpose

To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population.

Methods

prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF < 20%, LV end-diastolic diameter > 70mm or pulmonary artery systolic pressure > 70mmHg; Everest: LVEF < 25% or LV end-systolic diameter (LVESD)>55mm; MITRA-FR: LVEF < 15% or >40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p < 0.05 were considered significant.

Results

40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD > 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006).

Conclusion

There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD > 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results

Abstract P198 Figure. Kaplan-Meier Plots
P209 Mitraclip - experience of a portuguese tertiary care center - mid-term review of results
Authors: Dias Ferreira Reis J P , Moura Branco L , Almeida Morais L , Ilhao Moreira R , Rio P , Galrinho A , Fiarresga A , Cacela D , Ferreira R
Published: January 2020

Background

Mitral regurgitation (MR) is a marker of bad prognosis in heart failure (HF) patients (pts). Mitraclip implantation (MI) leads to a clinical improvement.

Purpose

To characterize the adult population submitted to MI and evaluate its mid-term results.

Methods

Prospective analysis of 40 pts with moderate to severe MR (grades III-IV) submitted to MI between 2013 and 2018. Paired sample t-test to assess the procedure’s effect on several variables. P-values < 0.05 were considered significant.

Results

40pts, 60% male, with a mean age of 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months (M), of which 67.5% presented with grade IV MR (mean regurgitant volume - 43.5 ± 29 ml; mean EROA - 34.8 ± 13 mm2 ) and 75% with functional MR. Mean LVEF of 35%±10.3, with 55% presenting a LVEF < 35%. Mean Euroscore II of 6.0 ± 7. 27.5% had already undergone a previous cardiac surgery, in most cases CABG (63.6%). 30% had already suffered an acute coronary syndrome and 62.5% had atrial fibrillation. Mean pre-procedural peak VO2 of 14.5mL/kg/min and mean distance in the 6 minute walk test (6MWT) of 321 ± 100m. The device implantation was successful in 39 pts with a device success rate of 85% (successful implantation and reduction in MR to grade 2 or less), with 55% of pts presenting mild MR before discharge. There were immediate complications related to the procedure in 17.5% of pts, with 4pts experiencing tendinous cord rupture and 2pts leaflet tear. There were no cases of pericardial tamponade or embolic complications. Follow-up mortality of 30% (12pts), 9 deaths (D) due to cardiovascular events. 9D in the first-year post-procedure (1D within the first M), with 1 pt referred to cardiac surgery due leaflet tear and 1pt to heart transplantation. Successful MIwas associated with an improvement in NYHA functional class (3.0vs2.0, p < 0.001) and in several echocardiographic variables in the first 6M following the procedure: left ventricular (LV) end diastolic volume: 194.5mLvs168.4mL, p = 0.012; LV end systolic volume: 132.6mLvs106.7mL, p = 0.008; systolic pulmonary artery pressure: 50.5mmHgvs40.8mmHg, p = 0.013. It was also associated with a significant improvement in both 6M peak VO2 (14.4vs15.5, p = 0.028) and 6MWT distance (321.3mvs374m, p < 0.001).

Conclusion

MI is a safe procedure with a low rate of periprocedural complications. It’s associated with a functional class improvement and a significant reverse left ventricular remodeling.
P210 The influence of the right ventricle on the right atrium: a speckle tracking echocardiography study
Authors: Zehnpfennig M , Braun C , Kupczynska K , Kasprzak J D , Michalski B , Wejner-Mik P , Wdowiak-Okrojek K , Szymczyk E , Lipiec P
Published: January 2020

Purpose

To investigate the relationship between right atrial deformation and the right ventricular size and function.

Methods

94 patients with various cardiovascular pathologies have been included in the study group. All patients underwent transthoracic echocardiography with subsequent off-line analysis using speckle tracking technique and measurement of numerous right atrial deformation parameters, including peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS), as well as established indices of right ventricular size and function, including right ventricular basal diameter in apical four-chamber view (RVITd), tricuspid annular peak systolic excursion (TAPSE) and global longitudinal strain (GLS).

Results

There was a statistically significant weak correlation between RA strain (PACS and PALS) and RV parameters. RV-GLS showed significant correlation with PALS (r = -0,38; p = 0,0015) and PACS (r = - 0,30; p = 0,013). Similarly, TAPSE correlated with PALS and PACS (r = 0,34; p = 0,02) and (r = 0,23; p = 0,04) respectively. However, there was no correlation between right atrial function and RVIT.

Conclusions

Right atrial deformation parameters weakly correlate with right ventricular function indices and show no correlation with the size of the right ventricle.
P215 Effects of ARNI therapy on left atrial and ventricular longitudinal deformation and functional capacity in HFrEF patients
Authors: Mandoli G E , Spera L , Giannoni A , Cassano F , Incampo E , Borrelli C , Sciarrone P , Taddei C , Emdin M , Mondillo S , Cameli M
Published: January 2020

Background

valsartan and sacubitril combination (angiotensin receptor-neprilysin inhibitor, ARNI) was superior, in randomized trials, to lone ACE inhibitors in terms of reduction of cardiovascular mortality rate and hospitalization for acute heart (HF) in patients with HF with reduced ejection fraction (HFrEF). Purpose: the main goal of our study was to assess the effects of ARNI on left atrial (LA) and left (LV) and right ventricular (RV) function, evaluated by standard and speckle tracking echocardiography (STE), and on patients’ functional capacity by cardiopulmonary exercise testing (CPET), in patients with HFrEF. Methods: we prospectively enrolled 16 patients with a LV EF ≤35% and >18 years old, in two different centers with high expertise in HF management. Exclusion criteria included: symptomatic hypotension, stage IV renal failure (eGFR < 30 ml/min/1.73 m2), ACE-inhibitor (ACEi) intolerance or previous angioedema, poor acoustic window, refuse to participate to the study. At enrollment (T0), all patients were in therapy with ACEi or sartans (ARBs) and underwent physical examination, ECG, blood test (including NT-proBNP), standard echo, STE and CPET. We shifted therapy from ACEi/ARBs according to HF guidelines and we repeated all tests after 6 months. Results: population had an average age of 63 ± 9 years, 94% was males. Etiology was ischemic in one third of the subjects. At 6 months follow up, NT-proBNP was significantly lower (512.2 ± 518.5 vs 431.2 ± 330.1 ng/l, p 0,001) together with reduced LV filling pressure evaluated by E/A ratio and E/e’ ratio (11.2 ± 8.6 vs 8.8 ± 4.8, p 0.01). LV EF improved from 31.7 ± 3.4% to 36.2 ± 7.2% (p 0.01) and LV dimensions decreased. LV global longitudinal strain (GLS) did not change significantly while free wall RV GLS increased from – 20.4 ± 6.3% to – 24.6 ± 9%, p 0.001, as peak atrial longitudinal strain (PALS) did (16.1 ± 2.6% vs 27.6 ± 4.1%, p 0.001). Between CPET indexes, only VE/VCO2 slope improved but only with borderline statistical significance (32.7 ± 5.3 vs 29.7 ± 6.8, p 0.05, Fig. 1). Conclusions: this preliminary study evaluated for the first time the effects of ARNI on echocardiographic and CPET parameters at the same time. Our results could explain the favorable clinical benefits of ARNI therapy in HFrEF: improved biventricular function, lower LV filling pressure and a more efficient ventilatory response during effort.

Abstract P215 Figure. Fig.1
P231 Cardiac metastasis mimicking a myocardial infarction
Authors: Chiampan A , Lanzoni L , Lanzoni L , Adamo E , Adamo E , Dugo C , Dugo C , Bonapace S , Bonapace S , Castagna F , Castagna F , Barbieri E , Barbieri E
Published: January 2020

We present the case of a 79 years old male patient affected by a lung squamous cell carcinoma (T4 N0 M1a) diagnosed in december 2018 with a 5x5 cm mass in the inferior lobe of the left lung close to the pericardium and a second 5 cm mass in the apical lobe of the right lung. TT echocardiography at that time was normal. Treatment with gemcitabine was scheduled with slight progression of the disease at the CT scan control in april 2019 when initial invasion of the left inferior pulmonary vein was detected. An ECG performed during routine control revealed the presence of q waves and ST segment elevation in the inferior leads. The patient was asymptomatic about the heart but the blood tests revealed a slight increase of HS Troponin I. We decided to repeat the TT echo, which showed the presence of a rounded mobile mass of about 3x2.5 cm in the left atrium close to the upper left pulmonary vein and another formation of about 5x2 cm infiltrating the inferior wall of the left ventricle that appeared akynetic. Both metastatic and thrombotic origins were debated and anticoagulant therapy with LMWH was started. We chose to perform a TE echocardiography, which confirmed the presence of the rounded mass in the left atrium, enlarged as compared to the TT evaluation. At the 3D reconstruction, it appeared to come from the left inferior pulmonary vein, completely occluding it, and expanding to the left superior vein, narrowing but not closing its orifice. The mass was well delimitated, disomogenous and vacuolated, thus confirming its likely neoplastic origin. From the trans-gastric view, we confirmed the large infiltration of the inferior wall of the left ventricle. General conditions of the patients quickly deteriorated and he experienced an ischemic stroke. At the TT echo re-evaluation the mass in the left atrium was greatly reduced as compared to the previous control. Cardiac metastases are a rare and frequently clinically silent occurrence; However, in a minority of cases they may present with ECG alterations such as ST-T segment modifications. In neoplastic patients an ischaemic ECG pattern not following its typical progression, without typical symptoms of ischaemia should rise the suspicion of a cardiac metastasis. In our case the abnormalities could be caused by a loss of viable myocardium secondary to the infiltrating mass or by a compression of the right coronary artery. In this context the echocardiography, both TT and especially TE, is a valuable tool that allow to recognize the real cause of these abnormalities and provides useful informations that enable to distinguish neoplastic mass from a thrombus. The ischaemic stroke was probably due to an embolization of the mass from the left atrium, as confirmed by its important reduction at the last echo control.

Abstract P231 Figure. ECG abnormalities and TE echo alteration
P233 A new onset pulmonary artery stenosis in a young man
Authors: Scheggi V , Mazzoni C
Published: January 2020

Background

Poorly differentiated and undifferentiated sarcomas are the most common primary tumors of the pulmonary arteries. They usually affect large caliber vessels and present with predominantly intraluminal growth. Dyspnea, cough, chest pain, and hemoptysis are the most common presenting symptoms; patients may have signs of chronic pulmonary hypertension. Clinical and imaging manifestations can mimic pulmonary embolism.

The overall prognosis is poor

combined therapy with surgical resection and chemo-radiotherapy offers the best survival rates.

Case presentation

A 31-year-old male was referred to our department because of recent onset dyspnea, a pre-syncopal episode and a new heart murmur.

He had normal spirometry results but a significant desaturation during the 6MWT. A thoracic CT scan showed an incremented diameter of the pulmonary artery.The echocardiogram showed the presence of a mass with irregular borders attached to the pulmonary trunk almost obliterating its lumen. The mass determined a flow acceleration with maximal velocity of 3.8 m/sec, and a peak gradient of 60mmHg; Doppler findings on the pulmonary valve and right heart function were within normal values. Compression ultrasonography ruled out the presence of deep vein thrombosis.

The lesion showed a dishomogeneous impregnation in the contrastographic phase at cardiac MRI and had an intense glucidic metabolism at a PET-CT scan. These findings were highly suggestive of an angiosarcoma of the pulmonary artery. Biopsy specimens were taken through bronchoscopy.

The patient then decided to continue treatment in another hospital, where the histologic samples were sent; the cytologic results showed atypical cellular elements. The patient died a few months later.

Discussion

The presence of a unique mass in the main pulmonary artery or proximal branches and rapidly progressive dyspnea in a patient at low risk of pulmonary embolism should raise the suspicion of primary sarcoma of the pulmonary artery, which is a rare but aggressive tumor with a very poor prognosis.

Abstract P233 Figure.
P1581 The global myocardial work index is a powerful predictor of major arrhythmic events in patients with organic heart disease and reduced left ventricular ejection fraction
Authors: Previtero M , Sammarco G , Genovese D , Azzolina D , Tenaglia R M , Ruozi N , Palermo C , Iliceto S , Muraru D , Badano L P
Published: January 2020

Background

Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection.

Purpose

We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF.

Material and Methods

we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF <50%, in whom we re-measured LVEF using 3DE, and obtained MD and GWI using 2DE speckle tracking. Major arrhythmic events were defined as sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation and appropriate ICD shocks. We assessed the predictive power of 4 different parameters: 2DE LVEF< 35%; 3DE LVEF< 35%; MD > 80 ms; and GWI< 672 mmHg% to identify patients at risk of major arrhythmic events.

Results

During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF< 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF< 35%, and 0.77 (95%CI 0.68-0.86) for GWI < 672 mm Hg%. Whereas, MD > 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)).

Conclusions

GWI< 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF < 50%.
P1586 Lung ultrasound and left atrial deformation analysis: a promising methods for the diagnosis of heart failure with preserved ejection fraction
Authors: Agoston G , Gargani L , Szabo I , Illes B , Varga A
Published: January 2020

Background

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

Aim

To evaluate the relationship between LUS, left atrial strain and NT-proBNP level in patients with HFpEF. Also to assess the diagnostic power of B-lines in HFpEF population.

Methods

Forty-seven consecutive patients (24 women, mean age 69 ± 11 years) with clinical signs of heart failure were prospectively enrolled. Exclusion criteria were: ejection fraction <55%, more than mild mitral and/or aortic valve disease, pulmonary disease, pulmonary arterial hypertension. Within one hour all patients underwent comprehensive echocardiographic evaluation including left atrial strain analysis (peak atrial longitudinal strain-PALS), lung ultrasound assessment of B-lines on the antero-lateral and posterior chest wall, and NT-proBNP levels.

Results

In 34 patients (72%) a significant number of B-lines (≥15) were observed. We found a positive correlation between the number of B-lines and NT-proBNP levels (p < 0,0001, r = 0,74, Figure 1.), left atrial volume (p < 0,05, r = 0,45), and PALS (p < 0,02, r = 0,4 ). We didn’t found any correlation between the number of B-lines and E/e’ ratio (p = 0,1, r = 0,28), or between E/e’ ratio and NT-proBNP level (p = 0,1, r = 0,2). We also assessed the diagnostic ability of ≥15 B-lines to predict markedly elevated pro-BNP level (≥ 220pg/ml), AUC was 0.89. If the total number of B-lines was greater or equal to 28, the sensitivity was 68% with the specificity of 100%, but if we changed the cut-off value to 12, the sensitivity grew to 89% with the specificity of 71%. (Figure 2.).

Conclusion

LUS is a simple, feasible tool to detect pulmonary congestion in HFpEF and it has a strong diagnostic power to predict elevated NTpro-BNP level. B-lines correlate with parameters of left atrial dysfunction. PALS is promising too, which better reflects pulmonary congestion and elevated NT-proBNP values than the conventional echocardiographic parameter E/e’.

Abstract P1586 Figure. NT-pBNP vs B-lines, AUC of Blines