Dopamine Transporter SPECT with 12-Minute Scan Duration Using Multiple-Pinhole Collimators

This study evaluated the potential to reduce the scan duration in dopamine transporter (DAT) SPECT when using a second-generation multiple-pinhole (MPH) collimator designed for brain SPECT with improved count sensitivity and improved spatial resolution compared with parallel-hole and fanbeam collimators. Methods: The retrospective study included 640 consecutive clinical DAT SPECT studies that had been acquired in list mode with a triple-head SPECT system with MPH collimators and a 30-min net scan duration after injection of 181 ± 10 MBq of [123I]FP-CIT. Raw data corresponding to scan durations of 20, 15, 12, 8, 6, and 4 min were obtained by restricting the events to a proportionally reduced time interval of the list-mode data for each projection angle. SPECT images were reconstructed iteratively with the same parameter settings irrespective of scan duration. The resulting 5,120 SPECT images were assessed for a neurodegeneration-typical reduction in striatal signal by visual assessment, conventional specific binding ratio analysis, and a deep convolutional neural network trained on 30-min scans. Results: Regarding visual interpretation, image quality was considered diagnostic for all 640 patients down to a 12-min scan duration. The proportion of discrepant visual interpretations between 30 and 12 min (1.2%) was not larger than the proportion of discrepant visual interpretations between 2 reading sessions of the same reader at a 30-min scan duration (1.5%). Agreement with the putamen specific binding ratio from the 30-min images was better than expected for 5% test-retest variability down to a 10-min scan duration. A relevant change in convolutional neural network-based automatic classification was observed at a 6-min scan duration or less. Conclusion: The triple-head SPECT system with MPH collimators allows reliable DAT SPECT after administration of about 180 MBq of [123I]FP-CIT with a 12-min scan duration.

Application of a Radiopaque Viscous Hydrogel Spacer for Prostate Cancer Radiotherapy - A Prospective Multi-Institutional Phase II Study

PURPOSE/OBJECTIVE(S)

Rectal dose can be significantly decreased after spacer application. An initially fluid spacer (FS) spreads in a predetermined space, whereas the positioning of a viscous spacer is determined by needle guidance. The aim of this study was to evaluate the application a radiopaque viscous spacer (RVS) for prostate cancer radiotherapy (RT).

MATERIALS/METHODS

In 30 patients including three centers, 10ml (median) of a RVS was injected between the prostate and anterior rectal wall. The resulting distance and distribution were determined in different planes and compared with a control group of 30 patients with a FS. A cone beam computed tomography (CBCT) was performed at least at the end of RT, a magnetic resonance imaging (MRI) 3 months and 12 months after RT. Injection and treatment tolerability were analyzed.

RESULTS

With a median prostate volume of 40cm3, no overlap was found between planning target volume and rectal volume in most cases (median = 0cm3, interquartile range, IQR 0-0.6cm3). The median contoured RVS before, at the end and 3 months after RT was 8.5cm3, 8.7cm3 und 6.4cm3. Signs of hydrogel migration were not found in any case. Hydrogel visibility in CBCT was rated with "4" on a scale between 1 (poor) and 5 (excellent). Small residues were detected in the MRI 12 months after RT in 3 cases (10%). The median distance between prostate and rectum at the base / midplane / apex was 14mm / 12mm / 11mm. The median rectal volume percentage within the 90% and 80% isodoses was 3.0% (IQR 1.5-4.5%) bzw. 5.9% (IQR 3.0-10.6%). On a scale between 1 (difficult) and 5 (very easy), ease of application was rated with "3-4". Procedure- or device related adverse events have not been observed in any case. Acute and late gastrointestinal toxicities were found in 17% and 3%, respectively (all grade 1). The control of gel distribution of RVS relative to FS was rated with "3-5" on a scale between 1 (much worse) and 5 (much better), the ease of application relative to FS with "2-3" on a scale between 1 (much harder) and 5 (much easier). With a median contoured FS volume of 9.9cm3, the prostate-rectum distance at the base / midplane / apex was 12mm / 10mm / 10mm (significantly smaller in comparison to RVS). However, the lateral gel extension of RVS was smaller in all planes, statistically significant for all comparisons (base: 28mm vs. 34mm, midplane: 28mm vs. 32mm, apex: 21mm vs. 26mm). The gel symmetry (right vs. left) was comparable.

CONCLUSION

The application of a radiopaque viscous hydrogel spacer is harder in comparison to the initially fluid spacer. However, it can be better controlled and is achievable without any complications. Visibility in CBCT is good. The resulting prostate-rectum distance is >10mm in most cases and slightly larger at the base in comparison to FS. The resulting rectum volume within the high dose region and radiotherapy toxicity are very low.

Entrustable Professional Activities for the Training of Postgraduate Primary Care Pediatricians

PROBLEM

Competency-based training is a model of medical education program that uses an organized framework of competencies to develop entrustable professional activities (EPAs) for each specialty. Implementation of EPAs varies by medical specialty and country. Although national models for primary care pediatrics have been suggested in the past, standardized EPAs have not been established.

APPROACH

The authors, all members of the curriculum working group of the European Confederation of Primary Care Paediatricians, describe the development and design of a training model based on EPAs specifically for pediatricians in primary care. The objective was to facilitate and disseminate a training model that standardizes and improves training in primary care pediatrics. They aimed to make the model flexible enough so that it can be adapted to different training models and different European health systems.

OUTCOMES

Between May 2017 and December 2019, the authors developed a framework that includes 7 domains of competencies for the training in pediatric primary care and a set of 11 core EPAs to guide the learning process. They structured each EPA as follows: title, activity profile, domains of competence, competencies within each domain, required knowledge and skills, learning objectives described in terms of outcomes, and a 3-stage rating supervision scale to evaluate the level of performance.

NEXT STEPS

The next step is the progressive implementation of these EPAs into the postgraduate primary care pediatrics training programs of European health systems. To support this implementation, the authors intend to develop training videos to assist in daily teaching of the EPAs. The authors will also develop a pan-European online resident forum designed specifically to facilitate EPA learning by sharing and discussing clinical cases. They plan to launch a pilot study on the use of the EPAs in primary care health centers in 6 European countries.

Long-term prognostic value of left atrial longitudinal strain in a low-risk community-based cohort

 

Numerous studies established the significant predictive value of left ventricular (LV) global longitudinal strain (GLS) on adverse clinical outcomes in various cardiac diseases. Despite the well-known importance of left atrial (LA) mechanics in diastolic function, data are scarce regarding the prognostic power of LA longitudinal strain and its potential added value in the risk stratification of a low-risk population.

Accordingly, our aim was to determine the long-term prognostic importance of 2D speckle-tracking echocardiography-derived peak atrial longitudinal strain (PALS) in a community-based screening sample comprising of low-risk adult individuals.

Three hundred fourteen volunteers were retrospectively identified from a population-based screening program (mean age 62±11, 58% female) with a median follow-up of 9.5 years. All subjects who participated in the screening program underwent 2D echocardiography to measure LV volumes and ejection fraction (EF), LV GLS and PALS, as well as low-dose cardiac CT to determine the Agatston score. The primary endpoint was all-cause mortality.

Thirty-nine subjects (12.4%) met the primary endpoint. Subjects with adverse outcome had significantly decreased LV GLS (dead vs. alive; −19.2±4.3 vs. −20.6±3.5%, p<0.05) and PALS (32.3±12.0 vs. 41.8±14.2%, p<0.001), whereas LV EF did not show a difference between the two groups (51.1±7.0 vs. 52.1±6.2, %, p=NS). By multivariable Cox regression analysis, PALS (hazard ratio 0.970 [95% CI: 0.943–0.998], p<0.05) and Agatston score were independently associated with all-cause mortality, whereas GLS was not (hazard ratio 1.008 [95% CI, 0.919–1.105], p=NS). Furthermore, we dichotomised the population based on PALS values using a guideline-directed cut-off of 39%. In subjects with lower PALS values, the risk of all-cause mortality was almost 2.5 times higher than in subjects with PALS values above 39% (hazard ratio 2.499 [95% 1.334–4.682], p<0.05) as shown on the Kaplan-Meier curve (Figure 1).

Beyond the assessment of LV EF and LV GLS, PALS offers incremental value in cardiovascular risk stratification in a community-based cohort. PALS was found to be the only significant and independent predictor of long-term mortality among other echocardiographic functional parameters. Our results emphasize the importance of a thorough evaluation of LA mechanics even in a low-risk population.

Funding Acknowledgement

Type of funding sources: None.

Machine learning based risk stratification of patients undergoing ventricular tachycardia ablation

Background

Monomorphic ventricular tachycardia (VT) is a potentially life-threatening condition. Although radiofrequency catheter ablation represents an effective treatment method for many of these patients, significant variability is observed in postprocedural mortality, which is attributable to multiple factors, including the high burden of comorbidities. Therefore, there is a great demand for an accurate risk stratification system.

Purpose

We sought to implement a machine learning pipeline to predict 1-year all-cause mortality in patients undergoing VT ablation.

Methods

For 265 consecutive patients who underwent VT ablation at our center, we retrospectively collected demographics, medical history, cardiovascular risk factors, laboratory results, echocardiographic measurements, and VT ablation-related parameters. To predict 1-year all-cause mortality based on these features, several supervised machine learning models were trained and evaluated using 5-fold cross-validation. We applied a recursive elimination technique to identify the optimal subset of input features. The area under the receiver operating characteristic curve (AUC) with a 95% confidence interval (CI) was calculated to quantify the models' performance. We also identified the most important predictors of mortality using Shapley values. As the final step, we used topological data analysis to discern and visualize patient subgroups with different mortality risk.

Results

57 (22%) patients died during the 1-year follow-up period. In predicting all-cause mortality, the best performance was achieved by a random forest model utilizing 18 input features [AUC: 0.73 (95% CI: 0.68–0.78)]. This model significantly outperformed other previously published risk scores such as the I-VT [AUC: 0.63 (95% CI: 0.55–0.70), p<0.001 vs. random forest] or the PAINESD [AUC: 0.63 (95% CI: 0.55–0.71), p=0.009 vs. random forest]. The most important predictors of mortality were mitral E-wave deceleration time, cardiac resynchronization therapy, age, electrical storm, and hemoglobin concentration. In the topological network created based on the 18 input features of the best-performing random forest model, we could identify five patient subsets with different clinical characteristics and 1-year mortality rates (Figure 1).

Conclusions

Our machine learning model could efficiently predict 1-year all-cause mortality in patients undergoing VT ablation. Thus, it could facilitate the prompt identification of high-risk patients and the personalization of treatment and follow-up strategies, ultimately leading to improved outcomes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Program, as part of the National Research, Development and Innovation Fund of HungaryThematic Excellence Programme of the Ministry for Innovation and Technology in Hungary

The impact of frailty index on long-term outcome in CRT patients

Background

Frailty is a complex clinical syndrome associated with ageing and comorbidities resulting from multiple organ impairment by losing homeostatic reserves and increased vulnerability to physiological decompensation. Frailty can be measured by quantifying the “vulnerability status” by the range of comorbidities.

Purpose

We assessed the long-term all-cause mortality based on Frailty Index (FI) among patients who underwent Cardiac Resynchronization Therapy (CRT) implantation.

Methods

We calculated patients' FI individually using 30 clinical parameters from our retrospective single centre large-scale registry. The applied clinical features incorporated patients' medical history, anthropometric-, laboratory and echocardiographic parameters. Based on previous studies, patients with FI ≤0.210 were classified as non-frail, and patients above that value were considered frail. Frail patients were divided into two different subgroups (F1; F2) by a FI increment of 0.100 based on the Rockwood method. Primary endpoint was all-cause mortality, log-rank and Cox multivariate analysis were performed.

Results

Among 1010 included patients, 58 (6%) were considered as Non-frail, while 245 (24%) and 707 (70%) participants were categorized to F1- and F2 groups. Patients in F2 group were older [non-frail 62 years (IQR 57–68) vs. F1 66 years (IQR 57–73) vs. F2 70 years (IQR 63–76); p<0.001], had worse laboratory parameters as higher creatinine, uric acid, lower sodium or hemoglobin levels (p<0.001) and more comorbidities than patients of Non-frail or F1 groups. During the median follow-up time of 4.4 (2.3–6.9) years, 17 (29%) patients in the Non-frail group, 103 (42%) in Frail group 1 and 479 (68%) in the Frail group 2 reached the primary endpoint. Non-frail patients showed the best outcome, and patients in the Frail group 1 demonstrated a 46% (HR 0.46, 95% CI 0.39–0.55; p<0.001) lower all-cause mortality risk compared to Frail group 2. In the total cohort, mortality predictors were also assessed, NYHA functional class, serum sodium, creatinine and TAPSE were identified as independent predictors of all-cause mortality.

Conclusion

By calculating individual frailty index among CRT patients, distinct groups could be identified, of which mortality differed significantly. Those with the highest Frailty index demonstrated the worse outcome compared to lower index or non-frail patients. Frailty index can help selecting the most vulnerable patients, requiring a strict follow-up.

Funding Acknowledgement

Type of funding sources: None.

There is more than just longitudinal strain: prognostic significance of biventricular circumferential mechanics

 

Global longitudinal strain is a well-established predictive parameter of adverse outcomes in several cardiac diseases, therefore, it is widely used in clinical practice. Despite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning the biventricular circumferential strain phenotypes and their prognostic value on long-term mortality.

Accordingly, the aim of our study was to assess both left (LV) and right ventricular (RV) global circumferential strain (GCS) using 3D echocardiography in order to determine the prognostic importance of the deterioration of biventricular circumferential mechanics.

Three hundred and sixty-four patients with various established left-sided heart diseases were retrospectively identified (age: 64.8±15.0 years, 69% males) with a median follow-up of 41 months. All patients underwent clinically indicated transthoracic echocardiography and left (LV) and right ventricular (RV) ejection fractions (EF) were measured by 3D analysis. 3D LV and RV GCS were also quantified by dedicated softwares. In order to determine the prognostic power of the different patterns of biventricular circumferential mechanics, we divided the patient population into four groups using the median values of LV and RV GCS (absolute values of 27.1% and 17.9%, respectively). Group 1 consisted of patients with both LV and RV GCS above median values; Group 2 was defined as patients with LV GCS above the median, while RV GCS below the median, whereas in Group 3 patients had LV GCS values below the median, while RV GCS was above median. Group 4 was defined as patients with both LV and RV GCS below the median. The primary endpoint of our study was all-cause mortality.

Fifty-five patients (15.1%) met the primary endpoint. The overall patient population showed balanced values of LV and RV EF (49.0±15.7 and 48.2±9.4%, respectively). Comparing the population separated into the above-mentioned four groups based on LV and RV GCS values enabled a detailed risk stratification as shown on the Kaplan-Meier curve (Figure 1.) When comparing Group 1 vs. Group 4, patients who had lower LV and RV GCS values the risk of all-cause mortality was more than 5 times higher than in patients with both LV and RV GCS above the median (HR, 5.240 [95% CI, 2.750–9.985], p<0.001). By comparing Group 2 with Group 3, the associated risks for all-cause mortality did not show a difference (HR, 0.461 [95% CI, 0.178 to 1.194], p=NS) as shown on the Kapan-Meier curve (Figure 2).

Based on the different phenotypes of LV and RV GCS, decreased biventricular circumferential shortening was associated with a significantly increased risk of long-term all-cause mortality. Interestingly, decreased RV GCS with maintained LV GCS showed a similar risk of adverse outcomes than decreased LV GCS with maintained RV GCS. Our results emphasize the importance of the assessment of biventricular circumferential mechanics.

Funding Acknowledgement

Type of funding sources: None.

Extension of fitness evaluations with muscle oxygen saturation measurements based on near-infrared spectroscopy analysis during cardiopulmonary exercise testing in elite athletes

Introduction

Many cardiovascular parameters of sport adaptation have become an area of detailed research in recent decades. However, details of local circulatory and metabolic processes ongoing in the working muscles during physical exercise need to be revealed.

Purpose

Our aim was to extend cardiopulmonary exercise testing with near-infrared spectroscopy measurements to focus on observing local changes in the contracting muscles during running.

Methods

Mixed muscle oxygen saturation values (SmO2) measured in the left vastus lateralis muscle of athletes were analyzed by near-infrared spectroscopy during vita maxima treadmill cardiopulmonary exercise testing with 2-min fingertip lactate measurements. Body composition analysis was carried out with bioimpedance method. One-way repeated measures ANOVA, Tukey post-hoc test, Shapiro–Wilk test and Pearson correlation were used for statistical analysis.

Results

The results of 66 elite athletes (male: 40; age: 17.9±3.6 y; training: 17.7±6.6 h/w; water polo player: 56, wrestler: 8, basketball player: 2) were analyzed. The 10-second averaged values of the measured saturation values were examined at rest (65.8±11.1%), at the anaerobic threshold (40.7±22.8%), at maximum load (30.2±20.5%) and after 5 minutes of cool-down (70.9±12.8%). Significant differences were measured between the four measurement time points in all pairings. A negative correlation was found between the achieved maximal oxygen uptake and the muscle oxygen saturation values measured at the anaerobic threshold and at the maximal load (respectively r=−0.30, p<0.02; r=−0.32, p<0.01). Oxygen uptake at the end of cool-down was also negatively correlated with muscle oxygen saturation values measured at the anaerobic threshold and at the peak of exercise (respectively r=−0.27, p<0.05; r=−0.27, p<0.05). The fat-free mass of the identical limb showed negative correlation with the muscle oxygen saturation values measured at the anaerobic threshold, at the maximal load and at the cool-down (respectively r=−0.43, p<0.01; r=−0.44, p<0.01; r=−0.35, p<0.01), while positive interactions were observed between the body-fat mass of the same limb and the muscle oxygen saturation values (respectively r=0.51, p<0.01; r=0.55, p<0.01; r=0.41, p<0.01). Muscle oxygen saturation values showed no significant correlations with exercise time, lactate levels, or heart rate measurements.

Conclusions

By our results, muscle oxygen saturation measurements can be reliably applied during exercise physiological measurements. During exercise, muscle oxygen saturation values negatively correlated with oxygen uptake. At the cool-down phase, a rebound effect could be observed compared to the resting measurements. On the identical limb, the higher the muscle mass was, the higher muscle desaturation could be measured. This easy-to-perform test provides insight into muscle metabolism processes and can help with training planning and athlete follow-up.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 135076). Supported by the ÚNKP-21-3-I-SE-68 New National Excellence Program of the Ministry for Innovation and Technology from the Source of the National Research, Development and Innovation fund.

Trajectory of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction and association with cardiac structure and function

Background

The PARADISE-MI trial examined the efficacy of sacubitril/valsartan in patients with acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion or both. Little is known about the trajectory and echocardiographic correlates of pulmonary congestion in this population.

Purpose

We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a subset of patients enrolled in PARADISE- MI.

Methods

Participants underwent 8-zone LUS at baseline and 8 months. B-lines were quantified offline, blinded to treatment group, clinical findings, timepoint and outcomes by a core laboratory. Paired t-tests, chi-squared tests, and linear regression analyses were conducted.

Results

Among 152 patients (median age 65 years, 32% women, 35% obese, mean LVEF 41%), any B-lines were detectable in 87%, the median sum of B-lines in 8 zones was 4 [IQR 2–8], and 67% had ≥3 B-lines indicative of congestion. Greater number of B-lines at baseline was associated with larger left atrial (LA) size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular (RV) systolic function, and higher tricuspid regurgitation velocity (P trend <0.05 for all) (Figure 1). Among 115 patients with 8-month LUS data, there was a significant decline in number of B-lines from baseline (mean ± SD: −1.6±7.3; p=0.018). Adjusted for baseline, B-lines at follow-up were on average 6 (95% CI: 3, 9) higher in a patient who experienced an intercurrent heart failure (HF) event than a non-HF patient (p=0.001). Among 75 patients with ≥3 B-lines at baseline, a decrease in B-lines to <3, indicating decongestion, occurred in 37% and was similar in the sacubitril/valsartan and ramipril groups (36% vs. 39%, p=0.83).

Conclusions

In this post-AMI cohort, sonographic B-lines, indicating pulmonary congestion, were common at baseline and were significantly higher at follow-up in those who developed HF. Worse pulmonary congestion at baseline was associated with prognostically important echocardiographic markers of LV filling pressure, pulmonary pressure, and RV function.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis

Clinical determinants of non-invasive global myocardial work index before and after transcatheter aortic valve implantation: a prospective study

 

The estimation of non-invasive global myocardial work indices is a novel method of the left ventricular (LV) functional assessment, which may overcome the load-sensitvity of the traditional functional measures. The diagnostic and prognostic role of this approach may gain particular importance in pressure overload states, such as in patients with severe aortic stenosis. However, the longitudinal changes of this recently introduced measure are scarcely investigated, and data are also lacking about the main determinants of these measures.

Accordingly, our aim was to investigate the clinical determinants of preoperative and also postoperative GMWI in patients undergoing transcatheter aortic valve replacement (TAVR).

Fifty patients (62% male, age: 78±5 years) were enrolled. Prior to the procedure, subjects underwent echocardiographic investigation and the detailed medical history was also recorded. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the systolic blood pressure. Using these measures, global myocardial work index (GMWI) and global constructive work index (CMWI) was quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

At follow-up, GLS has significantly increased (−13.0±4.1 vs. −14.8±3.8%; p<0.001), while GMWI was significantly lower compared to baseline (1789±748 vs. 1506±561 mmHg%, p<0.01). CMWI did not differ between the two time points (2309±782 vs. 2086±609 mmHg%, p=0.11). Using multivariable analysis, age (β=0.30; p<0.05) preoperative New York Heart Association (NYHA) class (β=−0.48; p<0.001) and having a pacemaker (β=−0.44; p<0.01) were found to be independent predictors of the preoperative GMWI (R2=0.39; overall p<0.001). On the other hand, postoperative GMWI was determined (R2=0.48; overall p<0.001) by gender (β=−0.25; p<0.05), the presence of diabetes mellitus (β=−0.37; p<0.01) and also by having a pacemaker (β=−0.38; p<0.01).

TAVR significantly alters LV functional measures. Different clinical factors influence GMWI before and after the procedure: age, NYHA class-based symptom severity and having a pacemaker were found to be independently associated with preoperative GMWI, while gender, the presence of diabetes mellitus and pacemaker device are the most important clinical determinants of the postoperative GMWI value.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular mechanics and its association with symptoms in transcatheter aortic valve replacement candidates: a three-dimensional echocardiography study

 

Aortic valve stenosis is one of the most prevalent valvular disease with significant clinical burden. While it is initially a disorder of the left ventricle (LV), long-term effects of the disease also affect the right ventricle (RV) as well. Nevertheless, data are scarce regarding the changes of RV mechanics and their association with symptomatic status of the patients. 3D echocardiography allows a more detailed assessment of the RV, which may unveil distinct changes of its morphology and function in this clinical setting.

Accordingly, our aim was to examine LV and RV mechanics in TAVR candidate patients with severe aortic stenosis using three-dimensional (3D) echocardiography.

Seventy patients (51% male, age: 80±6 years) were enrolled. Detailed medical history and symptomatic status were obtained. Beyond conventional transthoracic echocardiographic protocol, 3D loops were also acquired. We measured 3D LV and RV end-diastolic volume indexed to body surface area (EDVi), ejection fraction (EF) and global longitudinal (GLS) using dedicated software. Furthermore, we have determined 3D RV global longitudinal (RV GLS) and circumferential strain (RV GCS) using the ReVISION method.

LV EF (r=0.28, p<0.05) and LV GLS (r=−0.26, p<0.05) significantly correlated with age, while RV EF (r=0.21, p=0.11), RV GLS (r=−0.17, p=0.19) and RV GCS (r=−0.07, p=0.61) did not show association with it. 41% (n=29) of the patient population mentioned angina or had syncope. Patients with these symptoms had comparable LV EDVi (73±23 vs. 69±25 mL/m2, p=0.47), LV EF (47±15 vs. 51±10%, p=0.14) and LV GLS (−13.6±4.8 vs. −14.8±2.6%, p=0.25) to those who did not mention these complaints. On the other hand, patients with angina or syncope in their medical history had significantly lower RV EDVi (58±13 vs. 70±23 mL/m2, p<0.05), while having significantly higher RV EF (46±10 vs. 52±7%, p<0.05). Moreover, symptomatic patients had significantly lower RV GCS (−15.7±5.6 vs. −19.6±5.3%, p<0.01), while RV GLS did not differ (−15.8±4.8 vs. −17.4±4.1%, p=0.17).

Patients with severe aortic stenosis have marked changes in not only the LV, but the RV mechanics as well. While the symptomatic status does not seem to be associated with LV morphology and function, patients with angina or syncope had distinct changes in RV size and the contraction pattern of the chamber.

Funding Acknowledgement

Type of funding sources: None.

The benefits of adding a defibrillator to cardiac resynchronization therapy – systematic review and meta-analysis

Background

There is an long-standing debate whether cardiac resynchronisation therapy-defibrillation (CRT-D) is preferred over CRT-pacemaker (CRT-P). No randomised controlled trials have been designed to compare these treatments. However, several observational studies have been performed so far providing controversial results.

Methods

PubMed, CENTRAL and Embase until October 2021 were screened for studies comparing CRT-P and CRT-D, focusing on all-cause mortality, cardiovascular mortality, sudden cardiac death, and non-cardiac death. Conference abstracts were excluded. Odds ratio with 95% confidence interval (CI) was calculated, data from the selected studies were pooled using a random effect model (Mantel-Haenszel method, where more than 5 studies with Hartung-Knapp adjustment). τ2 was estimated by Paule-Mandel method with CI calculated by Q profile method. Statistical heterogeneity was assessed by Cochrane Q test and I2 test. Results were summarized by Forest and drapery plots.

Results

Altogether 20 observational retrospective studies (69,124 patients) were included (CRT-P: 37,461, CRT-D: 31,663). CRT-D was superior to CRT-P regarding all-cause mortality in multivariate analysis (aHR: 0.79; 95% CI: 0.69–0.88; p<0.01). Based on propensity matched studies (25,040 patients; 12,520 CRT-P, 12,520 CRT-D) CRT-D showed significantly better survival compared to CRT-P (HR: 0.83; 95% CI: 0.79–0.87; p<0.001). Three studies (47,846 patients, CRT-P: 27,344, CRT-D: 20,502) compared cardiovascular mortality between CRT-D and CRT-P. Univariate analysis showed a significantly lower rate of cardiovascular mortality in patients implanted with a CRT-D device compared to patients with a CRT-P device (HR: 0.61; 95% CI: 0.50–0.73; p=0.002). Three studies (4,623 patients. CRT-P: 2,518, CRT-D: 2,105) reported on heart failure death, where CRT-D was associated with decreased heart failure mortality compared to CRT-P (HR: 0.68; 95% CI: 0.41–0.95; p=0.008). Five studies (6,434 patients. CRT-P: 3,475, CRT-D: 2,959) were analyzed for sudden cardiac death, CRT-D was superior in univariate analysis (HR: 0.33; 95% CI: 0.28–0.89; p=0.03). Three studies (48,770 patients, CRT-P: 28,398, CRT-D: 20,372) reported on non-cardiac death, CRT-D showed significantly better survival than CRT-P (HR: 0.58; 95% CI: 0.55–0.60; p<0.001).

Conclusion

Our meta-analysis demonstrated that patients with CRT-D had a lower risk of all-cause mortality compared to CRT-P based on those studies that used multivariate analysis and propensity score matching. Univariate analysis showed a significantly lower rate of cardiovascular heart failure mortality, sudden cardiac death, and non-cardiac death in patients implanted with a CRT-D device compared to patients with a CRT-P. However, due to the heterogeneity of the articles coming from the selection bias of patients for CRT-D/CRT-P implantation, this question requires further analysis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The research presented here, carried out by Semmelweis University was supported by Semmelweis 250+ Excellence Scholarship (EFOP-3.6.3-VEKOP-16-2017-00009)as well as the Centre for Translational Medicine, Semmelweis University. This work was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. - I agree that this information can be anonymised and then used for statistical purposes only

Evaluation of the interplay between NASH and HFpEF in varied murine age groups

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 Research and Innovation Programme, grant agreement no. 739593

New National Excellence Program of the Ministry of Human Capacities (ÚNKP-21-3-II)

Introduction

Heart failure with preserved ejection fraction (HFpEF) is characterized by diastolic dysfunction, left ventricular hypertrophy, left atrial enlargement and increased serum levels of NT-pro-BNP. HFpEF accounts for 50% of heart failure cases, and typically develops in patients with metabolic comorbidities. Non-alcoholic fatty liver disease and subsequent steatohepatitis (NAFLD, NASH) is the most common chronic liver disease developing due to obesity. Although clinical/epidemiological data exists in humans showing that NASH may lead to cardiac dysfunction per se, experimental data in this regard is lacking.

Purpose

We aimed to evaluate whether NASH is an independent factor of cardiac dysfunction and to investigate the age-dependent effects of NASH on cardiac function.

Methods

Middle aged (10 months old) and aged (24 months old) C57Bl/6J mice were fed either control diet or Choline Deficient (CDAA) diet over a period of eight weeks. Young (2 months old) mice were used as a control. Before termination, echocardiography was performed. Upon termination, organs were isolated for further analysis.

Results

CDAA diet lead to the development of NASH in both age groups, without inducing weight gain, allowing us to investigate the direct effects of NASH on cardiac function. Left ventricular end-diastolic volume (EDV) was increased in aged animals, compared to young and middle aged animals, suggesting increased ventricular pressure. Aged animals were characterized by increased posterior wall thickness (PWT) during diastole and by increased LV mass, indicating left ventricular hypertrophy. Assessment of ejection fraction showed an age-dependent decline. Pulse wave and tissue Doppler measurements showed no difference in E/e’ ratio between the groups. However, strain analysis showed that diastolic dysfunction developed only in aged mice due to NASH.

Conclusion

We conclude that there were no observed changes in cardiac diastolic function due to NASH when using standard echocardiographic evaluation; however, the more sensitive method of strain analysis with 2D speckle tracking was able to show evidence of diastolic dysfunction due to NASH in aging animals.

Pacemaker upgrade to Cardiac Resynchronization Therapy-defibrillator or Cardiac Resynchronization Therapy-pacemaker without prior ventricular arrhythmias

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the ÚNKP-21-3-II-SE-47, ÚNKP-20-3-I-SE-43 New National Excellence Program if the Ministry for Innovation and Technology in Hungary. Project no. NVKP_16-1–2016-0017 (’National Heart Program’) has been implemented with the support provided by the National Research, Development and Innovation Fund of Hungary, funded under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. This work was also supported by the Semmelweis 250+ Excellence PhD Scholarship (EFOP-3.6.3-VEKOP-16-2017-00009).

Background

Cardiac Resynchronization Therapy (CRT) can reverse the harmful effects of right ventricular pacing (RVP). Data are scarce on comparing long-term survival among patients who undergone CRT-defibrillator (CRT-D) or CRT-pacemaker (CRT-P) upgrade from pacemakers (PM) without prior ventricular arrhythmias (VAs).

Purpose

We compared the differences in long-term all-cause mortality among PM patients receiving CRT-D or CRT-P upgrade.

Methods

Patients with conventional PMs developing heart failure despite optimal medical treatment and a high rate of RVP with no prior VAs were included. Altogether 326 patients were investigated, 117 (36%) upgraded to CRT-D, 209 (64%) to CRT-P in our retrospective registry. The primary endpoint was all-cause mortality. Subgroup analyses were performed by comorbidities and CRT device types. Using topological data analysis, we identified risk groups based on the primary endpoint.

Results

During the median follow-up time of 3.6 years, 33 (28%) CRT-D and 145 (69%) of CRT-P upgrade patients reached the primary endpoint. The CRT-D upgrade group showed a lower risk of all-cause mortality in the total cohort (HR: 0.55; 95% CI: 0.38-0.81; p=0.002) and by ischaemic aetiology (HR: 0.47; 95% CI: 0.29-0.76; p=0.002) compared to CRT-P. After adjustment, CRT-D, male gender and loop diuretics proved as independent predictors of all-cause mortality. Patients upgraded with CRT-D demonstrated favourable survival in the high-risk group over CRT-P.

Conclusions

Patients had survival benefit after CRT-D upgrade, compared to CRT-P, in the high-risk group and with ischaemic heart failre aetiology. However, no difference could be observed between the two groups among low- and intermediate-risk patients.

Changes of the non-invasive myocardial work in patient undergoing transcatheter aortic valve replacement: the influence of left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Patients with left bundle branch block (LBBB) are known to have substantially increased afterload sensitivity. It gains particular importance in subjects with aortic stenosis: patients with pre-existing LBBB may benefit more from interventions such as transcatheter aortic valve replacement (TAVR) by an effective and rapid reduction of the left ventricular (LV) pressures.

Accordingly, our aim was to investigate the changes of LV myocardial work indices in patients undergoing TAVR by the presence of preoperative LBBB. Non-invasive myocardial work indices are novel echocardiographic parameters which adjust LV deformation to the instantaneous LV pressure, overcoming the the load-sensitivity of the traditional LV functional measures.

Thirty patients undergoing TAVR were enrolled (37% female; age: 78±6 years; aortic valve area [AVA]: 0.7±0.3 cm2). Fourteen patients (47%; LBBB group) showed LBBB pattern on ECG, by demonstrating native LBBB (n=6; 20%) or having ventricular pacing dependency (n=8; 27%), while 16 patients had narrow QRS (53%; non-LBBB group). Prior to the procedure, subjects underwent a detailed echocardiographic investigation. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the aortic systolic pressure. Using these measures, LV global constructive work index (CMWI) and global work efficiency (GWE). were quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

As expected, AVA significantly improved after the procedure in the pooled study group (1.8±0.4 cm2; p<0.001). GLS also significantly increased (-13.2±4.2 vs. -15.2±3.9 %; p<0.01), while CMWI only showed a tendential decrease (2422±788 vs. 2166±640 mmHg%; p=NS) at the follow-up. GLS (-10.6±3.7 vs. -15.5±3.4%; p<0.001), CMWI (1877±679 vs. 2898±529 mmHg%; p<0.001), and also GWE (82±9 vs. 91±4%; p<0.01) was significantly lower in the LBBB-group compared to the non-LBBB patients. At the follow-up, GLS was still significantly lower in the LBBB patients (-13.2±4.6 vs. -16.9±2.1%; p<0.01), however, CMWI was comparable between the two groups (1956±776 vs. 2350±439 mmHg%, p=NS).

Pressure overload of the LV may affect patients with LBBB substantially more than subjects without it. TAVR causes an immediate and significant decrease in the LV afterload, which results in a more pronounced improvement in the LBBB group compared to those with no LBBB.

Biventricular mechanical pattern of the athlete"s heart: comprehensive characterization using 3D echocardiography

Funding Acknowledgements

Type of funding sources: None.

Regular, intense exercise results in complex morphological and functional cardiac remodeling, commonly referred to as the athlete"s heart. While left ventricular (LV) adaptation is thoroughly studied, data are scarce concerning the right ventricular (RV) mechanical changes and their continuum with exercise performance.

Accordingly, our aim was to characterize biventricular morphology and function and its relation to sex, age and sport classes in a large cohort of elite athletes using 3D echocardiography.

Four hundred and twenty-two elite, competitive athletes (male/female: 295/127, adult/adolescent: 207/215) from the 4 major sport classes (mixed type n = 293; endurance n = 88; power n = 33; skill n = 8) and healthy, sedentary volunteers (n = 55) were enrolled. 3D transthoracic echocardiographic datasets were acquired to quantify LV and RV end-diastolic volumes (EDVi), and ejection fractions (EF). In order to characterize biventricular mechanical parameters, LV and RV global longitudinal (GLS) and global circumferential strains (GCS) were measured using dedicated softwares. Additionally, all subjects underwent cardiopulmonary exercise testing in order to determine peak oxygen uptake (VO2/kg).

Athletes had significantly higher LV and RV EDVi compared with controls, whereas male athletes had larger volumes than female athletes, and adult athletes had also larger LV EDVi than adolescent athletes (all p < 0.05). However, RV EDVi was similar between the two age groups. Endurance athletes had significantly larger RV EDVi compared with the other sport classes (ANOVA p < 0.05). 

Concerning biventricular functional parameters, athletes had significantly lower resting LV and RV EF (athletes vs. controls; LVEF: 57 ± 4 vs. 61 ± 5%; RVEF: 55 ± 5 vs. 59 ± 5%; p < 0.001) as well as LV GLS (-19.2 ± 2.3 vs. -21.2 ± 2.0%), LV GCS (-27.7 ± 3.0 vs. -31.0 ± 3.5%), and RV GCS (-20.9 ± 4.4 vs. -24.5 ± 4.5%; all p < 0.001) compared with controls. In contrast, RV GLS (-21.8 ± 3.4 vs. -22.2 ± 3.6%) did not differ between athletes and controls. The exercise-induced relative decrease in LV GLS (9.5 ± 10.7%) and LV GCS (10.7 ± 9.8%) was similar, however, the decrement in RV GCS (14.8 ± 17.8%) was disproportionately larger compared with RV GLS (1.7 ± 15.4%, p < 0.01) in the athlete population. By multivariable linear regression analysis among echocardiographic parameters using ordinary least squares, RVEDVi was found to be the strongest and independent predictor of VO2/kg, followed by RV GCS and LV EDVi.

Regular physical exercise results in significant and specific changes in LV and RV geometry and function. Resting LV mechanics of the athlete"s heart is characterized by a balanced decrement in GLS and GCS, however, in the RV the circumferential shortening decreases disproportionately compared with the longitudinal shortening. Moreover, this mechanical pattern is associated with better exercise capacity, which emphasizes the importance of the RV in determining athletic performance.

Differences in mitral and tricuspid annular geometry in elite athletes with versus without functional mitral regurgitation: a 3D echocardiographic study

 

Intense exercise exposes the heart to significant hemodynamic demands, resulting in adaptive changes in cardiac morphology and function. Nevertheless, the athletic adaptation of the atrioventricular valves remains to be elucidated. Our study aimed to characterize the geometry of mitral (MA) and tricuspid (TA) annuli in elite athletes using 3D echocardiography.

Thirty-four athletes presented with functional mitral regurgitation (FMR) were retrospectively identified and compared to 34 athletes without MR, and 34 healthy, sedentary volunteers. 3DE datasets were used to quantify MA and TA geometry and leaflet tenting by dedicated softwares.

MA and TA areas, as well as tenting volumes, were higher in athletes compared to controls. MA area was significantly higher in athletes with MR compared to those without (8.2±1.0 vs. 7.2±1.0 cm2/m2, p<0.05, Figure 1). Interestingly, athletes with MR also presented with a significantly higher TA area (7.2±1.1 vs. 6.5±1.1 cm2/m2, p<0.05, Figure 2). Non-planar angle describing the MA's saddle shape was less obtuse in athletes without MR, whereas the values of athletes with MR were comparable to controls (Figure 1). The exercise-induced relative increases in left ventricular (35±25%) and left atrial (40±29%) volumes were similar; however, the increment in the MA area was disproportionately higher (63±23%, overall p<0.001). The relative increase in TA area (40±23%) was also higher compared to the increment in right ventricular volume (34±25%, p<0.05).

Atrioventricular annuli undergo a disproportionate remodeling in response to regular exercise. Athletic adaptation is characterized by both annular enlargement and increased leaflet tenting of both valves. There are differences in MA geometry in athletes presented with versus without FMR.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA; NVKP_16-1-2016-0017 National Heart Program). The research was partly financed by the Thematic Excellence Programme (Tématerületi Kiválόsági Program, 2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University. Figure 1Figure 2

Pacemaker upgrade to CRT-D or CRT-P without prior ventricular arrhythmias: a long-term single-centre retrospective analysis

Background

Cardiac Resynchronization Therapy (CRT) can reverse the harmful effects of right ventricular pacing (RVP). Data are sparse on comparing all-cause mortality among patients undergone CRT-defibrillator (CRT-D) or CRT-pacemaker (CRT-P) upgrade from pacemakers without prior ventricular arrhythmias (VAs).

Purpose

We compared the differences in long-term all-cause mortality, postprocedural complications and the occurrence of VAs among patients receiving CRT-D or CRT-P upgrade.

Methods

Patients with a previously implanted conventional pacemaker (PM) developing heart failure (HF) despite optimal medical treatment and high rates of RVP, were included. Altogether 270 patients were investigated, 83 (30.7%) upgraded to CRT-D, 187 (69.3%) to CRT-P in our retrospective registry. The primary endpoint was all-cause mortality, secondary endpoints were malignant VAs and implantation-related complications.

Results

CRT-D upgrade patients were more likely to be males, have a favourable renal function and lower left ventricular ejection fraction (LVEF). During the median follow-up time of 3.7 years, 25 (30.1%) of CRT-D and 131 (70.1%) of CRT-P upgrade patients reached the primary endpoint. The CRT-D upgrade group showed a lower risk of all-cause mortality in the total cohort (HR: 0.55; 95% CI: 0.38–0.78; p=0.004) and in the ischaemic subgroups compared to CRT-P. After adjustment, CRT-D, ischaemic HF aetiology and LVEF have been confirmed as independent predictors of all-cause mortality. Malignant VA occurrence was higher among CRT-D patients (10.8% vs 1.1%; p=0.001), while no difference was observed in the rate of complications between the two patient groups. However, lead removal was performed more frequently (13.3% vs 1.1%; p<0.001) during CRT-D upgrade procedures compared to CRT-P.

Conclusions

Patients among the total and ischaemic HF aetiology subgroup benefited more from the CRT-D upgrade, although VAs and lead removal were more common than in the CRT-P group.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the ÚNKP-20-3-I-SE-43 New National Excellence Program if the Ministry for Innovation and Technology in Hungary. Project no. NVKP_16-1–2016-0017 (“National Heart Program”) has been implemented with the support provided by the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. All-cause mort of pts after UPG

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

 

During the pandemic, several studies were carried out on the short-term effects of acute SARS-CoV-2 infection in athletes. As some cases of young athletes with serious complications like myocarditis or thromboembolism and even sudden death were reported, strict recommendations for return to sport were published. However, we have less data about athletes who have already returned to high-intensity trainings after a SARS-CoV-2 infection.

Athletes underwent cardiology screening (personal history, physical examination, 12-lead resting ECG, laboratory tests with necroenzyme levels and echocardiography) 2 to 3 weeks after suffering a SARS-CoV-2 infection. In case of negative results, they were advised to start low intensity trainings and increase training intensity regularly until achieving maximal intensity a minimum of 3 weeks later. A second step of cardiology screening was also carried out after returning to maximal intensity trainings. The above mentioned screening protocol was repeated and was completed with vita maxima cardiopulmonary exercise testing (CPET) on running treadmill. If the previous examinations indicated, 24h Holter ECG recording, 24h ambulatory blood pressure monitoring or cardiac MR imaging were also carried out. Data are presented as mean±SD.

Two-step screening after SARS-CoV-2 infection was carried out in 111 athletes (male:74, age:22.4±7.4y, elite athlete:90%, training hours:14.8±5.8 h/w, ice hockey players:31.5%, water polo players:22.5%, wrestlers:18.9%, basketball players:18.0%). Second screenings were carried out 94.5±31.5 days after the first symptoms of the infection. A 5% of the athletes was still complaining of tiredness and decreased exercise capacity. Resting heart rate was 70.3±13.0 b.p.m., During CPET examinations, athletes achieved a maximal heart rate of 187.3±11.6 b.p.m., maximal relative aerobic capacity of 49.2±5.5 ml/kg/min, and maximal ventilation of 138.6±31.2 l/min. The athletes reached their anaerobic threshold at 87.8±6.3% of their maximal aerobic capacity, with a heart rate of 93.3±3.7% of their maximal values. Heart rate recovery was 29.9±9.2/min. During the CPET examinations, short supraventricular runs, repetititve ventricular premature beats + ventricular quadrigeminy and inferior ST depression were found in 1–1 cases. Slightly higher pulmonary pressure was measured on the echocardiography in 4 cases. Hypertension requiring drug treatment was found in 5.4% of the cases. Laboratory examinations revealed decreased vitamin D3 levels in 26 cases, decreased iron storage levels in 18 athletes. No SARS-CoV-2 infection related CMR changes were revealed in our athlete population.

Three months after SARS-CoV-2 infection, most of the athletes examined had satisfactory fitness levels. However, some cases of decreased exercise capacity, decreased vitamin D3 or iron storage levels, arrhythmias, hypertension and elevated pulmonary pressure requiring further examinations, treatment or follow-up were revealed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary; The research was financed by the Thematic Excellence Programme of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

Long-term outcome after adding an ICD to CRT in non-ischemic patients

Background

There are limited and contradictory data on the long-term mortality benefit of cardiac resyncronization therapy with implantable cardioverter defibrillator (CRT-D)as compared to Cardiac resynchonization therapy with pacemaker.

Purpose

Our aim was to evaluate the long-term all-cause mortality benefit of CRT-D compared to CRT-P by ischemic aetiology.

Methods

Between 2000 and 2018, patients, who underwent successful CRT implantation were registered. From 2524 patients, 1366 (54%) had a CRT-D implantation and 1099 (44%) had CRT-P implantation. 59 (2%) patients were excluded from the current analysis, who had an ICD upgrade with a CRT-P device during the follow-up. The primary composite endpoint was all-cause mortality, LVAD implantation or heart transplantation. Kaplan-Meier and multivariate Cox regression analyses were used to assess all-cause mortality in the total cohort and by ischemic aetiology.

Results

The median follow-up time was 3.6 years. During this time 1389 patients died from any cause, 692 patients (50%) with a CRT-D device, and 697 patients (50%) with a CRT-P. Patients in the CRT-D group were younger (67 years vs. 70 years; p<0.001), had a less advanced functional class (NYHA III/IV., 52.2% vs. 61.4%; p<0.001), wider QRS [160ms (140/180) vs. 160ms (140/170); p=0.03] and less females (18.9% vs. 33.3%; p<0.001) with an ischemic aetiology (57.7% vs. 40.2%; p<0.0001). CRT-D patients had a better renal function [eGFR, 60.5 (ml/min/1.73m2) vs. 57 (ml/min/1.73m2); p=0.02], decreased ejection fraction (28% vs. 30%; p=0.002), had more frequently ventricular arrhythmia (36% vs. 9.8%; p<0.001). CRT-D patients took more amount of beta-blockers (90.2% vs. 87.3%; p=0.03), MRA (72.2% vs. 61.6%; p<0.001) and amiodaron (32.2% vs. 20%; p<0.001). By multivariate analysis in the total cohort gender, renal function, functional class, aetiology, and the presence of ICD were independent predictors of all-cause mortality. By multivariate analysis, patients with a CRT-D device showed a 25% decreased risk of long-term mortality compared to CRT-P alone in the total cohort. (aHR 0.75; 95% CI 0.58–0.97; p=0.03). When patients were analysed by their etiology, those with non-ischemic cardiomyopathy showed a significant mortality benefit from ICD even after adjusting for relevant clinical variables (aHR 0.45; 95% CI 0.28–0.72; p<0.01). In ischemic patients despite of having a clear mid-term mortality benefit of ICD, it is decreasing after 5 years and less considerable after adjusting for clinical variables (aHR 0.92; 95% CI 0.67–1.27; p=0.60).

Conclusions

Although, CRT-D had a notable mid-term mortality benefit in ischemic patients compared to CRT-P alone, after 5 years it became less pronounced. While in non-ischemic patients, the benefit of adding an ICD to CRT lasts over 10 years.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1–2016-0017 (“National Heart Program”) has been implemented with the support provided by the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. All-cause mortality

Frequent constriction-like echocardiographic findings in elite athletes following mild COVID-19: in the grasp of SARS-CoV-2?

 

The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (N-CA) cohort.

One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF – frequently seen in P-CA), LV eccentricity index (EI) was measured.

P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs N-CA; 77±12 vs 78±13mL/m²; 79±16 vs 80±14mL/m², respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p<0.001) and GLS (−18.2±1.8 vs −17.6±2.2%, p<0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p<0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p<0.001).

In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m², p<0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m²). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p<0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p<0.05) or chest pain (0 vs 15%, p=N/A) less frequently during the course of the infection; however, the presence of a mild pericardial effusion was more common (41 vs 12%, p<0.01).

Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings.

Funding Acknowledgement

Type of funding sources: None.

Changes of resting cardiac marker levels due to sport adaptation

Background

In acute and chronic heart diseases some cardiac necroenzymes and peptide fragments are essential during the diagnosis and following the progression of the diseases. Previous literature data are available about elevation of these cardiac markers after exhausting physical activity, but we do not have information about the resting levels in athletes.

Methods

In part of the extended cardiology screening of athletes in our institute, we analyzed the levels of hsTroponinT, CKMB, LDH and NT-proBNP from blood samples. All the samples were collected at least 12 hours after the last trainings or competitions. The results of the athletes were compared with a healthy sedentary non-athlete control group. After the blood collection all subject underwent echocardiography examinations and cardiopulmonary exercise testing. Depending on normality, groups were compared with two-tailed Student's t-test or Mann-Whitney U-test. Statistical analysis was processed in RStudio development environment.

Results

Results of 335 athletes from different sports (male: 162, age: 18.9±5.9 years, training: 15.8±5.9 hours/week) and 53 sedentary non-athletes (male: 23, age: 19.8±3.2 years, training: 2.7±2.3 hours/week) were compared. In athletes, increased level of hsTroponinT was found in 3.3% (n=11), of CKMB in 5.7% (n=18), of LDH in 2.7% (n=9) and of NT-proBNP in 1.2% (n=4). In the control group no elevation was found regarding the CKMB and hsTroponinT, while slightly elevated values of LDH and NT-proBNP were revealed in 1–1 cases. In athletes we measured higher CKMB (17.5±6.8 vs 12.3±3.4 U/l, p&lt;0.001) and LDH values (323.7±63.3 vs 286.0±51.1 U/l, p&lt;0.001), and lower values of NT-proBNP (27.2±29.2 vs 49 8±38.7 pg/ml, p&lt;0.001) compared to the control group, while in the hsTroponinT levels (4.3±1.4 vs 5.6±6.3 ng/l, p=0.33) no significant changes were measured. In term of the examined laboratory parameters significant correlation was found with maximal relative aerob capacity (CKMB: r=0.23, p&lt;0.001; LDH: r=0.18, p&lt;0.001; hsTroponinT: r=0.23, p&lt;0.001; NT-proBNP: r=−0.22, p&lt;0.001), but no correlation was found with age. Significant correlation was found between NT-proBNP levels and echocardiographic measurements of ventricular diameters and left ventricular wall thickness (LVEDD r=−0.15, p&lt;0.03; LVESD r=−0.18, p&lt;0.03; RVD: r=−0.15, p&lt;0.02; IVS: r=−0.22, p&lt;0.001; PWD r=−0.27, p&lt;0.001), CKMB levels correlated with left ventricular wall thickness (IVS: r=0.11, p&lt;0.05; PWD r=0.14, p&lt;0.02).

Conclusions

Based on our results, in connection with the sports adaptation of the heart, the resting levels of the cardiac markers also show significant changes, these changes are correlated with aerobic endurance and structural sport adaptation parameters as well. Our study draws attention to the importance of different assessment of cardiac markers in athletes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 135076).Supported by the ÚNKP-20-3-I-SE-41 New National Excellence Program of the Ministry for Innovation and Technology from the Source of the National Research, Development and Innovation fund.

Long-term mortality benefit of CRT-D vs. CRT-P upgrade procedures from conventional devices without prior ventricular arrhythmias

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the ÚNKP-20-3-I New National Excellence Program if the Ministry for Innovation and Technology in Hungary, the National Research, Development, and Innovation Office of Hungary (NKFIA; NVKP_16-1-2016-0017 National Heart Program), and the Higher Education Institutional Excellence Program of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development thematic program of the Semmelweis University. This work was also supported by the Artificial Intelligence Research Filed Excellence Program of the National Research, Development and Innovation Office of the Ministry of Innovation and Technology in Hungary (TKP/ITM/NKFIH). The research was also financed by the Thematic Excellence Program (Tématerületi Kiválósági Program, 2020-4.1.1-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Bioimaging thematic program of the Semmelweis University.

Background

 Cardiac Resynchronization Therapy (CRT) upgrade can reverse pacing-induced cardiomyopathy (PiCMP) and related major ventricular arrhythmias (MVA). However, there is a lack of data comparing mortality benefit of adding an ICD to CRT during upgrade procedures in those without prior malignant ventricular arrhythmias (VAs).

Purpose

 We aimed to compare the all-cause mortality, echocardiographic response, MVA occurrence and the rate of complications of patients with prior pacemakers (PM) upgraded to CRT-P or CRT-D devices. 

Methods

 Between 2000-2018 patients who underwent a successful CRT upgrade procedure from conventional pacemaker without a prior MVAs were collected. From 270 patients 83 (30.7%) upgraded to CRT-D, 187 (69.3%) to CRT-P device. The primary endpoint was all-cause mortality, secondary endpoints were echocardiographic response defined as left ventricular ejection fraction (LVEF) increase ≥5%, the occurrence of subsequent MVAs and the rate of periprocedural complications.

Results

 CRT-D upgrade patients were more likely to be males, have a favourable renal function and lower LVEF compared to CRT-P group. During the median follow-up time of 3.7 years, 25 (30%) CRT-D and 131 (70%) CRT-P upgrade patients reached the primary endpoint. By univariate analysis, CRT-D upgrade patients showed 45% (HR 0.55; 95%CI 0.38-0.78; p &lt; 0.01) lower all-cause mortality risk than CRT-P group. By multivariate analysis CRT-D (HR 0.39; 95%CI 0.23-0.66; p &lt; 0.01), male sex (HR 1.60; 95%CI 1.03-2.47; p = 0.04), LVEF (HR 0.97; 95%CI 0.94-0.99; p &lt; 0.01) have confirmed as independent predictors of all-cause mortality. Assessing secondary endpoints, LVEF response (66% vs 63%; p = 0.72), MVA occurrence (3.4% vs 0.8%; p &lt; 0.01) and the rate of periprocedural complications were comparable in the two groups (14.8% vs 7%; p = 0.87), despite the higher number of lead explantations during CRT-D procedures than CRT-P upgrade (13% vs 1%; p &lt; 0.001).

Conclusions

 Adding an ICD during CRT upgrade procedures showed 45% lower all-cause mortality risk than CRT-P alone in patients with a pacemaker and no previous ventricular arrhythmias. This beneficial effect was independent of the echocardiographic response, safety or subsequent ventricular arrhythmias. Abstract Figure.

Pursuing the non-invasive assessment of cardiac contractility: the added value of pressure-area-strain loop analysis in volume overload-induced heart failure

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the New National Excellence Programme (ÚNKP-19-3-I) of the Ministry for Innovation and Technology in Hungary, and the Artificial Intelligence Research Field Excellence Programme of the National Research, Development and Innovation Office of the Ministry of Innovation and Technology in Hungary.

Background

Global longitudinal strain (GLS) by speckle-tracking echocardiography (STE) is a sensitive parameter of left ventricular (LV) systolic function. Nevertheless, GLS is dependent on loading conditions. Through the analysis of pressure-strain loops, myocardial work was recently introduced and tested in different clinical scenarios. Myocardial work incorporates afterload, but still, it neglects changes in preload and LV geometry.

Purpose

Accordingly, our aim was to test our hypothesis that adding instantaneous LV size to myocardial work calculation can further mitigate the load-dependency of GLS, and therefore, a better correlation with intrinsic myocardial contractility can be achieved.

Methods

Volume overload-induced heart failure was established by an aortocaval fistula (ACF) in male Wistar rats (n = 12). Age-matched sham-operated animals served as controls (n = 12). STE was performed to assess GLS, which was immediately followed by invasive pressure-volume (P-V) analysis to assess LV pressure and to compute a gold-standard index of cardiac contractility (preload recruitable stroke work [PRSW]). Global myocardial work index (GMWI) was calculated from GLS and the invasively measured LV pressure. To compute GMWI indexed to LV area (GMWIA), the instantaneous power (calculated by multiplying the strain rate and the instantaneous LV pressure) was divided by the instantaneous LV area, and then it was integrated from mitral valve closure until mitral valve opening.

Results

LV ejection fraction did not differ significantly (ACF vs. controls: 59 ± 4 vs. 65 ± 9%, p = NS), whereas GLS (Figure 1A - representative animals) was slightly decreased in the ACF group (-13.2 ± 2.3 vs. -15.4 ± 1.9%, p &lt; 0.05). In contrast, PRSW, GMWI (Figure 1B - representative animals) and GMWIA (Figure 1C - representative animals) were considerably reduced in ACF compared to controls (57 ± 13 vs. 111 ± 38mmHg, 1383 ± 382 vs. 1928 ± 281mmHg%, 11.6 ± 3.7 vs. 47.9 ± 22.8mmHg%/mm2, all p &lt; 0.01). GLS showed moderate correlation with PRSW (r=-0.550, p &lt; 0.01), whereas GMWI correlated more significantly, but still moderately with the invasively measured LV contractility (r = 0.681, p &lt; 0.001). Correlation between the pressure-area-strain loop-derived GMWIA and P-V analysis-derived PRSW (Figure 1D) was found to be very strong (r = 0.924, p &lt; 0.001).

Conclusions

In the case of LV volume overload-induced heart failure, our pressure-area-strain loop-derived metric reflected LV contractility better than GLS and even GMWI. Therefore, the incorporation of instantaneous LV size into myocardial work calculation represents a promising clinical tool to assess and monitor intrinsic myocardial function independently of loading conditions.

Abstract Figure 1

Prognostic value of right ventricular mechanical pattern assessed with 3D echocardiography in patients with left-sided heart disease

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the New National Excellence Programme (ÚNKP-19-3-I) of the Ministry for Innovation and Technology in Hungary, and the Artificial Intelligence Research Field Excellence Programme of the National Research, Development and Innovation Office of the Ministry of Innovation and Technology in Hungary.

Background

Right ventricular (RV) ejection fraction (EF) has established prognostic significance, which is independent of left ventricular (LV) EF in various cardiac diseases. However, RV EF is a cumulative result of the complex interplay between distinct mechanical components (i.e., shortening along the longitudinal, radial, and anteroposterior directions), and the prognostic value of RV motion decomposition remains to be quantified.

Objective

Our aim was to explore whether the assessment of longitudinal, radial, and anteroposterior motion components of the RV with 3D transthoracic echocardiography offers prognostic value in patients with left-sided heart disease.

Methods

Two hundred and ninety-two consecutive patients (age 59 ± 17 years, 70% male) with left-sided heart disease underwent standard clinical investigations and 3D echocardiographic examination. They were followed-up for 6.7 ± 2.2 years, and cardiac death served as the primary endpoint. LV and RV volumes and ejection fractions were quantified by the offline analysis of 3D datasets. The ReVISION method was applied to the 3D models of the RV to decompose the motion along the three orthogonal axes and to calculate longitudinal, radial, and anteroposterior EF (LEF, REF, AEF, respectively). Conventional parameters of RV systolic function (tricuspid annular plane systolic excursion [TAPSE], fractional area change [FAC]) were also assessed.

Results

Cardiac death occurred in 60 (21%) patients. Patients who died had lower LV EF (39 ± 16 vs. 52 ± 12%, p &lt; 0.001), RV EF (40 ± 11 vs. 48 ± 8%, p &lt; 0.001), and each mechanical component showed significantly lower values compared to patients alive (LEF: 13 ± 6 vs. 19 ± 6%; REF: 22 ± 7 vs. 25 ± 7%; AEF: 14 ± 6 vs. 18 ± 5%, all p &lt; 0.001). LEF was decreased to a greater degree compared to RV EF (relative %: -30 vs. -18). In univariate Cox regression models, RV EF (Hazard Ratio [HR]: 0.928, 95% Confidence Interval [CI] 0.909 – 0.948, p &lt; 0.001), LEF (0.855 [0.816 – 0.896], p &lt; 0.001), REF (0.932 [0.898 – 0.967], p &lt; 0.001), AEF (0.879 [0.841 – 0.919], p &lt; 0.001), TAPSE (0.881 [0.841-0.923], p &lt; 0.001), and FAC (0.955 [0.933-0.977], p &lt; 0.001) were all found to be significant predictors of cardiac death. From all parameters that were predictive, the optimal combination of variables was identified with an automated stepwise selection algorithm. The final multivariate model included serum creatinine (1.015 [1.010 – 1.020], p &lt; 0.001), haemoglobin concentration (0.965 [0.948 – 0.982], p &lt; 0.001), LV EF (0.977 [0.955 – 0.999], p &lt; 0.05), and LEF (0.899 [0.843 – 0.959], p &lt; 0.01) as independent predictors of cardiac death. Notably, the algorithm rather selected LEF and not RV EF.

Conclusions

3D echocardiography-derived measurements of RV systolic function are able to predict outcomes in patients with left-sided heart disease independently of LV function. The separate quantification of RV mechanical components can hold additional prognostic value compared to conventional echocardiographic parameters.

Myocardial work index better reflects contractility than longitudinal strain in rat models of pressure- and volume overload-induced heart failure

Funding Acknowledgements

Type of funding sources: None.

Speckle-tracking echocardiography (STE)-derived global longitudinal strain (GLS) is considered to be a sensitive marker of left ventricular (LV) function in a wide variety of cardiovascular diseases. Still, evidence suggests that GLS is significantly influenced by loading conditions. Myocardial work index (MWI) evaluates myocardial deformation in the context of afterload through the interpretation of strain in relation to instantaneous LV pressure. MWI may potentially overcome the limitations of mere strain calculation, and may better reflect cardiac contractility in hemodynamic overload states.

Accordingly, our aim was to examine the relationship of GLS and MWI with load-independent markers of LV contractility in rat models of pressure- and volume overload-induced heart failure.

Male Wistar rats underwent transverse aortic constriction (TAC; n = 12) to generate LV pressure overload, or aortocaval fistula (ACF; n = 12) was established to induce severe LV volume overload. In case of the control groups, sham procedures were performed (n = 12/12). Echocardiography loops were obtained to determine STE-derived GLS and global MWI. Pressure-volume analysis with transient occlusion of the inferior vena cava was carried out to calculate preload recruitable stroke work (PRSW), as a load-independent „gold-standard" parameter of LV contractility.

GLS was mildly reduced in the ACF group (-13.2 ± 2.4 vs. -15.4 ± 2.0%, p &lt; 0.05), while it was significantly lower in TAC group compared to controls (-7.0 ± 2.8 vs. -14.5 ± 2.5%; p &lt; 0.001). In contrast with these findings, PRSW and also MWI were significantly reduced in ACF (58 ± 14 vs. 111 ± 40 mmHg; 1328 ± 411 vs. 1934 ± 308 mmHg%, both p &lt; 0.01), however, they were comparable between TAC and the corresponding sham group (110 ± 26 vs. 116 ± 68 mmHg; 1687 ± 275 Hgmm% vs. 1537 ± 662 Hgmm%; both p = NS). In the pooled population, GLS did not show relationship with PRSW (r=-0.23; p = 0.12), while MWI showed significant correlation with it (r = 0.70; p &lt; 0.001).

GLS is significantly influenced by loading conditions, therefore, in case of severe pressure- or volume overload it may not be a reliable marker of LV contractility. In our rat model of pressure overload induced heart failure, contractility was maintained despite decreased GLS, while in the model of volume overload induced heart failure, GLS was maintained despite decreased contractility. MWI reflects contractility in hemodynamic overload states, therefore, it may be a more suitable marker of systolic function.

Abstract Figure. Pressure-strain loops of the groups

Mechanical contraction patterns of the systemic right ventricle: a 3D echocardiography study

Funding Acknowledgements

Type of funding sources: None.

Background. In patients with transposition of great arteries (TGA) post atrial switch operation or with congenitally corrected TGA (ccTGA), the morphologically right ventricle (RV) has to adapt to the chronically increased systemic pressure.

Purpose. To investigate the functional adaptation of the systemic RV in patients with TGA post Mustard repair or ccTGA. 

Methods. RV volumes and EF were measured by 3D echocardiography in 33 patients with the systemic RV (21 TGA and 12 ccTGA; 45 ± 13y, 61% male), and in 33 healthy volunteers (44 ± 13y, 61% male). 

The 3D RV model was postprocessed by the ReVISION software and its contraction was decomposed along the longitudinal, radial and anteroposterior directions (Fig.A, Systemic RV in TGA) providing longitudinal, radial and anteroposterior EF (LEF, REF and AEF). Relative contribution of each component was measured as the ratio between LEF, REF and AEF to the global RVEF (LEFi, REFi and AEFi).

Results. Systemic RV was significantly larger with reduced function compared to controls (Tab). 3D RVEF demonstrated stronger correlation with BNP (Rho -0.76, p &lt; 0.0001) compared to other parameters of RV function (free wall strain 0.55, p = 0.0083; FAC -0.47, p = 0.024; S’ -0.39 and TAPSE 0.06, p &gt; 0.05).

While in healthy volunteers, all 3 components of RV systolic function contributed equally to the global RV EF, in patients with TGA the relative contribution of the anteroposterior component was dominant and differed significantly from longitudinal and radial components (AEFi 0.48 ± 0.06 vs LEFi 0.31 ± 0.07 vs REFi 0.36 ± 0.09, p &lt; 0.0001)(Fig. B,C). In patients with ccTGA the longitudinal component was dominant and provided a relative compensation for the reduced anteroposterior and radial components (LEFi 0.47 ± 0.07 vs AEFi 0.34 ± 0.07, p = 0.0002 and vs REFi 0.36 ± 0.09, p = 0.0023)(Fig. B,C). Relative contribution of the radial contraction was significantly reduced in all systemic RV patients.

Conclusions. Systemic RV contraction patterns change significantly with anteroposterior contraction being dominant in patients with TGA post Mustard repair and longitudinal component being dominant in ccTGA.

3DE should be a part of routine assessment of the systemic RV, especially in TGA since no conventional echo parameters take into account anteroposterior RV contraction.

Parameters of RV systolic function Parameter Control group (N = 33) All SRV patients (N = 33) TGA (N = 21) ccTGA (N = 12) 3D EF, % 60 ± 3.8 36 ± 8.6* 34 ± 7.3* 38 ± 10* FAC, % 41.4 ± 3.7 25.9 ± 9.3* 25.1 ± 9.2* 27.1 ± 9.9* TAPSE, mm 24.6 ± 4.2 11.9 ± 3.9* 11.1 ± 2.9* 13.2 ± 5.1* RV free wall strain, % -32.5 ± 4.2 -14.5 ± 3.5* -14.5 ± 2.9* -15.5 ± 3.5* * p &lt; 0.0001 Abstract Figure.

Functional adaptation of the right ventricle to different degrees of the left ventricular systolic dysfunction in patients with left-sided heart disease: a three-dimensional echocardiography study

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular (RV) systolic dysfunction in patients with left-sided heart disease is known adverse factor. However, the RV adaptation at the different degrees of left ventricular (LV) dysfunction remains to be clarified.

Purpose

 to assess the change in RV contraction pattern in relation to LV ejection fraction (EF) in patients with left-sided heart disease.

Methods. LV and RV volumes and EF were measured by 3D-echocardiography in 295 patients with left-sided heart disease (59 ± 17years, 69% male). The 3D meshmodel of the RV was postprocessed by the ReVISION software and its contraction pattern was decomposed along the longitudinal, radial and anteroposterior directions (Fig. A) providing longitudinal, radial and anteroposterior EF (LEF, REF, AEF). Relative contribution of each component to the RV systolic function was measured as the ratio between LEF, REF and AEF and global RVEF (LEFi, REFi, AEFi).

Results. Patients with LV systolic dysfunction also had reduced RVEF. Relative contribution of the longitudinal and anteroposterior components decreased, while radial component increased in patients with reduced LVEF (Table).

RV LEF and AEF significantly correlated with the LVEF (Rho 0.50 and 0.51, p &lt; 0.0001), while the correlation between REF and LVEF was weak (Rho 0.22, p = 0.0002).

There was a significant drop in LEF and AEF (Fig. B) and their relative contribution to the total RVEF (Fig. C) starting from the earlier stages of LV dysfunction. However, it was effectively compensated by significant increase in the radial RV component resulting in preservation of total RVEF in those with normal, mildly and moderately reduced LVEF (50 [46;54] vs 47 [44;52] vs 46 [42;49]%), whereas total RVEF dropped significantly only in severe LV dysfunction (30 [25;39]%; p &lt; 0.0001) (Fig. D).

Conclusions. The longitudinal and anteroposterior RV contraction was related to the LVEF and decreased from early stages of the LV systolic dysfunction. Increase in the radial component compensated for the loss of longitudinal and anteroposterior RV components in mild and moderate LV dysfunction to maintain total RVEF. Drop in all three components resulted in significant reduction of total RVEF in severe LV dysfunction.

Characteristics of study population Overall (N = 295) LVEF≥50% (N = 166) LVEF &lt; 50% (N = 129) LV EF, % 49.6 ± 14.3 59.9 ± 5.6 36.4 ± 10.9* RV EF, % 46.5 ± 9.2 49.8 ± 6.9 42.3 ± 10.0* RV LEFi 0.42 ± 0.09 0.45 ± 0.09 0.38 ± 0.09* RV REFi 0.47 ± 0.1 0.45 ± 0.1 0.50 ± 0.09* RV AEFi 0.39 ± 0.08 0.41 ± 0.08 0.37 ± 0.07* *p &lt; 0.0001 Abstract Figure.

Assessment of right ventricular segmental volumes and ejection fractions using a 15-segment model: three-dimensional echocardiographic study in healthy volunteers

Funding Acknowledgements

Type of funding sources: None.

On top of global ventricular function, segmental metrics may bear clinically relevant information. Concerning the left ventricle (LV), standardized segmentation is widely performed in different cardiovascular imaging modalities mainly to correlate regional dysfunction with coronary perfusion territories, or to appreciate and quantify distinct patterns in LV myocardial function. The same applies to the right ventricle (RV); as pulmonary hypertension, or arrhythmogenic cardiomyopathy are just two clinical examples among several others, where established regional dysfunction exists. Nevertheless, only a few options are available for the comprehensive and quantitative assessment of the segmental RV function due to its complex three-dimensional (3D) shape.

Therefore, our aim was to develop a 3D echocardiographic software solution for volumetric partitioning of the RV using a 15-segment model and to investigate a large number of healthy volunteers to describe the normal segmental pattern.

One hundred and fifty healthy adults with a balanced age range and an equal sex distribution were investigated (15-15 women and men in each age groups: 20-29, 30-39, 40-49, 50-59, 60+). Beyond standard two-dimensional echocardiographic protocol, full volume 3D datasets were acquired. Using commercially available software, we reconstructed the 3D mesh model of the RV and measured end-diastolic (EDV), end-systolic volumes and ejection fraction (EF). The 3D model was post-processed using the ReVISION method to calculate regional and segmental volumes and EFs. Fifteen standard segments were separated and quantified (Figure).

Increasing age resulted in significantly lower RV stroke volume (r=-0.17; p &lt; 0.05) and tended towards lower RV EDV (r=-0.15, p = 0.06). EDVs of inflow tract and outflow tract segments decreased during aging (r=-0.21, p &lt; 0.05 and r=-0.26, p &lt; 0.01, respectively). Between the pre-specified age groups, there was no difference concerning global RVEF (ANOVA p = NS). In the 50-59 age group, regional EF of septal segments and also free wall segments were significantly lower compared to subjects in the 30-39 and 40-49 age categories (both p &lt; 0.05). Global RV EDV was significantly lower in women (women vs. men: 95 ± 20 vs. 125 ± 28 ml; p &lt; 0.05) along with a higher RV EF compared to men (62 ± 4 vs. 59 ± 4; p &lt; 0.05). However, segmental EFs of apical, septal mid anterior, free wall mid posterior, free wall mid lateral, septal basal anterior and inflow tract segments were comparable between genders.

The ReVISION method allows a volumetric partitioning of the RV 3D models to investigate segmental geometry and function in a 15-segment model. We have explored segmental differences between different ages and genders. Further studies are warranted to justify the importance of segmental assessment of the RV in different cardiac diseases.

Abstract Figure. Separation of 15 standard RV segments

Lateral left ventricular lead position is superior to posterior position in long-term outcome of patients underwent cardiac resynchronization therapy

Background

Preferring side branch of coronary sinus during cardiac resynchronization therapy (CRT) implantation is empirical due to the limited data on the association of left ventricular (LV) lead position and long-term clinical outcome.

Purpose

We evaluated the long-term all-cause mortality by LV lead non-apical positions and further characterized them by interlead electrical delay (IED).

Methods

In our retrospective database 2087 patients were registered between 2000 and 2018. Those with non-apical LV lead locations were classified into anterior (n=108), posterior (n=643), and lateral (n=1336) groups. All-cause mortality was assessed by Kaplan-Meier and Cox analyses. Echocardiographic response was measured 6 months after CRT implantation.

Results

During the median follow-up time of 3.7 years, 1150 (55.1%) patients died, 710 (53.1%) with lateral, 78 (72.2%) with anterior and 362 (56.3%) with posterior positions. Patients with lateral position had significantly better outcome in all-cause mortality compared to others (HR 0.80; 95% CI: 0.71–0.90; p&lt;0.0001), which was also confirmed by multivariate analysis after adjusting for relevant clinical covariates (HR 0.81; 95% CI: 0.72–0.91; p&lt;0.0001). When echocardiographic response was evaluated in the lateral group, patients with an IED longer than 110 ms (ROC AUC 0.63; 95% CI: 0.53–0.73; p=0.012) showed 2.1 times higher odds of improvement in echocardiographic response 6 months after the implantation.

Conclusions

In this study we proved that after CRT implantation only the lateral LV lead location was associated with long-term mortality benefit. Moreover, patients with this position showed the greatest echocardiographic response over 110 ms IED.

Survival of total patient cohort

Funding Acknowledgement

Type of funding source: None

Exploring sex-specific patterns of mortality predictors among patients undergoing cardiac resynchronization therapy: a machine learning approach

Background

The relative importance of variables explaining sex differences in outcomes is scarcely explored in patients undergoing cardiac resynchronization therapy (CRT).

Purpose

We sought to implement and evaluate machine learning (ML) algorithms for the prediction of 1- and 3-year all-cause mortality in patients undergoing CRT implantation. We also aimed to assess the sex-specific differences and similarities in the predictors of mortality using ML approaches.

Methods

A retrospective registry of 2191 CRT patients (75% males) was used in the current analysis. ML models were implemented in 6 partially overlapping patient subsets (all patients, females or males with 1- or 3-year follow-up data available). Each cohort was randomly split into a training (80%) and a test set (20%). After hyperparameter tuning with 10-fold cross-validation in the training set, the best performing algorithm was also evaluated in the test set. Model discrimination was quantified using the area under the receiver-operating characteristic curves (AUC) and the associated 95% confidence intervals. The most important predictors were identified using the permutation feature importances method.

Results

Conditional inference random forest exhibited the best performance with AUCs of 0.728 [0.645–0.802] and 0.732 [0.681–0.784] for the prediction of 1- and 3-year mortality, respectively. Etiology of heart failure, NYHA class, left ventricular ejection fraction and QRS morphology had higher predictive power in females, whereas hemoglobin was less important than in males. The importance of atrial fibrillation and age increased, whereas the relevance of serum creatinine decreased from 1- to 3-year follow-up in both sexes.

Conclusions

Using advanced ML techniques in combination with easily obtainable clinical features, our models effectively predicted 1- and 3-year all-cause mortality in patients undergoing CRT implantation. The in-depth analysis of features has revealed marked sex differences in mortality predictors. These results support the use of ML-based approaches for the risk stratification of patients undergoing CRT implantation.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary

Mechanical diversity in the adaptation of left and right ventricular function to long-term exercise: 3D echocardiographic study in a large cohort of competitive athletes

 

Regular physical exercise results in complex remodelling of the left- (LV) and right ventricle (RV), commonly referred as the athlete's heart. Despite the well-known changes in ventricular volumes and mass, data are scarce regarding ventricular mechanics and its connection to exercise performance.

Accordingly, our aim was to characterize biventricular morphological and functional changes and their association with peak exercise capacity in a large cohort of athletes using three-dimensional (3D) echocardiography.

Competitive athletes of various training regimes (n=525, age: 20±6 years, training: 15±7 hours/week, 30% female) were enrolled, while 73 age- and gender-matched sedentary volunteers served as the control group. Full volume 3D echocardiographic datasets focused on the LV or the RV were acquired for further analysis: LV and RV end-diastolic volume (EDVi), LV mass (Mi) indices and ejection fraction (EF) were quantified. To characterize biventricular mechanics, LV and RV global longitudinal strain (GLS) and global circumferential strain (GCS) were also measured using dedicated software. Athletes also underwent cardiopulmonary exercise testing to determine peak oxygen uptake (VO2/kg).

Athletes had significantly higher LV and RV EDVi (81±13 vs. 64±11 mL/m2; 83±14 vs. 63±11 mL/m2; both p&lt;0.001) and also LVMi (87±15 vs. 65±12 g/m2; p&lt;0.001) compared to controls. LV and RV EF were significantly lower in athletes (57±5 vs. 60±6%; 55±5 vs. 58±5%; both p&lt;0.001). LV GLS (−19.5±2.1 vs. −20.6±2.6%; p&lt;0.001) and also LV GCS (−27.9±3.2 vs. −29.8±4.4%; p&lt;0.001) was lower in athletes compared to controls. In opposed to the LV, RV GLS did not differ between the two groups (−29.3±5.8 vs. −29.5±5.3%; p=NS), however, RVGCS was decreased in athletes compared to controls (−24.4±6.1 vs. −28.6±7.3%; p&lt;0.001). In athletes, ventricular morphology measured by LV and RV EDVi correlated with VO2/kg (both r=0.37; p&lt;0.001), while functional measures, such as lower resting LV GLS (r=0.22; p&lt;0.001) and RV GCS (r=0.14; p&lt;0.01) also showed relationship with better exercise performance.

According to our results, regular physical exercise is associated with significant changes of LV and RV geometry and mechanics. Resting biventricular systolic function of the athlete's heart is characterized by a mild reduction, which is attributable to a lower longitudinal and circumferential shortening on the left side of the heart, while on the right side lower circumferential shortening can be seen along with a maintained longitudinal shortening. Moreover, this mechanical pattern also correlates with exercise performance.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): “National Heart Program” NVKP_16-1-2016-0017; NKFIH K_16 K120277 to BM

Longitudinal strain reflects the interaction of myocardial contractility to afterload in rat models of hemodynamic overload-induced heart failure

Background

Two-dimensional (2D) speckle tracking echocardiography (STE)-derived myocardial strain parameters are sensitive markers of left ventricular (LV) systolic function. Novel findings suggest that the contractile state of the myocardium, afterload and preload are major determinants of STE measurements. However, the hypothesis that longitudinal strain expresses the interaction between contractility and loading conditions rather than contractility alone in hemodynamic overload-induced heart failure (HF) has not been tested.

Purpose

This study aimed to explore the connection between longitudinal strain and contractility, afterload and preload in rat models of pressure overload (PO)- and volume overload (VO)-induced heart failure (HF).

Methods

Pressure overload (PO)-induced HF was evoked by transverse aortic constriction ([TAC], n=14). Volume overload (VO)-induced HF was established by an aortocaval fistula ([ACF], n=12). Age-matched sham operated animals served as controls. Pressure-volume analysis was carried out to compute cardiac contractility (slope of end-systolic pressure-volume relationship [ESPVR]), afterload (arterial elastance [Ea]) and ventriculo-arterial coupling ([VAC] = Ea/ESPVR). Preload was evaluated by meridional end-diastolic wall stress (σend-diastolic). STE was performed to assess global longitudinal strain (GLS).

Results

GLS was impaired in both PO-induced HF (−5.9±0.6 vs. −12.9±0.5%, TAC vs Sham, P&lt;0.001) and VO-evoked HF (−11.7±0.7 vs. −13.5±0.4%, ACF vs Sham, P=0.048). Hemodynamic measurements indicated that the TAC group presented with maintained ESPVR, increased Ea and enhanced σend-diastolic. In contrast, the ACF group was characterized by reduced ESPVR, decreased Ea and enhanced σend-diastolic. Ordinary least squares non-linear regression revealed that GLS was predominantly determined by afterload (Ea) in the TAC model and by contractility (ESPVR) in the ACF model. In accordance, GLS showed a strong correlation with Ea in case of PO-induced HF (R= 0.848, P&lt;0.001) and with ESPVR in case of VO-evoked HF (R=−0.526; P=0.008), respectively. Furthermore, GLS also demonstrated strong correlation with VAC in both the TAC and the ACF models. Of particular interest, a robust correlation between VAC and GLS could also be detected in the entire study population (R= 0.654, P&lt;0.001).

Conclusion

Both afterload and contractility define GLS. Hence, under conditions when both factors become altered, GLS reflects VAC.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NVKP_16-1-2016-0017

Cardiac functional consequences of stroke induced by transient middle cerebral artery occlusion in a rodent model

Background

The cardiac functional consequences of ischaemic stroke are still need to be elucidated, while according to ethical issues only non-inasive measurents were carried out in patients underwent transient cerebral ischaemia.

Purpose

We aimed at investigating left ventricular function using non-invasive and invasive modalities in a rat model of transient focal ischaemia.

Methods

Age-matched, young adult rats were used for this study. Serial left ventricular echocardiographic measurements and speckle-tracking analysis were performed in rats (n=9) underwent transient middle cerebral artery occlusion (MCAO) before, during and immediately after the induction of stroke, with a follow-up at 24, 48, 72 hours; 7, 11 and 14 days. In another experimental setting, 48 hours after stroke induction (MCAO group, n=9) we characterized left ventricular function by pressure-volume analysis, that was compared to sham-operated controls (Co group, n=9).

Results

Serial echocardiographic measurements showed impaired systolic function, that was most severe 48 hours after MCAO (global circumferential strain, GCS: −14.8±2.6% 48 hours after MCAO vs. −19.3±2.4% baseline, p&lt;0.05). A complete recovery of systolic functional deterioration was observed after 14 days (GCS: −19.2±2.5% 14 days after MCAO vs. −19.3±2.4% baseline, n.s.). Heart weight (normalized to tibial weight) did not differ between MCAO and Co animals. Pressure-volume analysis revealed unaltered diastolic function and showed unchanged load-independent contractility index values (slope of end-systolic pressure-volume relationship, ESPVR: 2.56±0.29mmHg/μl MCAO vs. 2.55±0.59 mmHg/μl Co, n.s.) after MCAO. There was a tendency towards increased systolic pressure and deteriorated ventriculo-arterial coupling in animals underwent stroke.

Conclusions

Our data suggests that MCAO is associated with reversible impairment of systolic function during echocardiographic measurements, however without alteration of intrinsic myocardial contractility. The tendency towards increased afterload might explain the observed alterations in rats underwent stroke.

Funding Acknowledgement

Type of funding source: None

Resting levels of cardiac markers in athletes

Introduction

Examination of specific cardiac enzymes and peptide fragments is essential in cases of acute myocardial ischemia and heart failure. According to previous data, exhausting physical effort may cause temporary increase of cardiac necroenzyme levels, while no information is available on their resting values in athletes.

Methods

Resting serum levels of hsTroponinT, CKMB, LDH and NT-proBNP were measured as part of extended sports cardiology screening in healthy athletes and a healthy sedentary non-athlete control group. Depending on normality, groups were compared with two-tailed Student's t-test or Mann-Whitney U-test. Statistical analysis was processed in RStudio integrated development environment.

Results

Results of 237 healthy athletes from different sports (male: 144, age: 19.1±5.9 years, training: 16.0±6.7 hours/week) and 53 sedentary non-athletes (male: 23, age: 19.8±3.2 years, training: 2.6±2.3 hours/week) were analysed. In athletes, increased resting cardiac marker levels were measured as follows: CKMB: 6.3% (n=15), LDH: 3.4% (n=8), hsTroponinT: 4.2% (n=10), NT-proBNP: 0.8% (n=2) of the cases. No elevation of CKMB and hsTroponin T levels were measured in the control group, while only single cases of increased LDH and NT-proBNP were detected. We measured higher levels of CKMB (17.6±7.3 vs. 12.3±3.4 U/l, p&lt;0.001), LDH (322.4±60.8 vs. 286.0±51.1 U/l, p&lt;0.001) and hsTroponinT (6.2±4.7 vs. 4.3±1.4 ng/l, p&lt;0.05), while lower levels of NT-proBNP (23.9±27.2 vs. 49.8±38.7 pg/ml, p&lt;0.001) in athletes compared to the control group. In male athletes, higher levels of CKMB (18.5±6.6 vs. 16.0±8.2 U/l, p&lt;0.001), LDH (337.0±62.2 vs. 300.7±51.9 U/l, p&lt;0.001) and hsTroponinT (7.0±5.3 vs. 4.3±1.9 ng/l, p&lt;0.001), and lower levels of NT-proBNP (19.8±23.1 vs. 35.0±34.1 pg/ml, p&lt;0.001) were measured compared to female athletes. Levels of hsTroponinT decreased in athletes due to increasing age (r=−0.20, p&lt;0.05).

Discussion

According to our results, resting levels of cardiac markers show significant alterations due to sport adaptation of the heart. These changes depend on age and sex as well.

Conclusions

Our research attract attention to different assessment of cardiac markers in athletes in respect of recognition of cardiovascular pathologies.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary.

40Lateral left ventricular lead position and long interlead electrical delay predict long-term all-cause mortality in cardiac resynchronization therapy patients

Background

There is limited data on the association of left ventricular (LV) lead position and long-term clinical outcome in patients after cardiac resynchronization therapy (CRT).

Purpose

We evaluated the mid-term echocardiographic response and long-term all-cause mortality of patients who underwent CRT implantation by LV lead non-apical positions and further characterized them by right to left ventricular, interlead electrical delay (IED).

Methods

In our retrospective registry patients after CRT implantation between 2000 and 2018 were registered. Those with non-apical LV lead location were classified into anterior (n = 111), posterior (n = 652), and lateral (n = 1373) positions. Primary endpoint was all-cause mortality assessed by univariate- and Cox multivariate analyses. Secondary endpoint was echocardiographic response within 6 months after CRT implantation.

Results

From 2136 patients 1180 (55.2%) reached the primary endpoint during the mean follow up time of 4.5 years. Univariate analysis showed patients with lateral position had significantly better outcome compared to others (HR 0.80; 95% CI: 0.71-0.90; p &lt; 0.01), which was also confirmed by Cox multivariate analysis (HR 0.69; 95% CI: 0.50-0.93; p = 0.02) after adjusting for relevant clinical covariates such as IED and LBBB. The median value of IED was 106 (89/124) ms in the total patient cohort, which was significantly longer in the lateral group [anterior 80 (60/100) ms vs. lateral 110 (91/128) ms vs. posterior 100 (85/120) ms; p&lt; 0.01]. When echocardiographic response was further evaluated in patients with lateral position, those with an IED longer than 110 ms (ROC AUC 0.64, 95% CI: 0.54-0.74; p = 0.01) showed the greatest benefit within 6 months.

Conclusions

After CRT implantation the most beneficial outcome was associated with lateral left ventricular lead location, moreover the greatest echocardiographic response was found when interlead electrical delay was longer than 110 ms in this group.

Abstract Figure. All-cause mortality of total cohort

429 Right ventricular longitudinal and radial fiber contractility in patients undergoing mitral valve surgery: a PREPARE-MVR substudy

Severe mitral regurgitation results in significant hemodynamic demands of not only the left, but the right ventricle (RV) as well. Increased pulmonary pressures and consequential pressure overload of the RV induces complex remodeling, which can be partially restored by mitral valve repair/replacement (MVR). MVR is associated with marked changes of RV deformation, however, the clinical significance of these changes is not well estabilished. The PREPARE-MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) aims to determine parameters, which may predict the perioperative risk of acute RV failure.

In this current substudy, our aim was to determine the changes of RV global, longitudinal and radial fiber contractility before and following MVR.

Our study group consisted of 27 MVR patients (mean age: 64 ± 12 years, m/f: 19/8). Transthoracic 3D echocardiography was performed before the operation and following intensive care unit discharge. 3D beutel model of the RV was created and RV end-diastolic volume index (EDVi) among with RV ejection fraction (RVEF) were calculated using commercially available software. For in-depth analysis of RV mechanics, we have decomposed the motion of the RV using our custom software (ReVISION) to determine longitudinal (LEF) and radial ejection fraction (REF). Right heart catheterization was also performed before MVR and 24 hours after MVR as well to measure pulmonary arterial mean systolic pressure (mPAP), pulmonary arterial wedge pressure (PAWP) and RV stroke work index (RVSWi). Using the aforementioned parameters, we have calculated RV longitudinal (longRVSWi) and RV radial stroke work index (radRVSWi), which represent RV longitudinal and radial fiber contractility.

RV morphology did not change significantly according to RVEDVi (preop vs. postop: 71 ± 17 vs. 72 ± 20 mL/m², p = NS). RVEF slightly decreased after MVR (50 ± 6 vs. 48 ± 7 %, p &lt; 0.05), however, RV motion pattern markedly changed. Postoperative LEF was significantly lower compared to preoperative values (25 ± 6 vs. 16 ± 6%, p &lt; 0.0001), among with an increase in REF (21 ± 7 vs. 27 ± 7%, p &lt; 0.01). As expected, mPAP and PAWP decreased in response to MVR (mPAP: 30 ± 10 vs. 25 ± 7 mmHg; PAWP: 19 ± 7 vs. 13 ± 3 mmHg, both p &lt; 0.01). Global RV contractility decreased after surgery (RVSWi: 603 ± 355 vs. 474 ± 251 mmHg*mL/m², p &lt; 0.05). While RV longitudinal contractility also significantly reduced (longRVSWi: 289 ± 179 vs. 166 ± 122 mmHg*mL/m², p &lt; 0.001), radial contractility was maintained following MVR (radRVSWi: 240 ± 141 vs. 261 ± 144 mmHg*mL/m², p = NS).

MVR is associated with marked changes of RV function and hemodynamics. RV longitudinal and radial contractility have distinct response to surgery, which may be important in postoperative patient management. The PREPARE-MVR study aims to examine the role of preoperative RV mechanics in clinical outcome.

P947 Left- and right ventricular mechanics in athletes: a true marker of fitness?

Regular physical exercise results in marked changes of ventricular morphology and function, also referred as the athlete’s heart. Despite the marked changes of cardiac morphology and function in athletes, data is scarce regarding the relationship between exercise performance and cardiac adaptation to exercise.

Accordingly, our aim was to examine the relationship between ventricular morphology and function and exercise capacity in a prospective cohort study.

Young elite soccer players (n = 18, age: 16 ± 1 years) were enrolled and examined at baseline and following 1 year. Athletes underwent cardiopulmonary exercise testing to determine peak oxygen uptake (VO2/kg). Following exercise testing, 3D echocardiography was performed and LV and RV focused loops were obtained. By off-line analysis, we measured left- (LV) and right ventricular (RV) end-diastolic volume indices (EDVi) and LV mass index (LVMi) indexed to body surface area and LV and RV ejection fractions (EF). By 3D speckle-tracking analysis of the LV and RV we also determined global longitudinal (GLS) and circumferential (GCS) strains.

We found improved and decreased peak exercise performance as well during the 1 year follow-up with an overrall increased mean exercise capacity (dVO2/kg: 2.6 ± 7.3 ml/min/kg). LV and RV morphology did not change significantly according to LVEDVi and RVEDVi (LVEDVi: 84 ± 14 vs. 80 ± 7 ml/ m², RVEDVi: 82 ± 11 vs. 84 ± 10 ml/m², both p = NS). LVMi significantly increased (82 ± 14 vs. 89 ± 9 g/m², p &lt; 0.001). LV and RV EF did not change during one year follow-up (LVEF: 58 ± 4 vs. 57 ± 5%; RVEF: 57 ± 4 vs. 55 ± 6%, both p = NS), while LVGLS decreased compared to baseline (19.7 ± 1,8 vs. 19.3 ± 2,8%, p &lt; 0.01). The change in VO2/kg showed correlation with decreased LVGLS and also with decreased RVGCS (dLVGLS vs. dVO2/kg: r=-0.56, dRVGCS vs. dVO2/kg: r=-0.50, both p &lt; 0.05)

During 1 year follow-up cardiac morphology and function significantly changed in our athlete cohort, and these changes showed relationship with the changes of peak exercise performance. Detailed assessment of myocardial mechanics may help to monitor training in athletes.

P3105Cardiopulmonary exercise testing normal values for young athletes and non-athletes

Introduction

Cardiopulmonary exercise testing (CPET) is an important diagnostic method to evaluate athletes and non-athletes, however we do not have widely accepted normal values for correct evaluation and interpretation in the young.

Goals

Our aim was to compare CPET parameters of young athletes and non-athletes and determine reference values.

Methods

Exercise tests were performed in young non-athletes, aged <18 years between 2011 to 2016 at Mayo Clinic. Athletes underwent detailed sports cardiology screening including CPET at Semmelweis University Heart and Vascular Center between 2016 and 2018. Individuals with cardiovascular disease were excluded. We created 2 subgroups in both sexes: 12–14 years (Group 1), 15–17 years (Group 2). Statistical analysis was performed using SAS with analysis of variance under the general linear model adjusting for age, body mass index and test effort based on peak respiratory exchange ratio (RER).

Results

A total of 212 athletes (92% male, 15.5±0.6ys) and 207 non-athletes (68% male, 15.0±0.7ys) were included in the analysis. In Group 1 boys, athletes have higher peak HR (200.0±9.2 vs 188.5±16.8 bpm, p<0.0001), HR reserve (117.1±14.5 vs 108.9±19.8 bpm p<0.05), VO2 max (53.7±6.6 vs 44.7±9.1 mL/kg/min p<0.0001), ventilation (VE) (120.3±25.0 vs 70.7±21.6 L/min p<0.0001) and RER (1.12±0.0 vs 1.07±0.08, p <.001) compared to controls. In Group 2 boys, there was no difference in peak HR and HR reserve, but athletes have higher VO2 max (57.2±4.7 vs 45.3±9.3 mL/kg/min, p<0.0001) and VE (150.7±23.7 vs 104.1±25.9 L/min, p<0.0001), similarly as Group 2 girls: VO2 max (46.3±3.6 vs 34.9±8.5 mL/kg/min p<0.0001), VE (118.7±12.5 vs 68.4±20.6 L/min, p<0.0001). In male athletes, peak HR (200.6±9.2 vs 196.5±7.4 bpm p<0.05) and HR recovery (34.2±9.8 vs 29.8±11.1 bpm p<0.05) decreases with age, while VO2 max (53.7±6.6 vs 57.2±4.7 mL/kg/min, p<0.001) and VE (120.3±24.9 vs 150.7±23.7 L/min, p<0.0001) increases. Lower cut-off values were determined in each group (Figure).

Lower-cut off values

Conclusion

We created a unique Mayo-Semmelweis database of young athletes and non-athletes. As a result of intensive training, athletes show higher levels of CPET variables vs non-athletes. Our study provides CPET reference values in the pediatric age group, applying them could contribute to correct evaluation and interpretation of CPET, increasing its diagnostic potential.

P3445Subclinical myocardial dysfunction in pediatric kidney transplant recipients: a two-dimensional speckle-tracking echocardiography study

Chronic kidney disease is associated with increased risk of cardiovascular mortality and morbidity in pediatric patients as well. Renal transplantation results in improved survival, however, several factors contribute to markedly elevated cardiovascular complication rate compared to the healthy population. While major cardiac events occur rarely in pediatric population, detection of subclinical changes in cardiac morphology and function may be of high interest to effectively identify high-risk patients.

Accordingly, our aim was to investigate left (LV)- and right ventricular (RV) morphology and function using conventional and two-dimensional (2D) speckle-tracking echocardiography (STE) in pediatric renal transplant recipients.

Our study group consisted of 41 kidney transplanted children (RTX; mean age: 14±3 years, m/f: 25/16) and 39 age- and gender matched healthy controls. Using 2D echocardiography, LV and RV focused apical loops were obtained and LV end-diastolic volume index (EDVi), ejection fraction (EF), mass index (Mi), RV end-diastolic area index (EDAi) and fractional area change (FAC) were measured. Using STE, we have determined LV global longitudinal (GLS) and circumferential strain (GCS), RV GLS, and LV and RV early diastolic longitudinal strain rate (LSrE).

LV EDVi did not differ between RTX and controls (51±13 vs. 52±10 mL/m2, p=NS), while LVMi was markedly higher in RTX patients (36±8 vs. 28±6 g/m2, p<0.0001). LVEF was comparable between the two groups (62±5 vs. 62±3%; p=NS), while LV GLS was significantly lower in RTX (−20.6±2.1 vs. −21.8±2.1%, p=0.01) along with a tendential increase in LV GCS (−31.6±4.3 vs. −29.7±4.6%, p=0.06). LV LSrE was significantly lower in RTX patients (1.29±0.29 vs. 1.45±0.27 1/s, p<0.05). RV EDAi did not differ between the two groups (11.2±2.3 vs. 11.6±2.0 cm2/m2, p=NS). Interestingly however, RTX patients had significantly higher RV FAC and RV GLS (FAC: 46±7 vs. 42±4%, GLS: −24.6±3.7 vs. −22.4±2.6%, both p<0.01) along with lower RV LSrE (1.32±0.57 vs. 1.60±0.43, p<0.05).

Cardiac morphology and function shows distinct changes after RTX. Along with comparable ventricular dimensions, LV hypertrophy and subclinical systolic and diastolic dysfunction is present. RV systolic function is relatively increased accompanied by subclinical diastolic dysfunction of the chamber, which may refer to previous RV overload. STE may be a useful tool to reveal early myocardial dysfunction in pediatric kidney transplant recipients.

5107Survival prediction in patients undergoing cardiac resynchronization therapy: a machine learning based risk stratification system

Background

Cardiac Resynchronization Therapy (CRT) has well-known beneficial effects in patients with advanced heart failure, reduced ejection fraction and wide QRS complex. However, mortality rates still remain high in this patient population. Therefore, precise risk stratification would be essential, nonetheless, the currently available risk scores have several shortcomings which hamper their utilization in the everyday clinical practice.

Purpose

Accordingly, our objective was to design and validate a machine learning based risk stratification system to predict 2-year and 5-year mortality from pre-implant parameters of patients undergoing CRT implantation.

Methods

We trained two models separately to predict 2-year (model 1) and 5-year mortality (model 2). As training cohort of model 1 we used 1678 patients (67±10 years, 1251 [75%] males) undergoing CRT implantation. From this population, 1320 patients (66±10 years, 1005 [76%] males) also completed 5-year follow-up and they served as the training cohort for model 2. Forty-seven pre-implant parameters (demographics, cardiovascular risk factors and clinical characteristics) were used to train the models. Our models were designed in a way to tolerate missing values. Among non-linear classifiers, random forest demonstrated the best performance. We validated our models, along with the Seattle Heart Failure Model (SHFM), VALID-CRT risk score and EAARN score on an independent cohort of 136 patients (66±10 years, 110 [81%] males). Based on the predicted probability of survival, patients were split into quartiles and survival was plotted via Kaplan-Meier (KM) curves.

Results

There were 358 (21%) deaths in the 2-year, 697 (53%) deaths in the 5-year training cohort. In the validation cohort, there were 30 (22%) deaths at 2 years and 58 (43%) deaths at 5 years after CRT implantation. For the prediction of 2-year mortality, the Area Under the Receiver-Operating Characteristic Curve (AUC) for model 1 was 0.77 (95% CI: 0.67–0.87; p=0.002), for SHFM was 0.54 (95% CI: 0.39–0.69; p=0.006), for EAARN was 0.57 (95% CI: 0.46–0.68, p=0.002), and for VALID-CRT was 0.62 (95% CI: 0.52–0.71; p=0.002). To predict 5-year mortality, the AUC for model 2 was 0.85 (95% CI: 0.78–0.91; p=0.001), for SHFM was 0.62 (95% CI: 0.51–0.74; p=0.003), for EAARN was 0.61 (95% CI: 0.51–0.70, p=0.002), for VALID-CRT was 0.65 (95% CI: 0.56–0.74; p=0.002). The AUCs of the machine learning based models were significantly higher than the AUCs of the pre-existing scores (DeLong test, all p<0.05). The KM curves of the quartiles were significantly separating in both models (Log-rank test, both p<0.001).

Conclusion

Our results indicate that machine learning algorithms can outperform the already existing linear model based scores. By capturing the non-linear association of predictors, the utilization of these state-of-the-art approaches may facilitate optimal candidate selection and prognostication of patients undergoing CRT implantation.

5939Perioperative shift in right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of right ventricular failure?

Background

Severe mitral regurgitation (MR) induces significant changes not only in the left, but also in the right ventricular (RV) morphology and function. Early treatment of MR is recommended, however, surgical procedure disrupts the native RV contractile pattern and predisposes the at-risk ventricle to develop postoperative RV failure (RVF) which is associated with poor outcomes.

Purpose

Accordingly, the PREPARE-MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) aims to explore the alterations of RV contraction pattern in patients undergoing MVR and to investigate the association of preoperative echocardiographic findings with early postoperative RVF.

Methods

We prospectively enrolled 70 patients (62±12 years, 67% males) undergoing open heart MVR. Thirty age and gender matched healthy volunteers served as control group. Transthoracic 3D echocardiography was performed preoperatively and at intensive care unit discharge. Furthermore, focused 2D echocardiogram was also obtained during the ICU stay. Forty-three patients also completed 6 months follow-up. 3D model of the RV was reconstructed and end-diastolic volume index (EDVi) along with RV ejection fraction (RVEF) were calculated. For in-depth analysis of RV mechanics, we decomposed the motion of the RV to compute longitudinal (LEF) and radial ejection fraction (REF). Right heart catheterization was performed to monitor RV stroke work index (RVSWi).

Results

RV morphology as assessed by EDVi was unaffected by surgery (preoperative vs postoperative; 73±17 vs 71±16 mL/m2, p=NS). RVEF was slightly decreased after MVR (52±6 vs 48±7%, p<0.05), whereas RV contraction pattern has changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic function (LEF/RVEF vs REF/RVEF; 0.53±0.10 vs 0.43±0.12; p<0.001), whereas in controls the longitudinal and radial shortening contributed equally to RVEF (0.47±0.07 vs 0.43±0.09; p=NS). Postoperatively, the radial motion became dominant (0.35±0.08 vs 0.47±0.09; p<0.001). However, this shift was only temporary as 6 months later the contraction pattern became similar to controls showing equal contribution of the two components (0.44±0.10 vs 0.42±0.11; p=NS). Postoperative RVF (defined as RVSWi <300 mmHg*mL/m2 or ICU TAPSE <10 mm) was detected in 14 [20%] patients. Preoperative LEF was associated with postoperative RVSWi (r=−0.61, p<0.001) and it was an independent predictor of postoperative RVF (OR=1.16 [1.03–1.35], p<0.05).

Conclusion

Severe MR induces a significant shift in the RV mechanical pattern which may influence the development of postoperative RV dysfunction and failure after MVR. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict postoperative RVF.

P310Differentiation between arrhythmogenic right ventricular cardiomyopathy and athlete's heart using cardiac magnetic resonance based derived parameters and strain analysis

Acknowledgement/Funding

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277), ÚNKP-18-3-IV New National Excellence Program of Human Capacities.

6066Equal significance of longitudinal and radial wall motion represents the normal right ventricular mechanical pattern: 3D echocardiographic study in 231 healthy volunteers

Three main mechanisms contribute to right ventricular (RV) pump function: (1) shortening of the longitudinal axis with traction of the tricuspid annulus towards the apex; (2) inward (radial) movement of the RV free wall, which is often referred as the “bellows effect”; and (3) bulging of the interventricular septum into the RV during the left ventricular contraction and stretching of the free wall over the septum (causing shortening in the anteroposterior direction). Despite the established clinical value of the functional changes among the aforementioned components, their relative importance remains to be quantified during physiological conditions.

Accordingly, the aim of our study was to evaluate the relative contribution of the different RV motion directions to global RV function on both global and segmental level in a large set of healthy individuals.

We have recruited 231 healthy volunteers (44% female, with a wide and balanced age range from 8 to 81 years) from two experienced centers performing transthoracic 3D echocardiography (3DE) on a routine basis. 3DE datasets focused on the RV were obtained using multi-beat acquisition. We determined RV volumes and subsequent ejection fraction (RVEF) by dedicated software. Using the ReVISION method, we have decomposed the motion of the RV to determine longitudinal (LEF), radial (REF) and anteroposterior ejection fraction (AEF). Their ratio to RVEF quantifies the relative contribution of the given component to global RV function. Moreover, regional subvolumes were also analyzed in a 15-segment model.

Mean value of RVEF was significantly higher in female subjects compared to male subjects (60±7 vs. 56±7%, p<0.001). The relative contributions of LEF and REF to RVEF were comparable, while the contribution of AEF was significantly lower (LEF/RVEF vs. REF/RVEF vs. AEF/RVEF: 0.48±0.08 vs. 0.49±0.07 vs. 0.39±0.11, p<0.001) in the pooled population as well as in the genders separately. In line with higher RVEF found in women, female gender was associated with a higher longitudinal and radial contribution compared to males, however, AEF was similar (women vs. men; LEF/RVEF: 0.49±0.08 vs. 0.47±0.07, p<0.05; REF/RVEF: 0.50±0.07 vs. 0.48±0.06, p<0.01; AEF/RVEF: 0.38±0.12 vs. 0.40±0.10, p=NS). Interestingly, AEF/RVEF showed a significant deterioration with age (r=−0.354, p<0.001), while age-dependency of the longitudinal and radial contributions were not observed concerning both genders. An age-related decrease could be demonstrated by the volume fractions of the 5 septal volumetric segments (r=−0.229, p<0.001).

Motion decomposition and the 15 segments

In physiological conditions, the relative importance of longitudinal and radial wall motions is similar in determining global RV function. Aging accompanied by a decrease in anteroposterior shortening, which may point to a deteriorating systolic LV-RV interaction. Our results may facilitate further research concerning the alterations of RV mechanical pattern in various disease states.

P1631Machine-learning defined predictors of mortality in ischemic and non-ischemic heart failure patients undergoing CRT-P or CRT-D implantation

Background

Both Cardiac Resynchronization Therapy Pacemakers (CRT-P) and CRT Defibrillators (CRT-D) improve mortality in heart failure patients with reduced ejection fraction and wide QRS complex. However, not every patient benefits equally from each type of treatment and determinants of mortality may vary across the subgroups of patients with different etiologies and devices.

Purpose

Our aim was to investigate the differences in the predictors of long-term mortality in heart failure patients with different etiologies undergoing CRT-P or CRT-D implantation using machine learning.

Methods

We created 4 separate random forest models to predict 5-year all-cause mortality (models for ischemic and non-ischemic etiology in both CRT-P and CRT-D subgroups). A registry of 1650 patients (66±10 years, 1258 [76%] males, 751 [46%] CRT-D) was used as the training cohort for the prediction models. Forty-seven pre-implant parameters including cardiovascular risk factors and clinical variables were utilized to train our models. For each clinical parameter, we calculated the mean decrease in Gini impurity (dG). Based on the extent of decline, the 10 most important features were selected for each model. To keep the data comparable between the different models, we took the union of these features and plotted the results on radar charts.

Results

There were 879 (53%) deaths during the follow-up period. The mortality benefit of adding an Implantable Cardioverter Defibrillator could be observed only in ischemic patients (Hazard Ratio = 0.83, 95% Confidence Interval: 0.72–0.97, p<0.005), but not in the entire cohort or in patients with non-ischemic etiology. In patients with non-ischemic etiology, the pattern of mortality predictors were almost similar: in CRT-P patients the most important predictors were age, serum urea levels and left ventricular ejection fraction (LVEF) (dG: 0.114, 0.054 and 0.053, respectively) whereas in the CRT-D subgroup these factors were age, LVEF and serum sodium (dG: 0.116, 0.060 and 0.052, respectively). In CRT-P patients with non-ischemic etiology, the most relevant variables were age serum urea and LVEF in decreasing order (dG: 0.085, 0.060 and 0.050, respectively). The strongest predictors of mortality were age, hemoglobin and serum creatinine in ischemic patients with CRT-D (dG: 0.088, 0.060 and 0.052, respectively).

CRT-P vs. CRT-D by ischemic etiology

Conclusions

In patients with ischemic heart failure, CRT-D was associated with a mortality benefit compared to CRT-P. Our results also suggest that machine-learning may identify distinct patterns in clinical characteristics for a better mortality prediction. Taking these factors into consideration during the management of heart failure patients with CRT, risk stratification and outcomes could be improved.