bluuebunny/crossref_metadata_2025 huggingface dataset:
P201 Cost-effectiveness analysis of 3D versus 2D transesophageal echocardiography for the evaluation of patients with primary mitral regurgitation with indication of surgical treatment
Authors: Miglioranza M , Le Bihan D , De Resende M V C , Oliveira Jr W P , Nunes C G O , Lucchetta R C , Dos Santos W M , Holanda P , Rosim M P , Okumura L , Nita M E , Riveros B , Pedro G O , Vieira M
Published: January 2020

Funding Acknowledgements

Department of Cardiovascular Imaging / Brazilian Society of Cardiology

OBJECTIVES

To perform the cost-effectiveness analysis of three-dimensional transesophageal echocardiography (3DTEE) in comparison to two-dimensional transesophageal echocardiography (2DTEE) for the anatomic-functional evaluation and surgical planning of severe primary mitral regurgitation. METHODS: a complete economic study was based on a systematic review of 3DTEE and 2DTEE accuracy and private health system costs of two different surgical interventions: mitral valve plasty and mitral valve replacement. The prevalence of common postoperative complications was also predicted for elective procedures: atrial fibrillation (8.6%); acute myocardial infarction (1.4%); thrombosis (3.5%); bleeding (1.5%); endocarditis (6.3%). The decision tree method was adopted as a data analysis model. The Bayes" theorem was used based on sensitivity and specificity measurements. The costs, considering literature and professional tables, were: 3DTEE = US$ 349; 2DTEE = US$ 204; diagnostic evaluation = US$ 597; surgical procedure = US$ 3,643; surgical treatment = US$ 374. RESULTS: The deterministic analysis of the diagnostic test shows that 3DTEE (non-dominated) is superior to 2DTEE (absolutely dominated). The 3DTEE presents a cost reduction of US$ 1,147 and incremental effectiveness (true identification) of 22% when compared to 2DTEE. The multivariate probabilistic sensitivity analysis showed that after 100,000 iterations, the diagnosis based on the 3DTEE becomes the first choice regardless of the willingness to pay threshold. CONCLUSIONS: 3DTEE was cost-effective compared to 2DTEE. Thus, 3DTEE is a potential device to promote health compared to 2DTEE for surgical planning of severe primary mitral regurgitation

Abstract P201 Figure. Sensitivity Analysis
P203 Prognostic value of deformation parameters in stemi patients with preserved left ventricular ejection fraction
Authors: Oleinikov V , Galimskaya V , Kupriyanova S , Golubeva A
Published: January 2020

Purpose

to assess the ability of global deformation parameters, determined using the speckle tracking method, to predict the possible development of heart failure and pathological left ventricular (LV) remodeling 6 months after revascularization.

Methods

the study included 149 people with primary STEMI: 16 women and 133 males between the ages of 32 and 67 years (51.3 ± 8.5). Myocardial infarction was confirmed by ECG, a clinically significant level of cardiospecific markers (troponin T, CPK-MB) and according to the results of coronary angiography with the presence of a single infarction-related coronary artery without significant stenoses of other arteries. Echocardiography was performed with an ultrasound scanner at the 7-9 days and 6 months after the disease onset. A quantitative analysis of contractility was performed using global longitudinal and circumferential strain indicators (GLS and GCS) using a software. Longitudinal strain indices were obtained from frame-by-frame recording of speckle displacement with a frequency of at least 60 per second from apical 4, 2, and 5-chamber positions in each LV segment. The values of circumferential strain were obtained in parasternal positions at the level of the mitral valve and papillary muscles, respectively. LVEF was calculated by the Simpson biplane method from two-dimensional apical 4- and 2-chamber images. Analysis of the pathological remodeling development was carried out using ROC - analysis using three criteria. To assess the quality of the model, the area under the curve (AUC) was determined with the calculation of 95% confidence intervals and the statistical significance of the point estimate of the area.

Results

among those included in the study, 132 people (88.5%) in the early period of PCI had the EF more than 40% or corresponded to the normal level. After 6 months of follow-up among these patients in 8 (6%) cases the EF was below the critical value (40%). The AUC for GLS based on a criterion for EF <40% after 6 months from the myocardial infarction onset was 0.759 [95%, CI 0.647; 0.870], (p = 0.01); the cut-off point was 13.4%, sensitivity and specificity - 83.1% and 66.7%. For GSC, the AUC was 0.715 [95%, CI 0.602; 0.827], (p = 0.01); cut-off point - 13.4%, sensitivity - 84%, specificity - 67%, respectively.

Conclusions

GLS and GCS parameters, recorded by speckle tracking method with high sensitivity and specificity, make it possible to predict the development of systolic heart failure after 6 months of follow-up in STEMI patients with preserved LVEF.
P205 Maternal left ventricular global longitudinal strain correlates with parameters of fetal intrauterine growth and uteroplacental hemodynamics
Authors: Palermo C , Muraru D , Badano L , Balducci E , Carli S , Aruta P , De Virgilio A , Pinto F , Cosmi E , Visentin S
Published: January 2020

Impairment of physiological mechanisms responsible for maternal cardiovascular adaptation during pregnancy may be associated to intrauterine growth restriction (IUGR).

Purpose

To compare maternal cardiac parameters between pregnancies with IUGR and with fetal growth appropriate for gestational age (AGA).

Methods

Twenty-one IUGR (median age 31 years) were compared with 18 AGA matched for age, body size and gestational age (p > 0.35 for all). LV volumes and ejection fraction (LVEF) were measured by 3D echocardiography, and LV mass (LVM) and outflow velocity time integral (VTI) by conventional echocardiography. LV longitudinal strain (GLS) was assessed by speckle-tracking.

Results

Compared to AGA, IUGR mothers had similar LV volumes and LVEF, but larger LV mass (76 vs 63 g/m2, p = 0.006), LV mass/volume (1.14 vs 1.0 g/ml, p = 0.036) and lower VTI (19.9 vs 21.5 cm, p = 0.046) and GLS (-20 vs -22%, p = 0.032). Maternal LV GLS correlated with fetal growth and utero-placental hemodynamics (Table). At ROC curve analysis, maternal GLS had a good ability to discriminate IUGR from AGA (Figure).

Conclusions

IUGR had larger LV mass/volume and lower GLS than AGA. GLS was more sensitive than LVEF to detect LV function changes in IUGR. This is the first study reporting that worse maternal LV GLS correlates with fetal growth restriction and suboptimal utero-placental hemodynamics.

Rho Spearman p APGAR score 0.36 0.03 Birthweight percentile 0.38 0.02 Biparietal diameter 0.47 0.003 Cranial circumference 0.31 0.07 Abdominal circumference 0.30 0.07 Umbilical vein velocity 0.64 0.003 Uterine artery mean pulsatility index -0.36 0.028 LV length 0.36 0.034 LV mid diameter 0.32 0.05 LV end-systolic volume 0.34 0.046 MAPSE 0.45 0.006 TAPSE 0.41 0.004 Mitral E wave 0.50 0.002 Mitral A wave 0.38 0.02 Correlation of maternal GLS (considered as positive) and fetal parameters.

Abstract P205 Figure. GLS ability to discriminate IUGR vs AGA
P212 Computed tomography derived left ventricular outflow tract area downgrades severity of prosthesis-patient mismatch after transcatheter aortic valve replacement
Authors: Fukui M , Tiang L , Lesser J , Niikura H , Nunes M , Burns M , Schneider L , Han K , Garcia S , Gossl M , Sorajja P , Cavalcante J
Published: January 2020

Background

Prosthesis-patient mismatch (PPM) is associated with poor outcomes after surgical aortic valve replacement, but evidence in the era of transcatheter aortic valve replacement (TAVR) is small. Although PPM is conventionally defined by transthoracic echocardiogram (TTE) derived indexed effective orifice area (EOAi), TTE may underestimate left ventricular outflow tract (LVOT) area when compared with cardiac computed tomography angiography (CTA).

Purpose

To evaluate the inter-modality (TTE vs CTA) agreement and inter-valve (balloon-expanding valve (BEV) vs. self-expandable valve (SEV)) differences in EOAi and the severity of PPM after TAVR.

Methods

We analyzed all patients who underwent TAVR between 2015 to 2017and who had both of CTA and TTE at 30-days after TAVR. EOAi was calculated using the continuity equation and then indexed to body surface area as per guidelines using TTE derived LVOT diameter (EOAi-TTE) or post-procedure CTA derived LVOT area (EOAi-CTA). The external LVOT diameter was measured at inflow of TAVR bioprosthetic stent frame as per recommendations. The EOAi was used to define the grading severity of PPM: None (> 0.85 cm²/m²); Moderate (0.65 to 0.85 cm²/m²); and Severe (< 0.65 cm²/m²). Paired or Student t-test and Chi-square test were used to assess the inter-modality and inter-valve difference.

Results

A total of 280 patients were included (the mean age, 81.2 ± 8.1 years; 48%, female). BEV was used in 150 patients (54%). The mean EOAi-TTE vs. EOAi-CTA was 1.00 ± 0.32 and 1.41 ± 0.50 cm²/m², respectively, p < 0.001. Prevalence of severe (TTE 9% versus CTA 4%, p < 0.01) and moderate (TTE 28% versus CTA 7%, p < 0.01) PPM was lower when adjudicated by CTA (Figure-Panel A). There was a trends towards smaller EOAi by either TTE (0.97 ± 0.31 vs. 1.04 ± 0.33, p = 0.07) or CTA (1.38 ± 0.45 vs. 1.46 ± 0.56, p = 0.21) for BEV vs. SEV (Figure-Panel B). There was no significant difference in the severity of PPM defined by either EOAi-TTE (Figure-Panel C) or EOAi-CTA (Figure-Panel D) between these patients.

Conclusion

EOAi-CTA was larger and downgraded the severity of PPM than the EOAi-TTE. There was no significant difference in the severity of PPM defined by post-procedure CT between patients treated with BEV and those with SEV.

Abstract P212 Figure.
P235 A happy ending for a dancing thrombus on the right atrium
Authors: Ferreira J , Freitas A , Gomes R , Faria D , Beringuilho M , Roque D , Morais C
Published: January 2020

A 62-year-old male, was admitted in the emergency department with chest discomfort and dyspnea for the last 2 days; he also referred pain on the right leg. He had been submitted to prostatic surgery 1 month before and since then he reduced is usual physical activity. At admission he was normotensive, with sinus tachycardia, with elevated D-Dimers and hypoxemia and hypocapnia on arterial blood gas analysis. Transthoracic echocardiogram (TTE) was performed and it showed dilation of right ventricle with diastolic left ventricular "D-shape" compatible with right ventricle pressure overload. Furthermore, it was visible a large and filiform thrombus on the right atrium, causing procidency into the right ventricle through the tricuspid valve during diastole (image top-left and top-right). Patient was hemodynamically stable at that time, and the case was promptly discussed with cardiothoracic surgery. The decision was to adopt a conservative strategy, and non-fractioned heparin (NFH) perfusion was initiated accordingly to local protocol.

Patient remained hemodynamically stable, and, after 24h of treatment with NFH echocardiographic re-evaluation showed disappearance of the thrombus previously seen of the right chambers (image bottom-left). Angio-TC scan of thorax performed at that time showed extensive bilateral pulmonary thromboembolism, but with normal perfusion of the pulmonary artery trunk and both right and left pulmonary arteries. After 48h of NFH the patient started oral anticoagulation. The rest of the admission was unremarkable apart from a respiratory tract infection successfully treated with piperacillin-tazobactam.

Pre-discharge TTE performed 12 days after admission showed no dilation of the right ventricle, with normal systolic function (image bottom-right), as well as no evidence of pulmonary arterial hypertension.

Discussion

Large right atrial thrombus in the setting of PTE is a clinical situation in which there is no consensus regarding clinical management. In most cases, management is dictated by haemodynamic status of the patient. In the setting of a hemodynamically stable patient, systemic anticoagulation can be an option. Surgery, fibrinolysis and percutaneous aspiration have also been advocated. Successful treatment of right heart thrombus with anticoagulation alone has been reported, but there are also reports of unsuccess with that strategy. This is a case of a successful treatment with anticoagulation alone and so, we currently consider that the choice of treatment strategy based on hemodynamic status continues to be the wisest strategy to adopt.

Abstract P235 Figure. Thrombus before and after
P1587 Echochardiographic estimation of the impact of long-term treatment with Trimetazidine on myocardial dysfunction in patients with ST elevation myocardial infarction
Authors: Svanidze T , Saralidze T , Mamatsashvili I , Bediashvili T
Published: January 2020

Outcome of ST elevation acute myocardial infarction (STEMI) is usually complicatedby congestive heart failure (HF) that impacts quality of life and prognosis.

Spectrum of myocardial injury depends on intensity of impaired myocardial perfusion and on existing metabolic state. Metabolic changes occurring during early hours of myocardial infarction include increased secretion of catecholamines and production of circulating free fatty acids (FFAs). As myocardium depends on aerobic metabolism increased FFAs exert toxic effect on myocardium resulting in metabolic mismatch, decreased cardiac function and arrhythmias.

Our aim was to diminish signs of HF after STEMI especially in patients (P)who could not undergo reperfusion therapy because of different reasons.We used long-term metabolic therapy (MT) with TrimetazidineMR(TMZ)just from the first day of STEMI during 3 months.

Evaluation of heart function was based on ECG, Holter monitoring and echocardiographic (Echo) data received before and after treatment. We observed 50 P with STEMI who could not undergo reperfusion therapy. All were treated with standard therapy according to guideline. 35 of them (I group) additionally were treated with TMZ 80 mg p/o once a day for 3 months. The rest15 patients represented II - control group. P including in these groups were comparable according to echocardiographic data. These Patients did not reveal any life-threatening arrhythmias in the acute stage of MI and any prognostically indifferent arrhythmias in the following period.

Echoinvestigation in dynamic (before treatment and after 3 months) showed significant improvement of ejection fraction (EF by 14,2%) and stroke volume (SVby14,8%) in patients with STEMI treated with TMZwhile in control group EF (by 4,5%) and SV (by 6,8%) wereincreasedslightly. After 3 months improvement of diastolic function was also prominent in patients treated with TMZ that was revealed by decreased diastolic volume. In patients treated with MT end diastolic diameter (EDD) diminished by 4,8%, end systolic diameter (ESD) - by 5,7%, end diastolic volume (EDV) - by 9,3% and end systolic volume (ESV) - by 14,9% while in control group EDD was decreased by 1,9%, ESD - by 2,8%, EDV - by 4,7% and ESV - by 4,1%. Diastolic dysfunction was also estimatedaccording to left ventricular filling pressure (LVFP) E/ethat was especially interesting in P with HF with mid-range and preserved EF. Before treatment (LVFP) was increased in 17 P from the first group and in 7 P in control group. In the first group increased LVFP significantly decreased in 12 P and moderately in 5, while in control group LVFPwas only decreased moderately in 4and slightly in 3 P.

The received data make it relevant to useTMZmetabolic therapy for effective treatment of HF in patients with STEMI. MT not only improves the course of disease, but diminishes rehabilitation period as well.
P1588 micro rna expression profiling may predict cardiac remodeling after stemi
Authors: Ikonomidis I , Vlastos D , Katsanos S , Gazouli M , Thymis J , Triantafyllou C , Varoudi M , Andreadou I , Triantafyllidi H , Makavos G , Kapelouzou A , Vrettou A R , Frogoudaki A , Cokkinos D , Iliodromitis E K
Published: January 2020

Background

MicroRNAs have been recognised as important modulators of cardiovascular function. However, their proﬁling in ischemic heart disease and contribution to cardiac remodeling has not been deﬁned.

Methods

We examined 40 patients with STEMI and 20 healthy controls. MicroRNA expression proﬁling was carried out within 48 hours of the index ischemic event, measuring the expression of microRNA-144,-150,-499 (cardioprotective action), -21, and -208 (remodeling stimuli). In addition, every patient was evaluated by echocardiography, which was repeated after a 2-year follow-up period.

Results

Left-ventricular end-systolic volume (LVESV) and left-ventricular end-diastolic volume (LVEDV) decreased (from 57.7± 6.3 to 48.6± 5.2, p < 0.05 and from 102.1± 7.1 to 85.9 ± 5.7, p < 0.05, respectively) while the ratio of early mitral inﬂow velocity to mitral annular early diastolic velocity (E/e’) did not change (from 9.32± 0.6 to 9.56± 0.8, p= NS). Mir-208 and -499 expression within 48 hours of STEMI (1.91± 0.43/U6sn and 1.7± 0.48/U6sn respectively) were signiﬁcantly positively correlated with a reduction in LVESV, LVEDV, and E/e’. In speciﬁc, mir-208 expression was associated with an absolute (r= -0.41, p < 0.05) and a percent reduction (r=-0.45, p= 0.03) in LVEDV and an absolute reduction in E/E’ (r= 0.46, p < 0.05), while mir-499 was associated with an absolute (r= -0.4, p < 0.05) and percent reduction (p= -0.38, p < 0.05) in LVESV. Mir-499 median value (1.78[1.292.01]) predicted reverse remodelling (LVESV reduction by >15%) with satisfactory speciﬁcity (0.82).

Conclusion

Mir- 208 and -499 expression may contribute to cardiac remodeling after STEMI, while mir-499 could be used as a prognostic marker of reverse remodeling.
P1597 15-year follow-up of regional right and left ventricular function after the Senning operation: a colour-Doppler myocardial imaging study
Authors: Moya A , Roggen L , Troost E , De Meester P , Budts W , Van De Bruaene A
Published: January 2020

OnBehalf

Ana Moya, 1994

Introduction

Although the development of right ventricular (RV) dysfunction in patients who underwent an atrial switch procedure is a major concern, long-term follow-up data on the evolution of myocardial function over time, especially using deformation myocardial imaging, is still lacking.

Purpose

This study aimed (1) at evaluating regional (base-mid-apex) RV and left ventricular (LV) function using Colour-Doppler myocardial imaging over a 15-year follow-up period (longitudinal analysis) and (2) at comparing results with age- and gender-matched controls (cross-sectional analysis).

Methods

For the longitudinal analysis, we compared systolic and diastolic function between 2004 and 2019 in 10 Senning patients. For the cross-sectional analysis, we compared the subaortic RV (sRV) of Senning patients with the RV and LV of matched controls and the subpulmonary LV (spLV) of Senning patients with the LV of matched controls.

Results

The longitudinal analysis (2004-2019) of sRV function showed a significant decrease in peak systolic strain (-16.9 ± 7.1% vs -12.0 ± 4.0%; P = 0.045), peak systolic strain rate (-1.1 ± 0.3s-1 vs -0.8 ± 0.4s-1; P = 0.003) and peak early diastolic velocity (-2.0 ± 1.2 cm/s vs -1.0 ± 0.5 cm/s; P = 0.036) at the apex. spLV function showed a significant decrease in peak systolic velocity (mid: 5.6 ± 1.8 cm/s vs 3.7 ± 1.1 cm/s; P = 0.013 and apex: 5.0 ± 1.7 cm/s vs 2.1 ± 1.2 cm/s; P = 0.011) and peak systolic strain rate (mid: -1.7 ± 0.5s-1 vs -1.0 ± 0.4s-1; P = 0.048).

The cross-sectional analysis revealed significant lower values for peak systolic velocity, peak systolic strain rate, peak systolic strain at all myocardial regions of the sRV when compared to both LV and RV of matched controls (all P < 0.05). Similarly, early and late diastolic velocity were lower when compared to controls (P < 0.05). The spLV showed lower values for peak systolic velocity and peak systolic strain rate (mid and apex, P < 0.05), but not for peak systolic strain when compared to the LV of matched controls.

Conclusion

Our study shows little change in systolic and diastolic sRV function over a 15-year period, except in the apical region. Interestingly, there was a decline of spLV systolic function which may be of clinical value. On the other hand, when compared to age- and gender-matched controls, both the sRV and spLV of Senning patients exhibit significantly decreased measurements of longitudinal systolic and diastolic function.
P1600 Aortic dilatation in patients with chronic descending aorta dissection is related to maximum false-lumen systolic flow deceleration rate as evaluated by 4D-flow MRI
Authors: Ruiz Munoz A , Guala A , Teixido-Tura G , Dux-Santoy L , Sao-Aviles A , Lopez-Sainz A , Granato C , Servato L , Casas G , Gonzalez-Alujas T , La Mura L , Galian L , Ferreira I , Evangelista A , Rodriguez-Palomares J F
Published: January 2020

Background

Due to improved surgical strategies a growing number of patients survive acute aortic dissection. Patent false lumen (FL) is common in chronic dissection and it has been associated with poor prognosis, which is mainly driven by FL expansion. Several variables indirectly related to flow characteristics have been associated with progressive aortic dilation. We aimed to evaluate whether the maximum systolic flow deceleration rate (MSDR) in the FL, quantified by 4D-flow MR, is related to FL dilation in chronic type B aortic dissection.

Methods

Twenty-nine patients with a patent FL after aortic dissection and a prior follow-up of at least 3 years underwent contrast-enhanced 4D-flow MR. Marfan patients were excluded. Time-resolved FL flow acceleration was calculated in a 5 cm-long volume of the descending aorta around the level of the pulmonary bifurcation. MSDR was determined as the maximum minus the minimum acceleration in systole over the corresponding time interval (Figure 1a). Aortic growth rate (GR) was measured as the difference between final and initial maximum FL diameters obtained by angio-CT divided by follow-up duration. Population was divided into tertiles based on GR.

Results

Demographic and clinical variables were similar among GR tertiles (Table). MSDR was lower in patients with a GR <1mm/year (group 1) compared to both the other two patient groups (p = 0.009 and 0.003 for groups 2 and 3, respectively) (Figure 1c). MSDR showed a marked positive linear correlation with GR (R = 0.481, p = 0.008) (Figure 1b).

Conclusions

The MSDR in the FL of chronic type B aortic dissection is linearly related to FL growth rate and discriminated between tertiles of aortic dilation. Prospective longitudinal studies are need to unveil possible prognostic value of this parameter.

Table Group 1 (n = 9) Group 2 (n = 10) Group 3 (n = 10) p-value Age (years) 63.44 ±13.54 62.50 ± 13.60 64.56 ± 6.67 0.902 BSA (m2) 2.00 ± 0.18 1.77 ± 0.20 1.94 ± 0.12 0.213 Men 6 (86%) 4 (57%) 4 (100%) 0.210 Hypertension 4 (66%) 5 (71%) 4 (100%) 0.438 Atheroclerosis 1 (17%) 1 (14%) 0 (0%) 0.699 Initial Diameter (mm) 45.00 ± 7.69 36.00 ± 4.20 37.00 ± 6.48 0.078 Final Diameter (mm) 49.50 ± 6.74 44.86 ± 5.70 59.25 ± 9.84 0.049 Follow-up (year) 11.83 ± 8.79 7.82 ± 3.34 8.08 ± 4.05 0.921 GR (mm/year) 0.27 ± 0.29 1.18 ± 0.26 2.64 ± 0.97 <0.001 MSDR (cm/s3) 1212.18 ± 467.61 2410.54 ± 1034.30 2558.16 ± 1098.06 0.005

Abstract P1600 Figure 1
P1604 T1 mapping in asymptomatic patients with extracardiac sarcoidosis
Authors: Panovsky R , Doubkova M , Holecek T , Machal J , Feitova V , Masarova L , Opatril L , Kincl V
Published: January 2020

Funding Acknowledgements

LQ1605 from the National Program of Sustainability II (MEYS CR)

Introduction

Sarcoidosis is a systemic granulomatous disease affecting in particular the respiratory tract. Estimated 5% of these patients have clinical symptoms of heart involvement. Real number of patients with cardiac sarcoidosis is thought to be higher (around 20-30%), because the granulomatous process is sometimes asymptomatic. Cardiac magnetic resonance (CMR) including T1 relaxation time measurement could potentially detect early asymptomatic stadia of sarcoidosis of the heart.

Purpose

The aim of this study was to assess T1 mapping in detection of early cardiac involvement in asymptomatic patients with sarcoidosis.

Methods

One hundred twenty patients with sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis and without any heart disease history were included. One hundred thirteen of them underwent CMR examination at 3,0 MR scanner. Cine images for assessment of left ventricular (LV) volumetric and functional parameters, and pre- and post-contrast Saturation method using adaptive recovery times for cardiac T1 mapping (SMART1map) and Modified Look-Locker Inversion recovery (MOLLI) images were acquired for assessment of native T1 relaxation time and extracellular volume (ECV). The measured parameters were compared between sarcoidosis patients and 22 healthy controls.

Results

Sarcoidosis patients had not enlarged LV (end-diastolic volume 119 ± 24ml vs 97 ± 20ml, p = NS) and normal global and regional systolic LV function – LV ejection fraction (EF) 65 ± 5% vs 66 ± 7% (p = NS). Mean native T1 relaxation time was not prolonged - 1464 ± 93 msec vs 1482 ± 88msec (p = NS) measured by SMART1map and 1317 ± 60 msec vs 1313 ± 83msec (p = NS) measured using MOLLI sequence. Similarly, mean ECV value was not increased - 16,3 ± 3,4% vs 17,9 ± 3,7% (p = NS) measured by SMART1map and 30,9 ± 2,9msec vs 30,7 ± 5,0% (p = NS) measured using MOLLI sequence.

Conclusion

Myocardial native T1 relaxation time was not prolonged and ECV was not increased in asymptomatic patients with extracardiac sarcoidosis.
1633 Final non-invasive echo-guided assessment of left atrial pressure after percutaneous edge-to-edge procedure for mitral regurgitation
Authors: Gavazzoni M , Zuber M Z , Pozzoli A P , Taramasso M T , Maisano F M
Published: January 2020

Background/Introduction. Recently the central role of hemodynamic invasive monitoring during MitraClip (Abbott Vascular, Santa Clara, CA, USA) procedure has been raised. After removal of Steerable Guide Catheter (SGC) at the end of procedure, iatrogenic interatrial septum defect determines acute sub-clinical hemodynamic changes depending on right atrial (RA) and left atrial (LA) pressures. The possibility to assess LAP non-invasively by Doppler -echocardiography at the end of the procedure allows to quantify real hemodynamic impact of reduction of MR and leaves the door open to further therapeutic decisions (such as closure of iatrogenic IASd).

Purpose

This prospective study aimed to assess the role of evaluation of post-procedural mean trans-atrial gradient with continuous-wave (CW) Doppler (DPmean-IAS) in estimating final m-LAP after removal of SGC.

Methods

We prospectively performed the computation of trans-atrial CW- Doppler tracing for estimation of mean-transatrial gradient (meanGp-LA-RA) in patients treated with MitraClip; we added the estimation of central venous pressure (CVP) according to: i) dilatation of superior vena cava (IVC, mm); ii) presence or not of systolic excursion of IVC (end-inspiratory excursion was not evaluable in patients under sedation); iii) hepatic vein dilatation. The sum of CVP estimated and meanGp-LA-RA (mmHg) represents the m-LAP-Echo-measured at the end of procedure. This value has been compared with m-LAP measured invasively before removal of SGC. We tested the inter-rater reliability with the Intra-class Correlation Coefficient for comparing this method with the gold standard (invasive assessment of LAP).

Results

we included 19 patients; aetiology of MR was degenerative in 89% of cases. Basal m-LAP was 15 ± 13,3 mmHg and decreased by 32% by the end of procedure (mean-LAP at the end: 10,1 ± 3,3 mmHg, p < 0.001). At the end of the procedure mean Gp-LA-RA was 2.5 ± 1.2 mmHg and CVP 7.5 ± 3.5; the m-LAP-Echo-measured was 9.6 ± 2.4. The delay in time of computation of m-LAP by echocardiography with respect to last invasive assessment available was computed and settled around 5 minutes (IQR 3-9 min). The inter-rater reliability with the Intra-class Correlation Coefficient was high: 0.8, (CI95% 0.647-0.948, p < 0.01); with Bland-Altman test we could assess that bias of measures was acceptable for this clinical context with upper concordance limit of 2,7 mmHg and lower of 4,7 mmHg, with a bias of 0,9 mmHg, not relevant for this clinical purpose.

Conclusions

The present study represents the first validation of a Doppler-based method for non invasively assessing post-procedural LAP in percutaneous mitral valve interventions requiring transeptal approach. Follow up is needed for correlate this value with clinical outcomes.
1634 3D transoesofageal echocardiography in detection of anterior leaflet laceration during mitraclip implantation
Authors: Mariani M , Cerillo A G , Maffei S , Marchi F , Benedetti G , Zezza L , Cerone E , Paradossi U , Sorbo S , Pizzino F , Chiappino S , Trianni G , Al Jabri A , Ravani M , Berti S
Published: January 2020

Background

MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication.

Methods

An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated.

The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer.

Results

A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged.

Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence.

Conclusion

3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing.

Abstract 1634 Figure. Image 1
1636 Endomyocardial biopsy of right atrial mass with unfortunate consequence of right-to-left shunt
Authors: Kam K H K , Au D R , Lee PROF
Published: January 2020

Funding Acknowledgements

Nil

A 43-year old lady complained of dyspnoea with elevated jugular venous pressure. Transthoracic echocardiography (TTE) showed massive pericardial effusion [Figure 1A] with a huge heterogeneous mass (5x9cm) attached to right atrial free wall [Figure 1B]. Therapeutic pericardiocentesis yielded blood-stained pericardial fluid with negative for tumour cells.

Endomyocardial biopsy (EMB) was performed under transthoracic echocardiography (TTE) and fluoroscopy guidance. Right after procedure, there was a significant desaturation which could not be reversed by high flow oxygen supplement. The acute hypoxaemia was secondary to right-to-left shunt through a wide-open patent foramen ovale (PFO) as shown by transoesophageal echocardiography (TOE) [Figure 2A-D].

Transcatheter PFO closure was performed under TOE guidance with immediate correction of hypoxemia. [Figure 3]. Subsequent Computer Tomography demonstrated a large vascular mass at right atrium abutted onto the basal right ventricle and tricuspid valve [Figure 4] without evidence of tumor embolism.

The histological diagnosis confirmed it was a cardiac sarcoma. Given the infiltrative nature of cardiac sarcoma with significant right ventricular (RV) inflow obstruction, a debulking surgery was done rather than a complete curative resection. She was referred to oncologist for adjuvant chemotherapy.

We postulated that there is a shift in tumour location, i.e. more towards the tricuspid valve orifice which results in elevated right ventricular inflow obstruction which triggers the acute right-to-left shunting through PFO.

Abstract 1636 Figure. EMB
P240 Thebesian veins draining to the left ventricle mimicking left ventricular non-compaction
Authors: Durrer-Ariyakuddy K , De Boeck B W , Cuculi F , Kobza R , Staempfli S F
Published: January 2020

Description

We report about a 59-year old asymptomatic woman initially presented with lateral T-wave inversions in a routine ECG. Echocardiography suggested isolated left ventricular non-compaction (LVNC). An additional cardiac magnetic resonance imaging (cMRI) showed positive diagnostic criteria for LVNC. Six years later a diagnostic coronary angiogram revealed by a coincidence extensive shunting from the left coronary arteries to the left ventricle through Thebesian veins (sinusoids). Finally color Doppler flow confirmed that the irregular anatomy of the LV was not a result of incomplete LV compaction but due to the coronary anomaly.

Initial work up

A 59-year old asymptomatic woman presented with lateral T-wave inversions in a routine ECG. Echocardiography suggested isolated left ventricular non-compaction (LVNC) with deep recesses and a systolic non-compacted to compacted ratio in short axis of >2. To confirm the diagnosis cardiac magnetic resonance imaging (cMRI) was performed. Quality was not optimal due to premature contractions and insufficient breath-hold, but positive diagnostic criteria for LVNC (as described by Petersen, Left ventricular non-compaction: insights from cardiovascular magnetic resonance imaging. JACC, 2005 July 5;46(1):101-5) were reported (Figure 1A).

Diagnosis and Management

Six years later, the patient was referred to our institution for catheter ablation of a suspected paroxysmal supraventricular tachycardia causing palpitations. Since the patient also complained about recurrent chest pain, a coronary angiogram was performed in the same session and revealed a chronic total occlusion of the right coronary artery. However, also extensive shunting from the left coronary arteries to the left ventricle through Thebesian veins (sinusoids) was observed (Figure 1B, arrows).

Follow-up

In light of this new finding, echocardiography was repeated and color Doppler flow revealed diastolic filling of the recesses not from the LV cavity but from the coronary system, confirming that the irregular anatomy of the LV was not a result of incomplete LV compaction but due to the coronary anomaly (Figure 1C, apical short axis view, upper panel color Doppler in diastole, lower panel color M-mode). To exclude concurrent LVNC a cardiac CT was performed, confirming that the recesses, which initially led to the diagnosis of LVNC, exhibited diastolic flow from the coronary system (Figure 1D).

Conclusion

This case exemplifies that for the diagnosis of LVNC all echocardiographic criteria as defined by Oechslin and Jenni (Left ventricular non-compaction revisited: a distinct phenotype with genetic heterogeneity. EHJ, 2011 June;Volume 32, Issue 12, Pages 1446–1456) need to be fulfilled – including color Doppler assessment of flow in the recesses. Consequently, it illustrates that cMRI alone is not sufficient for the diagnosis of LVNC but both echocardiographic and cMRI criteria need to be applied.

Abstract P240 Figure.
1678 Impact of anemia in exercise stress echocardiography: effects on exercise capacity and stress testing safety
Authors: Bird J , Morant K , Kane G , Mccully R , Pellikka P , Luis S A
Published: January 2020

Funding Acknowledgements

None

Background/Purpose:

Anemia is a common condition in patients with cardiovascular disease. The effect of anemia in exercise stress testing has not been evaluated in a large cohort of patients.

Methods

We performed a retrospective review of patients undergoing exercise stress echocardiography over a 10 year period who had blood hemoglobin assessed within 48 hours of stress testing. World Health Organization cutoffs were used in defining the degree of anemia. The effect of anemia on exercise capacity and stress testing safety outcomes was assessed.

Results

In 15,652 patients, 90.3% were non-anemic, 7.6% mildly anemic, 2.1% moderately anemic, and 0.1% severely anemic. The incidence of serious supraventricular or ventricular arrhythmias and need to transfer to the hospital was low (0.1%) and did not correlate to anemia severity (p = 0.25). There was an increased incidence of non-sustained SVT or atrial fibrillation with moderate anemia and increased incidence of hypotension with stress testing with mild and moderate anemia. There was a significant reduction in duration of exercise (p < 0.001) and METS (p < 0.001) achieved with worsening anemia.

Conclusion

Our study demonstrates that exercise stress testing is safe in patients with mild and moderate anemia, albeit with reduced exercise capacity. Low numbers of severely anemic patients despite a large study population limit generalizability of these results in this group.

Exercise Capacity Severe Anemia (N = 9) Moderate Anemia (N = 332) Mild Anemia (N = 1183) Non-anemic (N = 14128) P value Resting heart rate 81 ± 13 # 79 ± 14 # 72 ± 14 74 ± 13 <0.001* Peak heart rate 148 ± 22 139 ± 24 # 138 ± 23 # 147 ±22 <0.001* Exercise duration 5.3 ± 2.5 # 6.3 ± 2.1 # 7.2 ± 2.5 # 8.6 ± 2.7 <0.001* METS 6.3 ± 2.5 # 7.1 ± 2.2 # 8.0 ± 2.5 # 9.5 ± 2.7 <0.001* Safety Hypotension with stress 0 (0%) 31 (9.4%) # 94 (8.0%) # 437 (3.1%) <0.001* Mild supraventricular arrhythmia 1 (11.1%) 15 (4.5%) # 20 (1.7%) # 237 (2.3%) 0.04* Severe supraventricular arrhythmia 0 (0%) 0 (0%) 0 (0%) 7 (0.1%) 0.99 Mild ventricular arrhythmia 0 (0%) 20 (6.0%) 74 (6.3%) 756 (5.4%) 0.94 Moderate ventricular arrhythmia 0 (0%) 3 (0.9%) 13 (1.1%) 182 (1.3%) 0.78 Severe ventricular arrhythmia 0 (0%) 1 (0.3%) 2 (0.2%) 1 (0.0%) 0.02 Transfer to hospital 0 (0%) 2 (0.6%) 1 (0.1%) 9 (0.1%) 0.29 Any severe arrhythmia or hospitalization 0 (0%) 2 (0.6%) 3 (0.3%) 17 (0.1%) 0.25 # Multi-comparison adjusted P-value <0.05 compared to non-anemic when group P < 0.05
1680 Left ventricular filling pressure assessment with exercise stress echocardiography in patients with non-valvular atrial fibrillation
Authors: Lara-Breitinger K , Ullah M W , Luong C L , Padang R , Oh J K , Pellikka P A , Mccully R B , Kane G C
Published: January 2020

Background

Noninvasive parameters of LV filling pressure (E/e’) and pulmonary pressures (RVSP) by Doppler echocardiography correlate with functional capacity and outcome in sinus rhythm (SR). Their role in AF is less clear. Elevated left ventricular filling pressures (E/e’) and pulmonary artery systolic pressures (PASP) by Doppler stress echocardiography correlate with impaired functional capacity in patients in sinus rhythm (SR). However, there is limited data in atrial fibrillation (AF).

Purpose

The aim of this study was to delineate the characteristics of patients with AF referred for exercise stress echocardiography and determine the prevalence and significance of E/e’ and PASP elevations in AF.

Methods

Subjects were patients referred for exercise treadmill stress echocardiography (n= 14,937) and underwent regional wall motion assessment, Doppler assessment of mitral inflow (E) and early tissue relaxation (e’) velocities and PASP at rest and immediately following maximum symptom limited exercise. Exclusion criteria included significant valvular heart disease (moderate or greater stenosis and/or regurgitation of any cardiac valve or previous valve repair or replacement) (1%), congenital heart disease (<1%) or refusal to participate in research (<1%).

Results

Patients with AF (n = 310, 2%) were older (71 ± 10 vs 59 ± 13 years, p < 0.001). While resting blood pressure was similar, resting heart rates were higher in AF (80 ± 17 bpm vs 73 ± 13 bpm, p < 0.0001). AF patients achieved lower workloads (6.4 ± 2.4 METS vs 9 ± 2.4 METS, p < 0.001) with lower peak double products (22336 ± 6677 vs 25148 ± 5438, p < 0.001). Rates of resting (27% vs 10%, p < 0.0001) and exercise-induced (37% vs 20%, p < 0.0001) regional wall motion abnormalities were higher in AF. Mean E/e’ was higher in AF at rest (12 ± 5 vs 9 ± 3, p < 0.001) and with exercise (12 ± 5 vs 10 ± 4, p < 0.001), with a higher percentage of patients in AF having E/e’ ≥15 at rest (20% vs 6% in SR, p= <0.001) and with exercise in (23% vs 8%, p < 0.001). PASP was higher in AF at rest (33 ± 8 mm Hg vs 28 ± 6 mm Hg, p < 0.001) and with exercise (48 ± 12 vs 42 ± 11, p < 0.001) compared to SR. E/e’ correlated with exercise capacity in AF and in SR, with an E/e’ cutoff of 11.7 that was best predictive of impaired functional capacity (< 5 METS in women and < 7 METS in men).

Conclusions

Abnormalities of E/e’ and PASP are more prevalent in patients with AF and correlate with impaired functional capacity. In patients with AF, a medial E/e’ ratio of ≥ 12 immediately following exercise is best associated with impaired functional capacity.
1681 Carotid screening prior to stress echocardiography, an opportunity to assess cardiovascular risk?
Authors: Matangi M , Cases M , Brouillard D , Johri A
Published: January 2020

BACKGROUND

Screening for atherosclerosis is an important method for assessing cardiovascular (CV) risk. Our data with carotid imaging shows a normal a carotid is associated with a very low 10-year CV risk of 1.6%. Even a low risk carotid still predicts a favourable outcome, 5.6-7.0% CV risk over 10 years. Increasing plaque burden as assessed by either total plaque area (>25mm2) or plaque score (>1) is associated with increasing CV risk, ranging from 20% to >30% over 10 years.

PURPOSE

This analysis was performed to estimate the prevalence and severity of carotid disease in men and women presenting for stress ECHO, with no prior documented evidence of CV disease.

METHODS

Data was collected from October 3, 2011 to January 22, 2019. Male patients aged 40-70yrs and female patients aged 50-75yrs undergoing stress ECHO underwent a screening carotid examination prior to the test. This involves only 2-3 images on each side to include, the CCA, carotid bulb and ICA. Maximal CCA IMT is measured using an automatic edge detection method, plaque score is calculated using the Rotterdam method and plaque area is measured in the carotid bulb and ICA bilaterally. Total plaque area being the sum of all area measurements. Apart from age criteria, patients were also excluded if they were diabetic, already taking a statin, or had a previous history of any vascular disease. A low-risk carotid was defined as a maximal CCA IMT <1.00m,with a plaque score of "0" or "1" providing the total plaque area was <25mm2. An unpaired t-test was used to detect differences between means and the Fisher’s exact test was used to detect differences between proportions. A p value of <0.05 was considered statistically significant.

RESULTS

There were 1683 patients, 1175 females and 508 males with a mean age of 60.9 ± 7.4 years. Of the 1683 patients 1058 had evidence of carotid plaque (62.9%), 368 males (72.4%) and 690 females (58.7%). 726 patients were classified as low-risk and 957 patients were classified as high-risk. See Table 1.

CONCLUSIONS

A brief screening carotid examination prior to stress ECHO reveals a large percentage of both men and women who have evidence of atherosclerosis, of which 56.9% are high-risk. These patients could be identified while in the ECHO laboratory. The patients could then be offered guideline therapy with statin therapy and low dose ASA.

Table 1. Number Age CCA IMT PS 0-1 PS 2-3 PS 4-6 Low-risk High-risk Males 508 58.4 ± 7.8 1.14 ± 0.47 138 213 56 161 347 Females 1175 62.0 ± 7.0 0.99 ± 0.49 726 395 54 565 610 P value <0.0001 <0.0001 <0.0001 <0.005 <0.0001 <0.0001 <0.0001 PS = Plaque score.
P1693 Mitral valve aneurysm complicating infective endocarditis
Authors: Hammad B , Ahmed F A , Elbadry A , Abayazeed R
Published: January 2020

Funding Acknowledgements

Nothing to disclose

Background

Mitral valve aneurysm is an uncommon sequelae of infective endocarditis (IE), early diagnosis and timely intervention is of paramount importance to prevent aneurysm rupture and hemodynamic deterioration.

Clinical presentation

A 25-years old gentleman with no known past medical history, presented with a history of unexplained fever for the past month partially responding to antipyretics along with exertional dyspnea. On examination he had a blood pressure of 120/80 mmHg, a heart rate of 110 bpm, a temperature of 39oC, a harsh pansystolic murmur over the apex and early diastolic murmur over the second aortic area. Laboratory results revealed anaemia, leukocytosis elevated ESR and CRP and blood cultures were positive for streptococcus viridians. Electrocardiography showed sinus tachycardia.

Methods and results

Trans-Thoracic Echocardiography (TTE) revealed the presence of an echolucent cavity measured 1.6x1.6 cm overlying a perforation of the anterior mitral valve leaflet (AML) a long with two small vegetations attached to the AML at the perforation edge, largest measures 0.8cm. There was a severe mitral valve regurgitation. The aortic valve is thickened trileaflet with lack of diastolic cooptation and evidence of severe regurgitation. The left ventricle dimensions were dilated and function was reduced, estimated LVEF = 50%.

3DTrans-esophageal Echocardiography(TEE) was done for better visualization of the mitral valve. The cavity involved A2 scallop, it was perforated and communicating with the LA with an additional regurgitation jet. The aortic valve showed no detectable masses or abscesses.

Accordingly, patient was diagnosed with infective enfocarditis complicated with AML perforation and aneurysm formation, anti-biotics were commenced and patient was referred for double valve replacement.

Discussion

Mitral valve aneurysm most commonly occurs secondary to infective endocarditis of the aortic valve, while our patient does not demonstrate evidence of vegetations at the aortic valve but he had an unhealthy valve with severe regurgitation jet that hits AML and might by a cause of hit lesion at the AML and eventually complicated by aneurysm formation.

Discussion

Echocardiography is a crucial imaging modality in patient with long standing fever and underlying valvular heart disease to rule out infective endocarditis. 3D-TEE is of added value along with TTE in better definition of vegetations, detection of infective endocarditis complication and it has a crucial role in proper diagnosis and surgical planning for better clinical outcomes.

Abstract P1693 Figure. Mitral valve aneurysm