Prognostic value of cardiac magnetic resonance in elderly patients soon after ST-segment elevation myocardial infarction

Background

Elderly patients with ST-segment elevation myocardial infarction (STEMI) represent a very high-risk population. Data on the prognostic value of cardiac magnetic resonance (CMR) in this scenario are scarce.

Purpose

We aim to study the prognostic value of an early (1-week) CMR in elderly patients after STEMI and to create a simple risk score including clinical and CMR variables.

Methods

The registry comprised 247 patients over 70 years of age discharged for a first STEMI treated with percutaneous intervention and included in a multicenter registry. Baseline characteristics, echocardiographic parameters and CMR-derived left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were prospectively collected. The additional prognostic power of CMR was assessed using adjusted C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

Results

During a 4.8-year mean follow-up, 66 (26.7%) first major adverse cardiac events (MACE) occurred (27 all-cause deaths and 39 re-admissions for acute heart failure). Higher GRACE score (HR 1.03 [1.02–1.04], p<0.001), more depressed CMR-LVEF (HR 0.97 [0.95–0.99] per increased %, p=0.006) and more extensive MVO (HR 1.24 [1.09–1.4] per segment, p=0.001) predicted MACE occurrence. The addition of CMR data significantly improved MACE prediction compared to the model with baseline and echocardiographic characteristics (C-statistic 0.759 [0.694–0.824] vs. 0.685 [0.613–0.756], NRI=0.6, IDI=0.08, p<0.001). The best cut-offs for independent variables were GRACE score >155, LVEF <40%, and MVO ≥2 segments. A simple score (0, 1, 2, and 3) based on the number of altered factors accurately predicted the MACE per 100 person-years: 0.78, 5.53, 11.51 and 78.79, respectively (p<0.001).

Conclusions

CMR data contribute valuable prognostic information in elderly patients submitted to undergo CMR soon after STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Infarction of the papillary muscle is an independent predictor of heart failure, ventricular tachycardia, and consequent mortality

Background

Previous studies have assessed the effect of papillary muscle infarction (papMI) as seen with Late Gadolinium Enhancement (LGE) Cardiac Magnetic Resonance imaging (CMR) after ST-segment elevation myocardial infarction (STEMI) on patient prognosis. As these studies delivered inconclusive results due to limited sample size and follow-up, we set out to assess whether STEMI patients with papMI are at an increased risk of cardiovascular mortality, heart failure, and arrhythmic events.

Methods

This is a 3-center observational study in n=1,055 consecutive STEMI patients who underwent CMR at a median of 6 (4–9) days, with a mean follow-up of 6.0 years (IQR 3.1–9.1 years). Any presence of papMI, be it supero-lateral, infero-medial, or double, was evaluated visually on the LGE images and checked on the matched cine images. The primary outcomes are time to cardiovascular mortality, heart-failure events defined as heart failure death and hospital admission for heart failure, and arrhythmic events, defined as arrhythmic death and ventricular tachycardia (VT).

Results

PapMI was diagnosed in 351 patients (33%). PapMI is an independent predictor of cardiovascular mortality after correction for clinically relevant parameters such as infarct size and left ventricular ejection fraction (Multivariate Cox Regression Hazard Ratio (HR)=2.46, 95% confidence interval (CI) 1.23–4.92). Secondly, papMI independently predicts the combined endpoints of heart failure death/heart failure (HR=1.72, 95% CI 1.12–2.63) and arrhythmic death/ VT (HR=4.52, 95% CI 2.18–9.36).

Conclusions

PapMI predicts cardiovascular mortality, arrhythmic death and heart failure. PapMI should be taken into account, especially when conducting new prognosis studies after STEMI and as a stratification factor in studies for secondary prevention of VT and arrhythmic death.

Funding Acknowledgement

Type of funding sources: Other.

Sex-based differences on adverse left ventricular remodeling and clinical outcomes after an ST-segment elevation myocardial infarction in the PCI era

Background

There is conflicting evidence regarding sex-based differences in myocardial salvage and clinical outcome in patients after an ST-segment elevation myocardial infarction (STEMI) in the contemporary era of primary percutaneous coronary intervention (PCI) and optimal medical treatment.

Adverse left ventricular remodelling (LVR) after a STEMI worsens outcomes, however, the influence of sex is not yet clear.

Aim/Purpose

To analyze whether there are sex differences in clinical outcomes and adverse LVR in patients after a STEMI.

Methods

Patients with STEMI who underwent primary PCI were included and a cardiac magnetic resonance (CMR) was performed during hospitalization (6.2±2.6 days) and after 6 months (6.1±1.8 months). LVR, myocardial salvage (MS), infarct size (IS), microvascular obstruction (MVO), and area at risk (AAR) were quantified. Adverse LVR was defined as a 15% increase in LV end-diastolic volume and a relative fall in LV ejection fraction of 3% at 6 months. The primary outcome was a composite of cardiovascular death, admission for heart failure, or ventricular arrhythmia.

Results

A total of 1046 patients were included (mean age: 59.8±9 years; 16.6% women), and a second CMR was completed in 589 patients. Women were older (58.8±8 years vs 65.0±10 years, p<0.0001) and presented more cardiovascular risk factors (Table). The primary outcome occurred in 310 patients during follow-up of 75 months (range: 36–112 months) and was more frequent in women than in men (35.8% vs 22.3%, p<0.001). After adjusting for baseline differences (age, diabetes, hypertension, Killip class, and time to reperfusion), female sex was not an independent predictor of major adverse cardiac events (Fig. 1A & B).

Although adverse LVR was a strong independent predictor for the primary outcome, no interaction was present between sex and LVR (women 6.4% vs men 8%, p=0.46) (Fig 1B), nor did we find significant differences between sex and other CMR derived variables such as MS, IS, MVO and AAR.

Conclusions

After a STEMI, women present worse clinical outcomes than men. However, these differences are related to their clinical characteristics and higher incidence of cardiovascular risk factors, and not to a higher incidence of adverse left ventricular remodeling.

Funding Acknowledgement

Type of funding sources: None.

A novel clinical and cardiac magnetic resonance risk score for early risk prediction after ST-segment elevation myocardial infarction

Background

Cardiac magnetic resonance (CMR) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. However, predictive models including clinical and CMR variables are scarce and not routinely implemented in clinical practice.

Purpose

We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients.

Methods

We performed a multicenter prospective registry in three Spanish university hospitals of reperfused STEMI patients (n=1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF), whichever occurred first. Univariate and multivariate analyses were performed and a risk score was computed using the variables which independently predicted the risk of MACE.

Results

During a median follow-up of 5.52 [2.63–7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3±12.3 years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion >4.15h (1 point), GRACE risk score >155 (3 points), CMR-LVEF <40% (3 points), and MVO >1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0–2 points), 5.44 in the intermediate-risk category (3–5 points), and 19.7 in the high-risk category (6–8 points): p<0.001 in multivariable Cox survival analysis.

Conclusions

A novel risk score including clinical (time to reperfusion >4.15h and GRACE risk score >155) and CMR (LVEF <40% and MVO >1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (FEDER) and Sociedad Española de Cardiología.

Aortic flow patterns by 4D flow CMR in Marfan and Loeys-Dietz patients before and after valve sparing aortic root replacement: a comparison with healthy volunteers

Introduction

Abnormal aortic flow patterns in patients with a connective tissue disorder (CTD), such as Marfan or Loeys-Dietz syndrome, may contribute to aortic root dilation [1,2]. Valve sparing aortic root replacement, which is effective in reducing the risk of aortic dissection in case of severe dilation, may also normalize flow patterns beyond the replaced aorta and potentially slow its progressive aortic dilation.

Purpose

To assess aortic flow dynamics in patients with a CTD by 4D flow cardiovascular magnetic resonance (CMR) before and after valve sparing aortic root replacement, and to compare the results with those of healthy volunteers (HV).

Methods

Patients with Marfan or Loeys-Dietz syndrome underwent two non-contrast enhanced 4D flow CMR, one before and another after undergoing valve sparing aortic root replacement. Healthy volunteers matched for age, sex and BSA were also included for comparison. Maximum velocity, in-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and wall shear stress (WSS) magnitude and its axial and circumferential components were obtained at 24 planes covering the thoracic aorta from the sinotubular junction to the descending aorta at the diaphragmatic level [3–5].

Results

Sixteen patients and 21 healthy volunteers were included. Demographic and clinical data is presented in Table. The mean time between the CMR prior and posterior to surgery was 15 months. Compared to HV, patients with CTD before intervention presented lower maximum velocity at the proximal ascending aorta (Fig. 1A), lower IRF and circumferential WSS at the arch and the proximal descending aorta (Fig. 1B and F), lower magnitude and axial WSS at the proximal ascending and descending aorta (Fig. 1E and D), and increased SFRR at the proximal descending aorta (Fig. 1C). The intervention completely restored maximum velocity and partially-restored physiological helical flow and circumferential WSS, but barely improved axial WSS and SFRR.

Conclusion

Valve sparing aortic root replacement in patients with Marfan or Loeys-Dietz syndrome partially restore to physiological level both in-plane rotational flow and circumferential wall shear stress in the descending aorta. This flow normalization may contribute to prevent progressive dilation after the surgery.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III (Spain) (PI17/00381)Spanish Society of Cardiology (SEC/FEC-INV-CLI 20/015)

Cardiac magnetic resonance predictors of readmission for heart failure in elderly vs not elderly patients after ST-segment elevation myocardial infarction

Background

Patients with ST-segment elevation acute myocardial infarction (STEMI) have an increased risk of re-admission for acute heart failure (AHF). However, identification of patients at higher risk of AHF is challenging, especially in elderly individuals. The implications of cardiac magnetic resonance (CMR) imaging soon after the acute event for this specific purpose are unknown.

Purpose

We aim to study the clinical and CMR predictors of AHF in elderly and not elderly patients after STEMI.

Methods

STEMI patients treated with percutaneous coronary intervention and discharged from three university hospitals were included in a multicenter registry. We registered baseline clinical characteristics, echocardiographic parameters and early (1-week) CMR parameters - left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments). Univariate and multivariate comparisons were performed in elderly (>70 years) and not elderly (≤70 years) patients to predict AHF during follow-up.

Results

The cohort was comprised of 759 patients, of which 177 (23.3%) were elderly (>70 years). During a mean follow-up of 5.23±3.54 years, 79 (10.4%) patients presented AHF. In not elderly patients, Killip class at admission (HR 2.05 [1.32–3.17], p=0.001), anterior infarction (HR 3.43 [1.13–10.36], p=0.03) and CMR-LVEF (HR 0.94 [0.91–0.98] per increased %, p=0.001) independently predicted AHF. However, a combined risk score comprising these variables was not superior to CMR-LVEF alone to predict AHF during follow-up (AUC 0.81 [0.74–0.88] vs. 0.81 [0.73–0.88], p=NS). In elderly patients, CMR-LVEF was the only predictor of AHF in the final multivariable model (HR 0.94 [0.91–0.97], p<0.001), although its predictive power was moderate (AUC 0.68 [0.56–0.80], p=0.001). Most AHF events in the not elderly subgroup occurred in patients with reduced (≤40%) CMR-LVEF (71%), while in the elderly subgroup AHF occurred more frequently in patients with preserved (≥50%, 30%) or mildly reduced (40–49%, 32%) CMR-LVEF than reduced (≤40%) CMR-LVEF (38%).

Conclusions

LVEF quantified by CMR soon after STEMI can accurately predict the risk of AHF in not elderly (≤70 years) patients and identify those individuals at higher risk (i.e. CMR-LVEF ≤40%). However, in elderly (>70 years) patients most AHF occur in patients with CMR-LVEF >40%, emphasizing the need for better predictive strategies in this population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Mapping of thoracic aorta growth rate on serial self-navigated 3D whole-heart magnetic resonance angiographies by image registration

Introduction

Accurate and reproducible assessment of aortic diameters and their growth rate is of key importance for the management of patients with thoracic aortic aneurysms [1,2]. It has been recently shown that image registration permits the assessment of progressive aortic dilation on ECG-gated contrast-enhanced CT angiography, outperforming manual quantification and allowing for 3D aortic size and growth mapping [3]. However, exposure to radiation makes it convenient to limit the use of CT for serial follow-up, especially in young patients. Self-navigated 3D whole-heart CMR acquisitions provides excellent image quality overcoming these limitations [4].

Purpose

To evaluate the accuracy and reproducibility of registration-based assessment of aortic dilation using self-navigated 3D whole-heart CMR acquisitions.

Methods

Fifteen patients with two self-navigated 3D whole-heart CMR images obtained at least 1 year apart were included. Aortic root and thoracic aorta diameters were measured by 2 independent observers both manually (multiplanar reconstruction) and with the registration-based technique. To perform registration-based assessment, the aorta was semi-automatically segmented and typical anatomical landmarks were placed by each observer at baseline [3]. Geometrical mapping between baseline and follow-up acquisitions was obtained using deformable image registration, and applied to the baseline aortic surface points to obtain their location at follow-up. Finally, aortic diameters and their growth rate were automatically measured and used to calculated 3D aortic dilation maps. Agreement between techniques and their inter-observer reproducibility were calculated.

Results

Patients age was 27.2±14.5 years and 40% were male. Mean follow-up duration was 2.7±1.6 years. Compared to manual assessment, the registration-based technique presented low bias and excellent agreement for aortic diameters (Table 1), and low bias and moderate agreement for growth rates both in the aortic root and the thoracic aorta (Table, Fig. 1A). The techniques presented similar inter-observer reproducibility in the assessment of aortic diameters (Table 1), while the registration-based method demonstrated much higher inter-observer reproducibility in the assessment of growth rates in the aortic root and the thoracic aorta (Table 1, Fig. 1A and B). Three-dimensional mapping of thoracic aortic diameters and growth was highly reproducible (mean regional ICC=0.90 for diameters; 0.82 for growth rate).

Conclusion

The assessment of the dilation rate of the thoracic aorta via registration of serial self-navigated 3D whole-heart CMR acquisitions is accurate and reproducible in the aortic root and the thoracic aorta. Thus, it allows to assess local aortic growth without the drawbacks of CT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III and Ministerio de Ciencia e Innovaciόn (Spain)

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Mitral valve prolapse but no mitral annular disjunction is related to mitral regurgitation progression in patients with Marfan syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

Mitral annular disjunction (MAD) is a structural abnormality of the mitral annular fibrosus characterized by a separation between the atrial wall-mitral valve junction, and the left ventricular attachment (1,2). It has been associated with mitral valve prolapse (MVP). Limited data is available regarding the impact of the presence of MVP on the evolution of mitral regurgitation in these syndromic entities.

Purpose

To evaluate the prevalence of MAD, PMV, and the combination of both in patients with syndromic hereditary thoracic aortic disease (HTAD) including Marfan (MFS), Loeys-Dietz (LDS), and vascular Ehlers-Danlos syndromes (vEDS), and its relationship with mitral regurgitation (MR) severity and the need for mitral surgery at the follow-up.

Methods

Adult patients with syndromic HTAD seen at our specialized unit were retrospectively included. The presence of MAD, MVP, and significant MR at the first echocardiogram were evaluated. Electronic medical records were reviewed to register the need for mitral surgery. The last echocardiogram available was also assessed to evaluate MR progression. 

Results

A total of 295 patients were included (235 MFS, 42 LDS, and 18 vEDS). The mean age at baseline was 39.0+-14.4 and 52.9% were female. MAD was present in 87 (37.0%) of MFS, 6 (14.3 %) of LDS and was not present in vEDS (p&lt; 0.001). MVP was found in 105 (44.7%) of MFS, 6 (14.3%) of LDS and 0 in vEDS (p&lt; 0.001).

In MFS, MAD was significantly associated with MVP (p= &lt;0.001) (Table 1). Concretely, 73 (31.1%) of the MFS patients had the concurrence of MAD and MVP and 14 (6.0%) of patients had isolated MAD (Table 2). At baseline, significant MR was observed in 30 (12.8%) of the MFS and in 18 (24.7%) of patients with concurrent MAD and MVP. Interestingly, significant MR was absent in patients with isolated MAD (Figure 1). MVP (OR 16.85 CI 4.43 – 64.07) but not MAD (p = 0.607), was associated with significant MR in the multivariate analysis.

A second echocardiogram was available in 220 patients at &gt; = 1 year (mean 4.1 +- 1.4 years). Overall, 25 (11.4%) presented significant progression of MR, 0 in the isolated MAD group, 13 (19.4%) in the MAD/MVP group and 6 (20.0%) of the isolated MVP (p = 0.007).

After a mean clinical follow-up of 7.5 +- 3.2yrs, 10 patients required mitral surgery (6 prostheses, 4 valvuloplasties).

After adjustment for the presence of MVP and time of follow-up, MAD was not associated with progression of MR (p= 0.529) but MVP was (OR 5.2 IC 1.70 - 15.93). Similarly, MVP (OR 5.6 CI 1.23 - 25.86)  but not MAD  (P= 0.096) was associated with the  need for mitral surgery ., 

Conclusions

The prevalence of MAD in syndromic HTAD is high, especially in Marfan syndrome, and absent in vEDS. In this retrospective observational study, the presence of MVP but not MAD was associated with mitral regurgitation evolution and the need for mitral surgery. Abstract Table 1  Abstract Figure 1

HF and CKD present a dire prognosis in young Type 2 Diabetic patients

Introduction

Type-2 diabetes (T2D) is one of the most relevant risk factors for both heart failure (HF) and chronic kidney disease (CKD). Target organ damage causes significant morbi-mortality, especially when these two conditions are combined with diabetes.

Understanding the natural history of the combination of these conditions is paramount to implement tailored preventive measures.

Purpose

To estimate the risk of all-cause death, cardiovascular (CV) death and non-fatal major CV events (MACE) in T2D patients younger than 65 years, either: i) without HF or CKD, ii) with HF (T2D-HF), or iii) with CKD (T2D-CKD) in a real-world clinical setting.

Methods

Retrospective cohort study performed in a healthcare centre that provides primary and secondary care. It included adults with T2D aged between 40 and 65 years of age stratified into three groups: i) T2D with HF defined as either: Ejection Fraction (EF) ≤40% and NT-proBNP ≥200pg/mL (≥600pg/mL if atrial fibrillation (AF)) or BNP ≥100pg/mL (≥125pg/mL if AF); EF &gt;40% in the presence of structural cardiac abnormalities), ii) T2D with CKD (eGFR ≤60mL/min using EPI-CKD formula) and T2D without HF or CKD. We modelled 1-year risk for CV death, all-cause mortality and non-fatal MACE using multivariate weighted cox regression models clustered by patient. Models were adjusted for age (using penalized splines), sex, age-sex interaction, prior history of hypertension, myocardial infarction, stroke, and peripheral arterial disease. We reported hazard ratios (versus T2D without HF or CKD) with 95% confidence intervals.

Results

We identified 14986 patients with T2D without HF or CKD, 1101 with T2D with HF and 3114 with T2D with CKD. Patients were in general 55–58 years old, with a slight predominance of the male gender across the groups. Event rate was 14% in T2D with HF, 15% in T2D with CKD and 5% in TD2 without these conditions.

One-year all-cause death risk was 2.77 (2.26–3.40) for T2D-HF and 3.09 (2.77–3.45) for T2D-CKD. CV death risk was 2.59 (1.72–3.91) for T2D-HF and 2.75 (2.19–3.46) for T2D-CKD. Non-fatal MACE risk was 2.82 (2.34–3.41) for T2D-HF and 1.90 (1.66–2.17) for T2D-CKD. Regarding MACE, the event rate was 32% in T2D-HF, 13% in T2D-CKD but only 6% in T2D. T2D-HF was associated with the highest risks of myocardial infarction (3.25 [2.60–4.06]) and end-stage kidney disease (9.9 [7.3–13.43]) when compared to T2D-CKD.

Conclusions

Young patients with T2D combined with HF or CKD have an increased risk of early adverse CV and renal events. HF was linked with highest risk of myocardial infarction and end-stage kidney disease.

These findings highlight the importance of an early identification and management of HF and CKD in T2D patients.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca Produtos Farmacêuticos Lda Figure 1. Outcomes for HF and CKD groups

Circumferential wall shear stress predicts co-localized progressive dilation in bicuspid aortic valve patients

Background

Bicuspid aortic valve (BAV), a congenital heart defect, is associated with ascending aorta (AAo) dilation. Whether the high prevalence of dilation in BAV patients is related to alteration of aortic blood flow and thus in wall shear stress (WSS) [1,2], which have been associated with aortic wall degeneration [3], or intrinsic abnormalities of the aortic wall, such as altered aortic stiffness [4], has not been established. Recently, a technique for the semi-automatic quantification of progressive aortic dilation maps via image registration has been introduced [5].

Purpose

To test whether ascending aorta WSS predicts co-localized progressive dilation in BAV patients.

Methods

Forty BAV patients free from moderate and severe aortic valve regurgitation (regurgitant fraction &lt;16%) and stenosis (maximum velocity at the aortic valve &lt;3m/s), with no previous aortic or aortic valve surgery or replacement and included in a double-blind clinical trial (BICATOR, NCT02679261) were enrolled. All patients underwent a baseline 4D flow CMR study to assess aortic hemodynamics, followed by two contrast-enhanced computed tomography angiographies to quantify progressive dilation. WSS was computed at 64 pre-specified standardized ascending aortic regions, automatically obtained dividing the ascending aorta into 8 equidistant longitudinal sections which were further divided along the circumference into 8 equal regions (I = inner, L = left, O = outer and R = right) [2]. WSS was also projected into axial and circumferential directions, as previously described [1,2]. Progressive dilation was assessed in terms of growth rate (GR), i.e. increase in diameter divided by follow-up duration [mm/year], following a previously described methodology [5], at the same 64 pre-specified ascending aortic locations. A two-tailed p-value &lt;0.05 was considered statistically significant.

Results

Demographic and clinical characteristics of the patients are shown in Table 1. WSS and growth rate maps are shown in Figure 1. Follow-up duration was 44.8±2.6 months. Growth rate (Figure 1A) was heterogeneously distributed, being highest (up to 0.26 mm/year) in the outer region of the mid AAo and in the inner region of the proximal-mid AAo. Circumferential WSS showed highest values in the outer region of the mid AAo (Figure 1C) while WSS (magnitude) and its axial component (Figure 1B and D) presented maximum values in the right region of the mid AAo. Maps of statistically significant association between GR and WSS values showed circumferential WSS to be correlated with GR in regions where progressive dilation was fastest, while WSS magnitude and its axial component resulted in limited associations with GR maps.

Conclusions

Circumferential wall shear stress predicts location-matched progressive dilation in bicuspid aortic valve patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study has received funding from the Instituto de Salud Carlos III (PI17/00381). Guala A. has received funding from Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I). Table 1. DemographicsFigure 1. GR and WSS maps and correlations

Clinical impact on treatment and prognosis of advanced cardiac imaging with echocardiography in the acute setting of a COVID-19 infection

Background and objectives

Despite myocardial injury being related to excess mortality in acute COVID-19 infection, its impact on imaging findings remains unclear. This study aimed to characterize transthoracic echocardiographic (TTE) findings in patients admitted with COVID-19 infections and its impact on management and prognosis.

Methods

A prospective observational cohort study was performed among 66 COVID-19 patients who were admitted to a tertiary center between March 1 and May 25, 2020 and underwent TTE. High-sensitivity troponin I (hs-cTnI) data, echocardiographic assessment of right and left ventricular (LV) functional parameters, strain, and myocardial work analysis were obtained.

Results

2025 patients were admitted with COVID-19 and in 200 a complete TTE study was performed. Due to poor image quality, only 66 studies were included in the final analysis. The median age was 62 years (IQR, 55–70) and 59.1% of patients were males. The most common comorbidity was hypertension (47%), followed by smoking history (30.3%), atrial fibrillation (9.1%), and chronic obstructive pulmonary disease (7.9%). More than half of the patients (39, 59%) were admitted to the ICU, and half of them (33, 50%) required invasive mechanical ventilation. TTE was mainly indicated because of concerns for systemic conditions (50%) and evaluation of hemodynamic assessment (30%). Thirty-six patients (54.5%) had an abnormal TTE result and 57% had elevated hs-cTnI levels. The most common cardiac abnormality was LV diastolic dysfunction in 33% of the patients, followed by right ventricular dysfunction (12%) and LV dysfunction (6%) (Figure 1). LV GLS was reduced in 48.5% of the cases. Myocardial work performance indices were all reduced in patients with an abnormal TTE (GWI 30%, GCW 30%, GWW 40%, and GWE 40%), although differences were not significant (P&gt;0.2 for all parameters). Patients with an abnormal TTE were older and presented a higher cardiovascular risk profile. There were no significant differences in the levels of D-dimer, NTproBNP, and hs-cTnI between patients with and without diastolic dysfunction, RV, or LV dysfunction (P&gt;0.3 for all parameters). Using Spearman rank correlation, there was an inverse relationship between hs-cTnI and LV strain and myocardial work analysis. TTE results impacted clinical management in 60 patients, mainly de-escalation of medical treatment (Figure 2). Abnormal TTE results did not impact in-hospital outcomes.

Conclusions

Severe echocardiographic abnormalities are uncommon in hospitalized patients with COVID-19 infections, presenting mostly with subclinical myocardial changes, such as diastolic dysfunction, reduced LV GLS, and myocardial work indices, both associated with high-sensitivity troponin I elevation. An echocardiographic study should be limited to rule out long-term ICU complications or to evaluate hemodynamic instability. Although TTE was a valuable tool for guiding management, it had no significant impact on prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Findings on TTE studies.Figure 2. Changes in management.

Mitral annular disjunction in patients with syndromic hereditary aorthopaties

Background

Mitral annular disjunction (MAD) is a structural abnormality of the mitral annular fibrosus characterized by a separation between the atrial wall-mitral valve junction, and the left ventricular attachment (1). It has been associated with mitral valve prolapse (MVP) (2) but also, with arrhythmias and sudden cardiac death (SCD) (3). There is no evidence of its prevalence and clinical significance in patients with syndromic hereditary aortopathies.

Purpose

To evaluate the prevalence of MAD, PMV, and the combination of both in patients with syndromic hereditary thoracic aortic disease (HTAD) including Marfan (MFS), Loeys-Dietz (LDS) and vascular Ehlers-Danlos syndromes (vEDS), and its relationship with arrhythmias, SCD, mitral regurgitation (MR) severity and the need for mitral surgery at the follow-up.

Methods

Adult patients with syndromic HTAD seen at our specialized unit were retrospectively included. The presence of MAD, MVP, and significant MR at first echocardiogram were evaluated. Electronic medical records were reviewed to register the occurrence of arrhythmic events and the need of mitral surgery. Last echocardiogram available was also assessed to evaluate MR progression.

Results

A total of 295 patients were included (235 MFS, 42 LDS and 18 vEDS). Mean age at baseline was 39.0±14.4 and 52.9% were female. MAD was present in 87 (37.0%) of MFS, 6 (14.3%) of LDS and was not present in vEDS (p&lt;0.001). MVP was found in 105 (44.7%) of MFS, 6 (14.3%) of LDS and 0 in vEDS (p&lt;0.001).

In MFS, the presence of MAD was significantly associated with MVP (p≤0.001) (Table 1). However, 14 (6.0%) of patients had isolated MAD (Table 2). At baseline, significant MR was observed in 18 (24.7%) of patients with concurrent MAD and MVP and was not present in patients with isolated MAD (Table 2). MVP (OR 16.85 IC 4.43 – 64.07) but not MAD (p=0.607), was associated with significant MR in the multivariate analysis.

A second echocardiogram was available in 220 patients at ≥1 year (mean 4.1±1.4 years). Overall, 25 (11.4%) presented significant progression of MR, 0 in the isolated MAD group, 13 (19.4%) in the MAD/MVP group and 6 (20.0%) of the isolated MVP (p=0.007).

After a mean clinical follow-up of 7.5±3.2 years, 10 patients required mitral surgery (6 prosthesis, 4 valvuloplasty), 22 (9.4%) presented atrial fibrillation, flutter or supraventricular tachycardia (SVT), and 2 (0.9%) SCD.

After adjustment for the presence of MVP and time of follow-up, MAD was not associated with progression of MR (p=0.529) need for mitral surgery (p=0.096), atrial fibrillation-flutter or SVT (p=0.510) nor SCD. (p=0.997).

Conclusions

The prevalence of MAD in syndromic HTAD is high, especially in Marfan syndrome, and absent in vEDS. In this retrospective observational study, the presence of MAD in Marfan was not associated with mitral regurgitation evolution or arrhythmic events.

Funding Acknowledgement

Type of funding sources: None. Characteristics of MFS patientsPresence of significant MR by groups.

Prevalence and characterization of heart failure in a population of integrated care users

Introduction

Heart failure (HF) is a clinical syndrome caused by structural and functional cardiac abnormalities resulting in impairment of cardiac function, entailing significant morbi-mortality. HF is an age-dependent entity associated with cardiovascular (CV) risk factors such as type 2 diabetes (T2D).

Purpose

Estimate the prevalence of HF and its subtypes, and characterize HF in a population of integrated care users.

Methods

Non-interventional cross-sectional study performed in healthcare centre that provides primary and secondary care. All adult patients at 31/12/2019 were included. Echocardiographic parameters [left ventricle ejection fraction (LVEF) and evidence of structural heart disease] and elevated level of natriuretic peptides were used to define two HF phenotypes: i) HF with reduced ejection fraction (HFrEF, LVEF ≤40% and either NT-proBNP ≥400pg/mL (≥600pg/mL if atrial fibrillation (AF)/flutter) or BNP ≥100pg/mL (≥125pg/mL if AF/flutter)and ii) HF with non-reduced ejection fraction (HFnrEF), that encompasses both HFpEF (LVEF ≥50% and either NT-proBNP ≥200pg/mL (≥600pg/mL if AF/flutter) or BNP ≥100pg/mL (≥125pg/mL if AF/flutter) in the presence of at least one structural cardiac abnormality) and HF mid-range ejection fraction (HFmEF, LVEF within ]40, 50% [and either NT-proBNP ≥200pg/mL (≥600pg/mL if AF/flutter) or BNP ≥100pg/mL (≥125pg/mL if AF/flutter) in the presence of at least one structural cardiac abnormality). The significance threshold was set at P≤0.001.

Results

We analysed 126636 patients with mean age of 52.2 (SD=18.3) years, 57% (N=72290) were female. The prevalence of HF was 2.1% (N=2700). HF patients mean age was 74.0 (SD=12.1) years and 51.6% (N=1394) were female. Regarding HF subtypes, HFpEF accounted for 65.4% (N=1765), 16.1% (N=434) had HFmEF and 16.3% (N=439) had HFrEF. Patients with HFrEF were younger (P&lt;0.001) and had a history of myocardial infarction more frequently (P&lt;0.001) comparing to HFnrEF, with no other significant differences between HF groups. HFrEF patients were more frequently prescribed CV medications than HFnrEF patients, namely antiplatelet agents, ACE inhibitors (55.6% vs 32.7%, P&lt;0.001), beta blockers (79.3 vs 55.8%, P&lt;0.001) and aldosterone receptor antagonists (48.7 vs 8.3%, P&lt;0.001).

T2D was present in 44.7% (N=1207) of HF patients. CKD was more frequently present in T2D vs non-T2D HF patients at every stage (P&lt;0.001) as well as stroke, peripheral artery disease and microvascular disease (P&lt;0.001) (Table 1).

Conclusions

In this cohort, considering a contemporary definition, HF prevalence was 2.1%; HFrEF accounted for 16.3% of cases, with similar clinical-epidemiological profile previously reported in the literature. Our study revealed a high prevalence of patients with HFpEF (65.4%), raising awareness for the increasing prevalence of this entity in cardiology practice. These results may guide local and national health policies and strategies for HF diagnosis and management.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca, Produtos Farmacêuticos Lda Table 1. HF Patient Characteristics by subtype

Insights from cardiopulmonary exercise testing in pediatric patients with hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is characterized by extremely varied phenotypic expression ranging from asymptomatic to heart failure (HF) to sudden cardiac death (SCD). Although children with HCM are considered in the highest risk spectrum, the most common recommendations on pharmacological and non-pharmacological treatment (i.e. drugs, ICD, septal reduction procedures, inclusion in cardiac transplantation list) are often disregarded or too much postponed in this setting and strong evidence-based risk prediction models are missing. A systematic cardiopulmonary exercise test (CPET) assessment might be helpful to disclose an unsuspected functional limitation.

Purpose

The aim of our multicenter retrospective study was to investigate possible clinical insights, in terms of functional and prognostic assessment, coming from a full CPET assessment in a cohort of pediatric HCM outpatients aged less than 18 years old.

Methods

Sixty consecutive pediatric HCM outpatients aged &lt;18 years-old were enrolled, each of them undergoing a full clinical assessment including a CPET; a group of 60 healthy subjects served as controls. An unique composite end-point of HF-related and SCD or SCD-equivalent events was also explored. During a median follow-up of 53 months, a total of 13 HF- and 7 SCD-related first events were collected.

Results

An impaired exercise capacity, consisting on peak VO2 values &lt;80% of the predicted, has been found in the 78% of the study sample (n. 47 patients). Despite most of the HCM patients were classified in NYHA I functional class, most of them (n. 33, 73%) showed a reduced exercise capacity, the percentage of impaired exercise capacity raising in the NYHA II group (n. 14 patients, 93%).

Respect to the control Group, the HCM patients showed a significantly poorer functional status in terms of maximum workload achieved, peak VO2 (regardless the adopted correction), circulatory power and VE/VCO2 slope values (Figure 1, panel A).

HCM patients who experience adverse events during the follow-up (Event Group) showed the worst CPET profile (Figure 1, panel B).

The composite end-point occurred more frequently in patients with the worst CPETs' profiles. At the univariate analysis, peak VO2% was the variable with the strongest association with adverse events at follow-up (C-index=0.72, p=0.025) and a cut-off value equal to 60% was the most accurate in identifying those patients at the highest risk (Figure 2).

Conclusions

Our findings support the role of CPET analysis as an insightful approach in the young HCM clinical management. In a group of young asymptomatic or slightly symptomatic HCM patients, the CPET allowed us to estimate accurately their functional capacity and to disclose a portion of un-recognized exercise impairment. Our data argue in favor of a possible role of some CPET-derived variables in the early identification of those young HCM patients at highest risk of HCM related events.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Cardiorenal syndrome and death risk in patients with heart failure or chronic kidney disease: an unmet cardiorenal need?

Introduction

Heart failure (HF) and chronic kidney disease (CKD) have interlinked pathophysiological pathways and patients having both conditions simultaneously are defined as having cardiorenal syndrome (CRS).

Purpose

To estimate the risk of CRS in patients with initial presentation of HF (without prior CKD) or CKD (without prior HF) compared to mean age overall population in a real-world clinical setting. Also, to estimate the risk of all-cause death, cardiovascular (CV) death and non-fatal major CV events (MACE) in patients with HF, CKD and CRS compared to the mean-age overall population.

Methods

Clinical database analysis of a single primary and secondary healthcare institution from 2008–2019. We defined 4 incident cohorts: Control - patients at age 75; HF - HF patients without prior CKD; CKD - CKD patients without prior HF; CRS - patients with HF and CKD. Patients were indexed at the date of first event and followed one year. We defined HF as either: i) Ejection Fraction (EF)≤40% and NT-proBNP≥200pg/mL (≥600pg/mL if atrial fibrillation (AF)) OR BNP≥100pg/mL (≥125pg/mL if AF); ii) EF&gt;40% in the presence of structural cardiac abnormalities. We defined CKD as eGFR≤60mL/min using EPI-CKD formula. All definitions were constructed using laboratory-level data complemented with episode-level data. Hazard ratios (HR) and 95% confidence intervals were estimated using Cox regression models adjusted for age, sex, age-sex interaction, prior history of hypertension, myocardial infarction, stroke, peripheral artery disease and type 2 diabetes.

Results

We identified 3973 patients with HF, 13990 with CKD, 6784 with CRS and 16182 controls. Patients were in general 75–77 years old. The majority were females and were well treated with CV risk reducing drugs (Table 1). All-cause death risk was 4.7 (4.1–5.2) for HF and 4.9 (4.5–5.4) for CKD. CV death risk was 8.6 (6.8–10.8) for HF and 8.7 (7.1–10.6) for CKD. Non-fatal MACE risk was 7.4 (6.3–8.7) for HF, 4.6 (4.0–5.3) for CKD, and 7.1 (6.1–8.3) for CRS. CRS was associated with the highest risks of all-cause and CV death when compared with the control group- 7.1 (6.4–7.9) and 13.7 (11.7–17.0), respectively (Figure 1). More than half of events occurred in the first 90 days of follow-up for all outcomes.

Conclusions

Cardiorenal disease (HF or CKD) was associated with very high short-term risk (1 year) of developing CRS or death. Consecutively, patients with established CRS had the highest risk of dying. These results demonstrate serious cardiorenal risks in a real-world setting, supporting an urgent need for improved primary and secondary prevention of cardiorenal disease and cardiorenal syndrome.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca Produtos Farmacêuticos, Lda. Table 1. Baseline characteristicsFigure 1. Outcomes for CKD, HF and CRS

Prognostic value of baseline versus 6-month follow infarct size in patients with reperfused STEMI

Background

Acute infarct size is a predictor of clinical outcomes in acute ST segment elevation myocardial infarction (STEMI) patients, although its prognostic value has differed between studies. In acute STEMI, infarct size is often overestimated due to the presence of extensive myocardial oedema, a confounder that is no longer present at a 6-month follow-up study. It was our purpose to assess whether infarct size in the acute phase or at 6-months follow-up provided superior prognostic information in STEMI patients.

Methods

STEMI patients who underwent successful primary percutaneous revascularization were included and a cardiac magnetic resonance (CMR) was performed between 5–7 days after STEMI and at 6 months to study infarct size (as a % of myocardial mass). The primary endpoint was a composite of cardiovascular mortality, hospitalization for heart failure and ventricular arrhythmia.

Results

A total of 796 patients were included (mean age 58.3±11.5 years, 82.4% male, 52.3% anterior infarction). During a mean follow-up of 59 months, 59 patients (7.4%) presented with the primary end-point (cardiovascular death n=7, hospitalization for heart failure n=52, ventricular arrhythmia n=1). ROC curve analysis (figure 1) showed a non-significant difference between baseline and 6-month infarct size for the prediction of the primary endpoint (baseline AUC 0.685 95% CI 0.610–0.760, 6-month AUC 0.713 95% CI 0.643–0.782, p=0.60). Optimal cut-off values for baseline and 6-months follow-up infarct size for prediction of outcomes, respectively 22% and 17.5%, were used for Kaplan-Meier curve analysis (figure 2).

Conclusion

Infarct size estimated during the first week after STEMI and at 6-months follow-up showed similar predictive value and with similar cut-off values. Therefore, the prognostic information provided by infarct size can be obtained during initial STEMI admission and does not require a waiting period for infarct size stabilization.

Funding Acknowledgement

Type of funding sources: None. ROC curve analysisKaplan-Meier analysis

Do morphological, haemodynamic and biomechanical parameters relate to aortic growth rate in chronic type B aortic dissection? A 4D flow CMR study

Background

Aortic dissection (AD) is the most devastating complication of thoracic aortic disease (1). In the chronic phase, yearly clinical and imaging follow-up of the maximum aortic diameter is recommended, since indication for thoracic endovascular aortic repair or surgery is suggested by guidelines in case of thoracic aortic enlargement or false lumen (FL) aneurysms (2). Most of the reported parameters related adverse events in chronic AD are focused on morphological variables (3) and not on the haemodynamics and biomechanics of the FL.

Purpose

To evaluate the relationship between aortic growth rate and anatomical variables, flow patterns and aortic stiffness in patients with chronic type B AD.

Methods

Forty-one patients with chronic type B aortic dissection, no connective tissue disorders and with an imaging follow-up including two computed tomography angiograms (CTA) acquired at least 3 years apart underwent contrast-enhanced 4D-flow CMR and MR angiography (MRA). The FL volume was segmented from MRA, and velocity data inside the 3D volume of the FL was extracted from 4D-flow CMR and used for parameter quantification. Retrograde systolic and diastolic flow, wall shear stress (WSS) and in-plane rotational flow (IRF) were calculated at 8 equidistant planes in the distal descending aorta (DAo), from the pulmonary bifurcation to the diaphragmatic level, and averaged values were used [4]. Aortic stiffness in the FL was assessed in terms of pulse wave velocity (PWV), which was calculated from the third supraortic trunk to the diaphragmatic level on 4D-flow CMR [5]. The percentage of thrombus in the FL was calculated as the ratio of thrombus and FL volumes on MRA. Dominant entry tear area was quantified on the baseline CTA (Figure 1). Aortic growth rate (GR) was defined as the difference between final and baseline aortic diameters as measured on CTA divided by follow-up duration.

Results

Anatomical, haemodynamic and biomechanical parameters are shown in Table. Twenty-five patients have repaired type A AD with residual entry tear and 16 have type B AD. Mean follow-up duration was of 4.9±2.7 years. In bivariate analysis, WSS, IRF and PWV were positively related to GR, whereas dominant entry tear area and percentage of thrombus in the FL showed a positive tendency with GR (Table) (Figure). In multivariate analysis IRF, PWV, dominant entry tear area and thrombus in the FL were positively and independently associated with GR (Table). Retrograde systolic and diastolic flow were not related to GR while WSS tended to statistical significance.

Conclusions

In-plane rotational flow, regional aortic stiffness, dominant entry tear area and percentage of thrombus in the false lumen are positively and independently related to aortic growth rate in patients with chronic type B aortic dissection. Further prospective studies are needed to confirm if the assessment of these parameters may help to identify patients at higher risk of adverse clinical events.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Accurate and reproducible aortic growth rate mapping via registration of serial contrast-enhanced computed tomography angiograms

Introduction

Accurate assessment of aortic diameters and growth rates is key for clinical management of patients with aortic aneurysms [1]. Manual assessment on multiplanar reformatted views of computed tomography angiograms (CTA) is recommended [1], although its reproducibility in the assessment of growth rates has not been reported [2]. Image registration has been proposed to provide 3D maps of aortic diameters and growth [3], but its accuracy and reproducibility have not been established.

Purpose

To quantify accuracy and inter-observer reproducibility of aortic root and thoracic aorta diameters and growth rate by registration of serial CTAs compared to current standard.

Methods

Forty non-operated patients with ≥2 contrast-enhanced ECG-gated CTA acquired at least 6 months apart were included. Aortic diameters and growth rates were measured in the aortic root and thoracic aorta by two independent observers, both with the current standard and with the registration-based technique. To perform registration-based assessment, each observer semi-automatically segmented the aorta at baseline and located typical anatomical landmarks (Fig. 1A). Then, deformable image registration was used to map baseline and follow-up CT scans and deformation was applied to the baseline aortic surface points to obtain their location at follow-up (Fig. 1B). Finally, aortic root diameters and growth rate and 3D maps of thoracic aortic diameters and growth rate were automatically obtained (Fig. 1C). Agreement between techniques and their inter-observer reproducibility were calculated.

Results

Follow-up duration was 3.3±1.5 years (range 0.52–6.2). Compared with manual assessment, registration-based aortic diameters presented low bias and excellent agreement in the aortic root (0.42 mm, ICC=0.99) and the thoracic aorta (0.55 mm, ICC=0.99), and similar inter-observer reproducibility (ICC=0.99 for both). Compared with manual assessment, registration-based growth rates presented low bias and good agreement in the aortic root (0.12 mm/y, ICC=0.84) and the thoracic aorta (0.03 mm/y, ICC=0.77) (Fig. 2A), and much higher inter-observer reproducibility (ICC=0.96 vs 0.68 in the aortic root, ICC=0.96 vs 0.80 in the thoracic aorta) (Fig. 2B and C). Registration-based aortic growth rates reproducibility at 6 months follow-up was comparable to that obtained by manual assessment at 2.7 years (LoA = [−0.01, 0.33] and LoA = [−0.13, 0.21], respectively). Aortic diameters and growth rate 3D maps were highly reproducible (ICC&gt;0.9) in the whole thoracic aorta.

Conclusions

Progressive aortic dilation assessment via registration of CTAs is accurate and more reproducible than the current standard even over follow-ups as short as 6 months, and further provides robust 3D mapping of aortic diameters and growth rates. Its application may provide new insights in aneurysms pathophysiology and improve the clinical management of these patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study has received funding from the Instituto de Salud Carlos III (PI17/00381). Guala A. has received funding from Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I). Figure 1. Methodology.Figure 2. Growth rate comparison.

Bicuspid aortic valve fusion length correlates with maximum aortic diameter and heamodynamic abnormalities: a 4D flow CMR study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities.

Background

Bicuspid aortic valve (BAV), a congenital heart defect, is associated with ascending aorta dilation, possibly via alteration of aortic blood flow [1]. In BAV abnormal flow condition have been associated with aortic extracellular matrix dysregulation and elastic fiber degeneration [2]. Current morphological classification of BAV patients with aortic valve with a single fusion between two adjacent leaflets does not allow for risk stratification.

Purpose

This research work tested whether the extent of fusion between leaflets is related to AAo diameter and flow alterations.

Methods

Ninety BAV patients free from moderate and severe aortic valve disease and with no previous aortic or aortic valve surgery or replacement were prospectively enrolled. A comprehensive magnetic resonance protocol comprised a stack of double-oblique 2D balanced steady-state free-precession (bSSFP) cine CMR of the aortic valve, which was used to measure the length of the fusion between leaflets, a cine CMR at the level of the pulmonary bifurcation to assess aortic diameter and 4D flow MRI sequence to assess flow characteristics and regional stiffness [3]. Jet angle and flow radial displacement, quantifying the extent of flow eccentricity, and systolic flow reversal ratio (SFRR), assessing the relative amount of backward flow during systole, were computed at 8 equidistant planes in the ascending aorta and 4 equidistant planes in the aortic arch [4]. A two-tailed p-value &lt; 0.05 was considered statistically significant.

Results

The length of leaflet fusion varied widely (median 7.7 mm, inter-quartile range [5.5; 10.2]), Table 1). In bivariate analysis, fusion length was also associated to ascending aortic diameter (R = 0.391, p &lt; 0.001), age (R = 0.313, p = 0.005) and body surface area (R = 0.396, p &lt; 0.001). It was also positively related to flow abnormalities: like displacement in the proximal and distal ascending aorta, jet angle in the mid ascending aorta, and SFRR in the ascending aorta and the aortic arch (see Figure 1). The association between fusion length and ascending aorta diameter persisted in multivariate analysis after correction for age (p = 0.006).

Conclusions

Bicuspid aortic valve fusion extent varies greatly and it is associated with aortic diameter, possibly through flow alterations. Prospective longitudinal studies are needed to establish whether fusion length may allow for risk stratification in bicuspid aortic valve patients.

Sequential cardiovascular magnetic resonance assessment of left ventricular ejection fraction for prediction of subsequent events in a large multicenter STEMI registry

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER”

Background. Cardiovascular magnetic resonance (CMR) is the best tool for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of sequential LVEF assessment for major adverse cardiac event (MACE) prediction after ST-segment elevation myocardial infarction (STEMI) is uncertain.

Purpose. We explored the prognostic impact of sequential assessment of CMR-derived LVEF after STEMI to predict subsequent MACE.

Methods. We recruited 1036 STEMI patients in a large multicenter registry. LVEF (reduced [r]: &lt;40%; mid-range [mr]: 40-49%; preserved [p]: ≥50%) was sequentially quantified by CMR at 1 week and after &gt;3 months of follow-up. MACE was regarded as cardiovascular death or re-admission for acute heart failure after follow-up CMR.

Results. During a 5.7-year mean follow-up, 82 MACE (8%) were registered. The MACE rate was higher only in patients with LVEF &lt; 40% at follow-up CMR (r-LVEF 22%, mr-LVEF 7%, p-LVEF 6%; p-value &lt; 0.001). Based on LVEF dynamics from 1-week to follow-up CMR, incidence of MACE was 5% for sustained LVEF³40% (n = 783), 13% for improved LVEF (from &lt;40 to ³40%, n = 96), 21% for worsened LVEF (from ³40% to &lt;40%, n = 34) and 22% for sustained LVEF &lt;40% (n = 100), p-value &lt; 0.001. Using a Markov approach that considered all studies performed, transitions towards improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to higher incidence of subsequent MACE.

Conclusions. LVEF constitutes a pivotal CMR index for simple and dynamic post-STEMI risk stratification. Detection of reduced LVEF (&lt;40%) by CMR at any time during follow-up identifies a small subset of patients at high risk of subsequent events.

Serum iPTH range in a reference population: From an integrated approach to vitamin D prevalence impact evaluation

BACKGROUND

The iPTH upper reference limit (URL) reported by our laboratory provider (Abbott Laboratories) at Tor Vergata University Hospital was evaluated by internal verification procedures as not representative of our population and resulting as underestimated. In this study, a new reference interval has been investigated and established by comparing a direct and an indirect method based on a statistical reduction from results stored in the laboratory database.

METHODS

For reference interval calculation from the healthy population, we analyzed a cohort of 100 blood donors (84% males and 16% females) screened with no bone-related and malabsorption diseases. We analyzed a cohort of 495 patients retrieved from more than 800 iPTH results by excluding subjects with pathological measurement for calcium, phosphorus, and creatinine for the reference interval evaluation. Patients with vitamin D results were included in the analysis. Vitamin D sufficiency status during the period from January to September 2020 was also evaluated by investigating 3,050 patients.

RESULTS

The iPTH reference interval of a healthy blood donor population was measured as 25.2-109.1 pg/mL (2.7-11.6 pmol/L) at 2.5 and 97.5 distribution percentile. The iPTH reference interval from data stored in the laboratory database was 19.3-112.5 pg/mL (2.0-11.9 pmol/L). Furthermore, 60% of the whole population had prevalently insufficient vitamin D concentration (<30 ng/dL; <75 nmol/L). The impact of vitamin D concentration on the iPTH reference interval was measured for insufficient vitamin D (<30 ng/dL; <75 nmol/L) as 15.2-127.7 pg/mL (1.6-13.5 pmol/L), desirable vitamin D (30-40 ng/ml; 75-100 nmol/L) as 25.6-105 pg/mL (2.7-10.7 pmol/L) and optimal vitamin D (>40 ng/ml; >100 nmol/L) as 26.2-89.2 pg/mL (2.8-9.4 pmol/L), respectively.

CONCLUSIONS

The URL reported in manufacturer datasheets likely refers to a normal population with non-pathological vitamin D levels. On the contrary, the considered population was mostly vitamin D insufficient, resulting in a URL shift. On this basis, we suggest describing in medical reports the iPTH range for vitamin D deficiency for diagnosis of primary hyperparathyroidism even when a specific vitamin D request is lacking. On the other hand, reporting optimal vitamin D-based iPTH reference interval could be clinically relevant in supplemented patients as a marker of treatment efficacy.

Intermittent outpatient administration of levosimendan improves right ventricular-pulmonary arterial coupling in ambulatory patients with advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Intermittent infusions of levosimendan in an outpatient setting have been associated with improved symptoms and reduced hospitalizations in patients with advanced heart failure (HF). Little is known on the potential effect of intermittent levosimendan infusions on right ventricle (RV)-pulmonary arterial (PA) coupling in ambulatory patients with advanced HF.

Purpose Aim of the present study was to explore the effects of intermittent levosimendan infusions on the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PAPs), an echocardiographic measure of RV/PA coupling, in ambulatory patients with advanced HF, and on left ventricular arterial coupling (VAC), expressed as the relationship between arterial elastance (Ea) and ventricular elastance (Ees).

Methods 17 ambulatory patients with advanced HF treated with intermittent levosimendan (6-hour intravenous infusion, 0.2 ug/kg/min without bolus) received baseline clinical, biochemical and echocardiographic evaluation and changes in TAPSE/PAPs ratio were assessed from baseline to 48 hours after the infusion, based on the pharmacokinetic profile of levosimendan. VAC, expressed as Ea/Ees ratio, was obtained by a calculator (iElastance) designed for non-invasive single beat measure of end-systolic Ees  and Ea according to Chen"s method.

Results After 48 hours from levosimendan infusion, there was a significant improvement of TAPSE/PAPs  ratio (p = 0.04), stroke voume (SV) (p = 0.05) and cardiac output (CO)(p = 0.04). We observed a significant reduction of Ea (p = 0.007) and of Ees (p = 0.01) and a non significant improvement of VAC (p = 0.4)(Tab.1). 

Conclusion. Our results show that an intermittent 6-hour levosimendan infusion at 0.2 ug/kg/min improves after 48 hours RV-PA coupling, SV, CO, Ea and Ees in ambulatory patients with advanced HF. Further studies including more patients are necessary to confirm these preliminary findings.

Tab.1 Baseline 48h afterlevosimendan infusion p value NT-proBNP (pg/mL) 5607 ± 4300 3868 ± 3856 &lt;0.001 LVEF (%) 24.1 ± 7.7 25.7 ± 7.3 0.5 SV (mL) 36.8 ± 12.4 46.1 ± 14.8 0.05 CO (L/min)36.8 ± 12.4 2.6 ± 0.7 3.2 ± 0.9 0.05 TAPSE/PAPs (mm/mmHg) 0.38 ± 0.13 0.49 ± 0.16 0.04 Ea (mmHg/mL/m2) 2.9 ± 0.9 2.1 ± 0.6 0.007 Ees (mmHg/mL/m2) 1.3 ± 0.4 1.0 ± 0.2 0.01 VAC 2.2 ± 0.6 2.0 ± 0.4 0.4

Aortic root longitudinal strain by speckle-tracking echocardiography predicts progressive aortic root dilation in Marfan syndrome patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; Instituto de Salud Carlos III

Introduction

In Marfan syndrome (MFS) patients reduced longitudinal strain of the ascending aorta (AAo) as measured by applying feature-tracking on cine cardiac magnetic resonance (CMR) images predicts aortic root dilation and aortic events during the follow-up. Speckle-tracking is well established for cardiac deformation assessment but proximal aorta applications are challenging due to limited wall thickness and substantial cardiac motion. Moreover, echocardiography is widely used in the clinical assessment aortic diseases.

Purpose

We aimed to test a speckle-tracking tool for root longitudinal strain analysis in terms of comparison with CMR-derived AAo longitudinal strain and reproducibility and as predictor of dilation in MFS patients.

Methods

Thirty-five MFS patients diagnosed by original GHENT criteria, with maximum aortic root diameter of 45 mm and free from previous aortic dissection or cardiac/aortic surgery and non-severe aortic regurgitation were consecutive enrolled and followed-up. CMR and echocardiography were performed less than 2 months apart. Baseline and final aortic root diameter were measured on CMR images. To quantify aortic root cyclic elongation by echocardiography, two regions of interests were manually created covering both walls in a parasternal long-axis view and tracked along the cardiac cycle (Figure 1). Longitudinal strain was computed as the average of maximum increase in relative distance of several sub-regions covering both walls. CMR-derived AAo longitudinal strain was available in 29 patients. Intra-observer reproducibility was tested in 15 patients via intraclass correlation coefficient (ICC) for single-rater absolute agreement.

Results

Aortic root longitudinal strain by echocardiography was mildly related to CMR-derived AAo longitudinal strain (R = 0.27) and was larger compared to CMR-derived values (16.2 ± 6.0 vs 11.3 ± 4.3). Reproducibility was high, with ICC of 0.811, R = 0.802, p &lt; 0.001. After a mean follow up of 76 ± 13 months, aortic root diameter grew in 20 patients with a rate of 0.29± 0.24 mm/year. Overall mean growth-rate was 0.87 ± 0.33 mm/year. In multivariable analysis corrected for age and baseline aortic root diameter, baseline longitudinal strain by echocardiography was independently and inversely related to progressive dilation (p = 0.033).

Conclusions

The measurement of aortic root longitudinal strain by speckle-tracking echocardiography is feasible. Aortic root longitudinal strain is an independent predictor of progressive dilation in MFS patients. This may permit the improvement of risk-stratification in aortic diseases in large scale studies.

Abstract Figure 1

Leaflets fusion length in bicuspid aortic valve is related to ascending and aortic root dilation and ascending aorta wall shear stress

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities, Instituto de Salud Carlos III

Background

Bicuspid aortic valve (BAV) is the most common congenital heart defect, consisting in the fusion of two aortic valve leaflets. Altered flow patterns have been related to aortic wall degeneration in BAV patients and may be responsible for the high prevalence of aortic disease in these patients. A number of studies on excised BAV or using advanced imaging modalities reported a wide variability of fusion extent between leaflet, but no previous study assessed whether leaflet fusion length may be used to stratify BAV patients.

Purpose

We aimed to test whether leaflet fusion extent can be quantified by cardiac magnetic resonance imaging (CMR) and whether it is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty BAV adults with no previous aortic or aortic valve surgery or significant valvular disease were consecutively enrolled. Patients with two sinuses of Valsalva (true BAV) or fusion of the left and non-coronary cusps, both being rare forms of BAV, were excluded. Twenty-eight healthy volunteers were also included for comparison. A 4D flow CMR sequence was acquired and circumferential wall shear stress and pulse wave velocity were assessed in the ascending aorta. A stack of double-oblique cine images of the aortic valve were used to quantify the length of the fusion between leaflets.

Results

The length of the fusion between leaflets was effectively measured in 112/120 patients (93%). Reproducibility was good (ICC = 0.826). Fusion length varied greatly (range 2.3 – 15.4 mm, 7.8 ± 3.2 mm, tertiles cut-off points were 6 and 9.3 mm). After correction for age, BSA, stroke volume and BAV fusion morphotype, fusion length was independently associated with diameter at the sinus of Valsalva (p = 0.002). Moreover, once corrected for age, stroke volume and ascending aorta pulse wave velocity, fusion length was positively related to ascending aorta diameter (p = 0.028). The comparison of maps of circumferential peak-systolic WSS in healthy volunteers (left) and BAV patients pertaining to the three leaflet fusion length tertiles is shown in Figure 1. Circumferential WSS progressively increase with larger fusion length. This trend was statistically significant (p &lt; 0.05) in the right and outer regions of the proximal and mid ascending aorta.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably and it is independently associated with ascending aorta and aortic root dilation, possibly through flow alterations.

Abstract Figure 1

Regional curvature in thoracic aortic aneurysms of different aetiologies and its relationship with established risk factors

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities ; Instituto de Salud Carlos III

Introduction

The aorta is a 3D hollow, curvilinear elastic structure whose diseases have life-threatening consequences. Despite much effort has been paid to study aortic diameter, diameter is a poor predictor of events. Conversely, much less is known about aortic curvature, its distribution in the thoracic aorta and the potential impact of risk factors in aneurysms associated with different conditions. Currently, 4D flow magnetic resonance imaging (4D flow CMR) allows to obtain 3D geometry, 4D flow data and regional aortic stiffness.

Purpose

We aim to study regional aortic curvature in thoracic aorta aneurysms of different aetiologies and define its relationship with established risk factors.

Methods

One-hundred twenty patients (40 for each group, selected out of prospective cohorts of 156 bicuspid aortic valve – BAV-, 77 Marfan –MFS- and 67 patients with a degenerative aneurysm – TAVdeg-) were matched for age, sex and BSA via propensity score with 40 healthy volunteers (HV). The thoracic aorta was semi-automatically segmented from angiograms and the centreline was computed. Local curvature was assessed at 20 planes covering the thoracic aorta from the sinotubular junction to the proximal descending aorta (DAo) at the level of the pulmonary artery bifurcation. Local curvature was normalized by subject mean thoracic aorta curvature. Length was measured as centreline length. Aortic stiffness was measured in the DAo by pulse wave velocity (PWV). Aneurysm was defined by z-score ≥ 2 using diameters measured by double-oblique cine CMR.

Results

Matching was successful in all groups with the exception of a residual age difference between HV and TAVdeg. Curvature in HV showed a fairly smooth transition between the straighter ascending aorta (AAo) and DAo to a more curved aortic arch, with a peak in the mid aortic arch (Figure 1A).  Conversely, all patients’ groups presented a peak in curvature in the proximal DAo and a decreased local curvature in the aortic arch and mid DAo close to the level of the pulmonary artery. BAV and TAVdeg patients showed also increased curvature in the mid AAo, were dilation is prevalent. Conversely, in the same area MFS showed a reduced curvature and limited prevalence of aneurysm. In the overall population, age, AAo and root diameters, mean blood pressure, DAo PWV and aortic length, all established risk factors for aortic events, were inversely related to curvature in the distal AAo and aortic arch (Figure 1B).

Conclusions

Aneurysms related to different aetiologies show similar abnormalities in aortic curvature, with limited curvature in the aortic arch and a peak soon after the third supra-aortic vessel. Age, aortic diameter, length, stiffness and blood pressure, all known risk factors, are all related to reduced curvature in the distal ascending aorta and aortic arch.

Abstract Figure.

Prognostic implications of myocardial work in patients with reduced left ventricular ejection fraction: a preliminary study

Funding Acknowledgements

Type of funding sources: None.

Background. Myocardial work (MW) is a new imaging technique to assess left ventricular (LV) systolic function. It incorporates both deformation parameters (global longitudinal strain -GLS-) and loading conditions and gives information on global constructive work (GCW), global wasted work (GWW), global LV myocardial work index (GWI) and global LV myocardial work efficiency (GWE).

Purpose. The aim of this study was to describe the prognostic role of MW in predicting major adverse cardiovascular events (MACE) in patients with reduced LV ejection fraction (LVEF), and to compare it with GLS and LVEF.

Methods. We retrospectively included consecutive patients from 2012 to 2019 with dilated LV and LVEF &lt; 50% of any aetiology.  Clinical variables were collected and LVEF, GLS and MW were evaluated from baseline echocardiogram. MACE was defined as heart failure (HF) and/or ventricular arrhythmia (VA) and/or cardiac arrest and/or all cause death. 

Results. 99 patients were included, 26 were women (26.3%), mean age at diagnosis was 57 years (SD 23). Mean LVEF was 32.5% (SD 10.3). Baseline patients characteristics are described in Table 1. During a median follow-up of 25 months (IQR 12), 24 MACE were recorded (24.4%). Patients with MACE had worse MW parameters: significantly lower MWI (805 ± 360 % vs 638 ± 277 %, p = 0.04) and lower GCW (1116 ± 535 mmHg vs 874 ± 458 mmHg, p = 0.05), and a tendency to lower GWE (83 ± 11 % vs 77 ± 16 %, p = 0.084).  Of note, both LVEF (33 ± 10% vs 29 ± 9%, p = 0.123) and GLS (-9.99 ± 3.7% vs -8.8 ± 3.0, p = 0.170) showed a trend but were not significantly associated with outcomes. This might suggest that MW variables are stronger prognostic predictors than traditional imaging parameters.

Conclusions. In patients with reduced LVEF, MW parameters including global  MWI and GCW were associated with major adverse cardiovascular events. Of note, both EF and GLS seem to have less prognostic implications in this cohort when compared with MW. Our results are preliminary and larger studies are needed in order to fully understand the clinical utility of MW beyond traditional parameters.

Baseline patient characteristics GLOBAL EVENTS NO EVENTS p Hypertension, % 41 67 29 0.014 Ischaemic etiology, % 14 20 12 0.448 Creatinine, mean (SD) - mg/dL 0.96 (0.04) 1.11 (0.09) 0.90 (0.04) 0.021 Bblockers, % 98 100 97 0.514 Nitrates, % 4 13 0 0.025 Diuretics, % 65 93 53 0.006 SD standard deviation Abstract Figure. Results

Semi-automatic quantification of aortic root progressive dilation by automatic co-registration of computed tomography angiograms: a preliminary comparison with manual assessment in Marfan patients

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities Instituto de Salud Carlos III

Background. Dilation of the aortic root is a key feature of Marfan syndrome and it is related to the occurrence of aortic events and death. On top of maximum diameter, rapid annual growth rate is suggested by guidelines for indication of aortic root replacement. Current gold-standard for aortic root diameter assessment is manual quantification on multiplanar reformatted 3D computed tomography (CT) or magnetic resonance angiogram. However, inter- and intra-observer reproducibility are limited and different measurement methods, i.e. cusp-to-cusp and cusp-to-commissure, may be used in different clinical centres, leading to difficulties in the clinical assessment of progressive dilation.

Purpose. We aimed to test whether aortic root growth rate during follow-up can be reliably quantified by semi-automatic co-registration of two CT angiograms.

Methods. Seven Marfan syndrome patients, free from previous aortic surgery, with a total of 11 pairs of CT were identified. Manual assessment of six aortic root diameters (right-non coronary -RN- , right-left -RL- and left-non coronary -LN- cusp-to-cusp and R, L and N cusp-to-commissure) was obtained from all CTs by an experienced researcher blind to semi-automatic results. The thoracic aorta and the outflow tract were semi-automatically segmented in the baseline CT and commissure and cusps were manually located. A 10 mm-thick region of interest containing the aortic wall was automatically generated from segmentation boundary. Co-registration was obtained with three, fully-automatic steps. Firstly, baseline and follow-up CT scans were aligned by means of a rigid registration. Then, scans were co-registered with multi-resolution affine followed by b-spline non-rigid registrations based on mutual information metric. The transformation pertaining to the location of baseline commissure and cusps points was used to locate the same points in the follow-up scan (Fig. 1 top).

Results. Follow-up duration was 35 ± 22 (range 12-70.3) months. Automatic quantification of diameter growth during the follow-up was obtained in 62 out of 66 (94%) diameter comparisons. High Pearson correlation coefficients (R) and ICC were found between manual and semi-automatic assessment of growth rate, both for cusp-to-cusp and cusp-to-commissure diameters: R = 0.727 and ICC = 0.678 for RN; R = 0.822 and ICC = 0.602 for RL; R = 0.648 and ICC = 0.668 for LN; R = 0.726 and ICC = 0.711 for R; R = 0.911 and ICC = 0.895 for L and R = 0.553 and ICC = 0.482 for N. Scatter and Bland-Altman plots for all growth rates (Fig. 1) confirmed very good correlation (R = 0.810) but a slight tendency (R=-0.270) for underestimation at high growth rate.  No correlation was found between follow-up duration and difference between techniques (R = 0.06).

Conclusions. Semi-automatic quantification of aortic root growth rate by co-registration of pairs of CT angiograms is feasible for follow-up as short as one year. Larger studies are needed to confirm these preliminary data.

Abstract Figure. CT measurements. Automatic vs manual.

Are aortic root and ascending aorta echocardiographic diameters by adult vs paediatric guidelines recommendations interchangeable?

Background

Both aortic root size and ascending aorta are clinical parameters with significant therapeutic implications which can be easily assessed by transthoracic echocardiography (TTE). However, measurement values may vary according to cardiac cycle and the edge convention used.

Purpose

This study aimed to compare the aortic diameter values measured using the lastest recommendations of two different guidelines, adults and children, to determine the influence of these methods on echocardiographic measurements.

Methods

Two hundred and fifty adult patients (56% male, 63±15 years of age) and 67 children (65% male, 10.04±4.5 years of age) in whom TTE was clinically indicated were included. Aortic diameters were measured twice at 2 levels (sinuses of Valsalva and ascending aorta): leading edge to leading edge during diastole, (L-L in D) following the 2015 American Society of Echocardiography (ASE) adults guidelines and inner edge to inner edge during systole (I-I in S) following the 2010 ASE paediatric guidelines.

Results

Mean aortic diameters obtained by L-L in D and I-I in S are shown in Table 1. Correlation coefficient was 0.990 (CI95% 0.988–0.992) for sinuses of Valsalva measurements and 0.991 (CI95% 0.989–0.993) for ascending aorta in adult patients and 0.983 (CI95% 0.975–0.973) and 0.970 (CI95% 0.956–0.952) in childrens respectively. When both populations were analysed together, concordance correlation coefficients were 0.991 (CI95% 0.989–0.993) and 0.970 (CI95% 0.991–0.994), respectively. Bland- Altman analysis for each level measured (A: aortic root; B: ascending aorta) in the total cohort of 317 patients is shown in Figure 1. Mean aortic diameters and differences in the whole group are shown in Table 1.

Conclusions

Measurement of aortic root and ascending aorta showed a significantly larger diameters by L-L in D than by I-I in S. However, these differences had subclinical significance and management implications. These similar diameter values may be used indifferently but systematically during follow-up. Systolic diameter expansion has a similar value to that of anterior aortic wall thickness; however, it is more vulnerable to changes in haemodynamic conditions.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Vall d'Hebron Research Institute

Validation of the EUROMACS right-sided heart failure risk score in left ventricular assist device patients: a single center experience

Background

Right Heart failure (RHF) is a severe complication after left ventricular assist device (LVAD) implantation, increasing early and late mortality. A simple 5-item score, the EUROMACS-RHF risk score, was developed to predict early RHF and mortality after implantation.

Purpose

The aim of the study was to investigate whether EUROMACS-RHF risk score was applicable in a single center to predict early (&lt;30 days) post-operative RHF.

Methods

From February 2011 to October 2019 all LVAD implanted patients in our institution were retrospectively reviewed. Only patients with complete data for risk score calculation and RHF analysis were included. Baseline characteristics and hospitalization data, including preoperative clinical, biological, echocardiographic and hemodynamic data were obtained. Based on these informations, EUROMACS-RHF risk score was calculated and classified in low, intermediate and high.

The link between the EUROMACS-RHF risk score and early severe RHF was investigated using Pearson's exact chi-square tests.

Results

The analysis included 88 patients (67 males; 49±2 years). Etiology of HF was ischemic in 36 patients (41%), dilated cardiomyopathy in 21 (24%) and others causes in 31 (35%). A Heart Ware LVAD (94%) was implanted as bridge to transplantation in 96% of the patients; 81 patients (90%) had severe INTERMACS (1–3) profile.

RHF was identified in 21 patients (24.1%), of which 15 (18%) were treated with inotropes for ≥14 days, 8 (9%) had an RVAD, and 11 (13%) were treated with inhaled NO for ≥48 hours. Patients with severe RHF had a significantly longer length of ICU stay compared to patients without (median 20 days versus 6,5 days). The early (&lt;30 days) post-operatory mortality was of 43% (n=9/21) in the RHF group and 6% (n=4/69) in patients without RHF (p&lt;0.001). Three of the twelve patients alive in the RHF group had an emergency transplant.

The prediction of RHF from the EUROMACS-RHF risk score and the observed severe RHF are presented in the table. A high preoperative EUROMACS-RHF score was able to predict the presence of RHF in 52% of patients (p=0.005), while a low score predicted the absence of RHF in 52% of patients (p&lt;0.001). In contrast, an intermediate EUROMACS risk score was not found to predict early RHF (p=0.283).

Conclusion

In our cohort, the EUROMACS-RHF risk score was effective in predicting early severe RHF, in particular for patients with preoperatory low (no RHF) and high (RHF) scores. This external validation confirms the clinical usefulness in risk prediction before LVAD implantation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Late gadolinium-enhanced cardiac magnetic resonance in repaired tetralogy of Fallot: characterization of the right ventricular arrhythmogenic substrate

Introduction

Ventricular arrhythmias are one of the main causes of morbidity and mortality in patients with repaired tetralogy of fallot (rTF). These life-threatening arrhythmias are related to specific isthmuses of viable tissue between areas of scar and/or valve rings of the right ventricle (RV) that have been already described in the literature. Late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) has proven useful in characterizing the arrhythmogenic substrate in several heart diseases. Nevertheless, LGE-CMR evidence in patients with rTF is scarce.

Purpose

To compare the characterization of the ventricular arrhythmogenic substrate by means of LGE-CMR and electroanatomic mapping (EAM) of the right ventricle (RV) in patients with rTF.

Methods

Unicentric and observational study of consecutive patients with rTF who underwent LGE-CMR performed with 1.5T equipment and RV high-density voltage map, performed with multipolar catheter and completed with contact force-sensing catheter. The LGE-CMR segmentation was performed with dedicated software. The extent (area and percentage) and location of the dense scar (defined as &lt;0.5 mV in EAM and &lt;40% of the maximum intensity pixel in LGE-CMR) were compared, as well as the location of the isthmuses of viable tissue.

Results

Eight patients were included (45.7±10.4 years; 50% male). The extent of the scar was 20.7±13.6 cm2 (15.1±9.3%) by EAM and 21.7±8.8 cm2 (11.8±7.6%) by LGE-CMR. There was an absolute correlation regarding the location of the dense scar and the distribution of the isthmuses of viable tissue. The quantification of the dense scar evidenced a positive linear correlation between both techniques (area correlation: ρ = 0.71, p=0.047; percentage correlation: ρ = 0.88; p=0.004). The average time spent for the segmentation of the LGE-CMR with the dedicated software was 19.9±3.0 minutes.

Conclusions

Characterization of the RV arrhythmogenic substrate in patients with rTF with LGE-CMR is feasible. An absolute association regarding the location of the dense scar and the distribution of the isthmuses of viable tissue was observed when compared to the RV high-density EAM. In the same way, a statistically significant linear correlation in the quantification of the dense scar between both techniques was documented.

LGE-CMR and EAM of two patients with rTF

Funding Acknowledgement

Type of funding source: None

Relationship between aortic distensibility and aortic regurgitation depending on aortic valve anatomy. A CMR study

Background

Aortic regurgitation (AR) can be evaluated by cardiac magnetic resonance (CMR).The most commonly used method to quantify AR is direct measurement using phase contrast (PC) imaging, at the aortic root (as close as possible to the aortic valve), for the calculation of regurgitant fraction (RF). Aortic distensibility (AD) may affect aortic valve dynamics and, as a result, aortic regurgitation grade. However, the impact of aortic distensibility in this evaluation remains unknown.

Purpose

The aim of the study was to evaluate the relationship between AD and AR in patients with different aortic valve anatomy.

Methods

213 patients with different AR severity grades and aortic valve anatomy (tricuspid (TAV) and bicuspid valve (BAV) patients) were enrolled (32.2% female, 74% BAV, 55.5±15.4 years), excluding connective tissue disease. All patients underwent a CMR study with PC sequences for the evaluation of regurgitant fraction at the aortic valve level. AR was considered as mild (&lt;15%), moderate (15–30%) or severe (&gt;30%) depending on RF value. Furthermore we used cine-sequences to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

Results

159 (73.7%) AR were mild, 30 (14.1%) moderate and 24 (11.3%) severe. RF significantly correlated with aortic root diameter (r=0.337, p&lt;0.001) and did not correlate with AD at the level of proximal descending aorta (r=0.121 and p=0.107). Furthermore descendig aorta distensibility correlated with age (r=−0.631, p&lt;0.001) and aortic root diameter (r=−0.224, p=0.002). Dividing population in two different groups, depending on aortic valve anatomy, in TAV patients RF continued to not correlate with AD (r=0.159, p=0.369). In contrast, RF in BAV patients was positively correlated with AD (r=0.223, p=0.007) even after adjustment for aortic diameter and age in a multiple regression model (p&lt;0.001, R2=0.478).

Conclusions

In our study, aortic regurgitation is positively related to descending aorta distensibility in BAV patients, regardless of age and aortic root diameter. Thus, AD may play a role in the evaluation of AR in case of bicuspid valves. In contrast, in TAV patients, distensibility does not seem to influence the assessment of AR severity.

Descending aorta distensibility

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Research grant provided by the Cardiopath PhD program

Patients with blunt traumatic thoracic aortic injury treated with TEVAR present increased flow dynamics alterations and pulse wave velocity: a 4D flow CMR study

Background

Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of blunt traumatic thoracic aortic injuries. Aortic flow dynamics and mechanical implications of this intervention are poorly investigated and may be of particular interest in the long-term follow-up of these mostly young patients.

Purpose

To assess whether the presence of TEVAR in a cohort of otherwise healthy subjects was related to dilation of the proximal aorta or increase in aortic stiffness and flow alterations.

Methods

Nineteen patients who underwent TEVAR implantation after a traumatic injury of the thoracic descending aorta (DAo) (10.0±6.1 years from intervention) and 44 healthy volunteers (HV) underwent 4D flow CMR to compute ascending aorta (AAo) pulse wave velocity (PWV), a marker of aortic stiffness, systolic flow reversal ratio (SFRR), quantifying backward flow during systole and in-plane rotational flow (IRF), measuring in-plane strength of helical flow. IRF and SFRR were assessed at 20 planes between the sinotubular junction and the mid thoracic DAo. Aortic diameters were measured using double-oblique cine CMR.

Results

Patients with TEVAR and HV did not differ in age, sex, body surface area, blood pressure and DAo diameter distal to TEVAR (Table). However, TEVAR patients presented larger diameters at the sinus of Valsalva and AAo, increased AAo PWV and strong flow alterations: IRF was reduced from the distal AAo to the proximal DAo, while SFRR was increased in the whole thoracic aorta (Figure).

Conclusions

In patients with blunt traumatic thoracic aortic injury treated with TEVAR the aorta proximal to TEVAR is dilated, stiffer and present potentially pathogenic flow conditions. Longitudinal studies are needed to assess whether these alterations have prognostic value and may improve clinical prevention and management of these patients.

Figure 1. IRF and SFRR in healthy vs TEVAR

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been funded by Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation (PI19/01480). Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

The length of the fusion between leaflets in bicuspid aortic valve is independently related to ascending aorta dilation and flow dynamics alterations assessed by 4D-flow CMR

Background

Aortic dilation in bicuspid aortic valve (BAV) patients has been related to altered flow patterns, which contribute to aortic wall degeneration. However, preventive aortic replacement is currently based on a diameter threshold. Several studies on excised BAV reported wide variability of fusion extent.

Purpose

To unveil whether leaflet fusion extent can be quantified by CMR and is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty adults with non-dysfunctional BAV and no previous aortic or aortic valve surgery and 28 healthy volunteers underwent double-oblique cine and 4D flow CMR. BAV patients with two sinuses of Valsalva or left and non-coronary cusps fusion were excluded. Peak systolic circumferential wall shear stress (WSSc) and pulse wave velocity (PWV) in the ascending aorta (AAo) were assessed by 4D flow CMR. Fusion length between leaflets was measured using a stack of double-oblique cine CMR images of the aortic valve.

Results

The length of the fusion was effectively measured in 112/120 (93%) patients with good reproducibility (ICC = 0.826) and showed great variability (range 2.3–15.4 mm, 7.8±3.2 mm and tertiles cut-off points 6 and 9.3 mm). In multivariate analysis adjusted for clinical and demographic characteristics and PWV, fusion length was independently associated with the diameter at the sinus of Valsalva (p=0.002) and the AAo (p=0.02) (Table). WSSc progressively increased with larger fusion length (Figure), with statistical significance (p&lt;0.05) in the right and outer regions of the proximal and mid AAo.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably, and it is independently associated with AAo and aortic root dilation, possibly through flow alterations.

Figure 1. Maps of circumferential WSS

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been partially funded by Instituto Carlos III, Spanish Ministry of Science and Innovation (PI17/00381). Guala A. has received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

Prognostic implications of myocardial work in patients with reduced left ventricular ejection fraction: a preliminary study

Background

Myocardial work (MW) is a new imaging technique to assess left ventricular (LV) systolic function. It incorporates both deformation parameters (global longitudinal strain -GLS-) and loading conditions and gives information on global constructive work (GCW), global wasted work (GWW), global LV myocardial work index (GWI) and global LV myocardial work efficiency (GWE).

Purpose

The aim of this study was to describe the prognostic role of MW in predicting major adverse cardiovascular events (MACE) in patients with reduced LV ejection fraction (LVEF), and to compare it with GLS and LVEF.

Methods

We retrospectively included consecutive patients from 2012 to 2019 with dilated LV and LVEF &lt;50% of any aetiology. Clinical variables were collected and LVEF, GLS and MW were evaluated from baseline echocardiogram. MACE was defined as heart failure (HF) and/or ventricular arrhythmia (VA) and/or cardiac arrest and/or all cause death.

Results

99 patients were included, 26 were women (26.3%), mean age at diagnosis was 57 years (SD 23). Mean LVEF was 32.5% (SD 10.3). Baseline patients characteristics are described in Table 1. During a median follow-up of 25 months (IQR 12), 24 MACE were recorded (24.4%). Patients with MACE had worse MW parameters: significantly lower MWI (805±360% vs 638±277%, p=0.04) and lower GCW (1116±535 mmHg vs 874±458 mmHg, p=0.05), and a tendency to lower GWE (83±11% vs 77±16%, p=0.084). Of note, both LVEF (33±10% vs 29±9%, p=0.123) and GLS (−9.99±3.7% vs −8.8±3.0, p=0.170) showed a trend but were not significantly associated with outcomes. This might suggest that MW variables are stronger prognostic predictors than traditional imaging parameters.

Conclusions

In patients with reduced LVEF, MW parameters including global MWI and GCW were associated with major adverse cardiovascular events. Of note, both EF and GLS seem to have less prognostic implications in this cohort when compared with MW. Our results are preliminary and larger studies are needed in order to fully understand the clinical utility of MW beyond traditional parameters.

Results

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Universitary Hospital Vall d'Hebron

Iron deficiency is associated with larger infarcts and with adverse remodeling in STEMI patients and reduces myocardial tolerance to ischemia/reperfusion by inhibiting the eNOS/sGC/PKG pathway in mice

Background

Iron deficiency (ID) interferes with the cardioprotective pathway endothelial nitric oxide synthase/soluble guanylate cyclase/protein kinase G (eNOS/sGC/PKG), but its role in acute myocardial infarction remains unclear.

Methods

Patients (n=125) with a first anterior STEMI treated with PCI underwent magnetic resonance imaging in the acute phase and at 6 months. We assessed whether ID (ferritin level &lt;100 μg/L or &lt;300 μg/L if transferrin saturation was &lt;20%) was associated with infarct size acutely or with adverse left ventricular (LV) remodeling (LV end-diastolic volume increase at 6 months &gt;20%, n=105). C57BL6/N mice were fed with standard diet or iron-deficient diet for 4 weeks before undergoing 45-min coronary occlusion/24-h reperfusion.

Results

Patients with ID (43.2%) had larger infarcts (22.8±10.2 vs 16.8±9.8% of LV mass, P=0.002) and more frequent microvascular obstruction (70.0 vs 43.3%, P=0.004) in the initial exam than the rest. They also developed adverse LV remodeling more often (38.6 vs 14.8%, P=0.005), even after adjusting by infarct size and final TIMI flow grade (OR 3.1, 95% CI 1.1–8.6, P=0.027). In mice, ID diet reduced myocardial iron content, serum ferritin and hemoglobin levels without reaching anemic values and without inducing echocardiographic alterations. ID diet reduced myocardial eNOS protein content, its dimeric form, and nitrites/nitrates and cGMP levels. eNOS decrease was associated with reduced HSP90 levels and increased eNOS ubiquitination in correlation with oxidative and nitrosative stress. Weekly iv administration of iron sucrose effectively reverted the ID-diet effects. Infarct size was larger in the ID group than in controls (58.8±3.0 vs. 40.3±3.6%, P=0.03) but was not increased in ID-diet animals treated with iron sucrose (36.3±4.0%) or receiving the sGC activator ataciguat before ischemia (31.0±2.5%).

Conclusions

ID is associated with larger infarcts and with more frequent adverse LV remodeling in patients with STEMI and reduces myocardial tolerance to ischemia/reperfusion in mice by attenuating eNOS/sGC/PKG pathway activity. Iron sucrose treatment and sGC activation reverted these deleterious effects of ID in mice. Iron supplementation might be beneficial in STEMI patients with ID.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIBER-CV. Instituto de Salud Carlos III (PI16/00232), co-financed by the ERDF

Impact of the dynamics of ejection fraction on risk stratification in a large multicenter registry of STEMI patients using sequential CMR

Background

Left ventricular ejection fraction (LVEF) has traditionally been used as the cornerstone for risk stratification after ST-segment elevation myocardial infarction (STEMI) and it can be accurately quantified by cine cardiovascular magnetic resonance (CMR). In recent years, the additional prognostic value of contrast CMR-derived infarct size (IS) and microvascular obstruction (MVO) has been demonstrated.

Purpose

We explored the impact of sequential assessment of CMR-derived LVEF on dynamic risk stratification after STEMI.

Methods

Data were obtained from three prospective registries of reperfused STEMI patients (n=1036) in whom LVEF, IS and MVO were sequentially quantified by CMR (at least at 1 week and at 6 months). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (HF), whichever occurred first. Late events were regarded as those occurring after the 6-month CMR.

Results

During a mean and median follow-up of 5 years, 105 first MACE (10%, 36 deaths and 69 HF) and 82 late MACE (8%, 35 deaths and 47 HF) were registered. From 1-week to 6-month CMR, LVEF improved (49±12 vs. 53±12%), IS decreased (21±14 vs 17±12% of LV mass) and MVO vanished (1.3±1.9 vs. 0.1±0.7% of LV mass), p&lt;0.001 for all comparisons. At 1-week CMR, 207 patients (20%) displayed reduced LVEF (r-LVEF, &lt;40%), 328 (32%) mid-range LVEF (mr-LVEF, 40–50%) and 501 (48%) preserved LVEF (p-LVEF, &gt;50%). At 6-month CMR, 144 patients (14%) displayed r-LVEF, 247 (24%) mr-LVEF and 645 (62%) p-LVEF. The total MACE rate was higher (p&lt;0.001) only in patients with r-LVEF at 1 week (22%) vs. 7% in those with mr-LVEF and 7% in those with p-LVEF. Similarly, the late MACE rate was higher (p&lt;0.001) only in patients with r-LVEF at 6 months (20%) vs. 7% in those with mr-LVEF and 5% in those with p-LVEF. The late MACE rate was very low in patients with sustained mr- or p-LVEF (41/794, 5%), intermediate in those with improved LVEF from r-LVEF at 1 week to mr- or p-LVEF at 6 months (12/98, 12%) and high in patients with sustained r-LVEF (22/109, 20%) or worsened LVEF from mr- or p-LVEF at 1 week to r-LVEF at 6 months (7/35, 20%), p&lt;0.001 for the trend. Using a Markov approach, only r-LVEF (at any time assessed) significantly related to a higher MACE rate.

Conclusions

Of available CMR parameters, LVEF persists as the pivotal index for simple post-STEMI risk stratification. Mid-range or preserved LVEF in acute phase associates with excellent long-term outcome. Changes in LVEF provide valuable dynamic prognostic information. Maintenance of mid-range or preserved LVEF in chronic phase occurs in the majority of patients and associates with a very low risk of late clinical events. Whereas late improvement reaching at least mid-range LVEF exerts salutary effects, detection of reduced LVEF at this point identifies the small subset of patients at high risk in the long term.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants).

Risk stratification in patients discharged for STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance

Background

CMR permits robust risk stratification of discharged STEMI patients but an indiscriminate use in all cases is unfeasible.

Purpose

We evaluated the usefulness of left ventricular ejection fraction (LVEF) by echocardiography (Echo) as the gatekeeper for identifying those patients discharged for ST-segment elevation myocardial infarction (STEMI) who benefit most from cardiac magnetic resonance (CMR) for prognostic purposes.

Methods

Echo and CMR were performed in 1119 patients discharged for STEMI included in a multicenter registry. The prognostic power of CMR beyond Echo-LVEF was assessed using C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

Results

During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 re-admissions for acute heart failure). Lesser Echo-LVEF and CMR-LVEF associated with the occurrence of MACE but only CMR-LVEF and microvascular obstruction were independent predictors. The MACE rate significantly increased only in patients with CMR-LVEF &lt;40% (≥50%: 7%, 40–49%: 9%, &lt;40%: 27%, p&lt;0.001). The majority of patients (629, 56%) displayed Echo-LVEF ≥50% and most of them (94%) were at the “safe zone” (CMR-LVEF &gt;40%). On the other hand, 490 patients (44%) exhibited Echo-LVEF &lt;50% and 33% of them were incorrectly classified either in the “safe zone” (CMR-LVEF ≥40%) or in the “risk zone” (CMR-LVEF &lt;40%). C-statistic, NRI and IDI demonstrated potent reclassification for MACE prediction by CMR in patients with Echo-LVEF &lt;50% but not in those with Echo-LVEF ≥50%.

Conclusions

Echo-LVEF &lt;50% identifies the subset of discharged STEMI patients who may benefit most from CMR in terms of long-term risk prediction.

Figure 1. LVEF reclassification

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants).

The role of descending aorta diastolic reverse flow in the quantification of aortic regurgitation by CMR

Background

EACVI recommends the use of an “integrative approach”, using several parameters, in aortic regurgitation (AR) quantification. This approach is easily achieved by echocardiography although cardiovascular magnetic resonance (CMR) remains the gold standard for the quantification of regurgitant fraction (RF).

Purpose

The aim of the study was to analyze the accuracy of descending aorta (DA) diastolic reverse flow in the assessment of chronic AR severity by CMR to identify an additional parameter.

Methods

188 patients (34% female, 54.6±15.6 years) with different severity grades of chronic AR were enrolled. All patients underwent a CMR study. Aortic regurgitation was considered as absent (≤1%), mild (≤15%), moderate (≤15%) or severe (≥30%) depending on RF value at valve level. Furthermore, cine-sequences were used to estimate aortic diameters and distensibilities using Art Fun software. Velocity-time integral (VTI) of reverse flow in DA was calculated from maximum velocity curves by an in-house MatLab code.

Results

AR was absent in 21 (12%) patients, mild in 114 (62.9%), moderate in 23 (12.7%) and severe in 21 (11.6%).DA VTI reverse flow was significantly higher as was the RF at valve level (r=0.805, p&lt;0.001) (IMG, Table). It also positively correlated withaortic root diameter (r=0.347, p&lt;0.001) and DA distensibility (r=0.279, p&lt;0.001). It did not correlate with age (r=−0.91, p=0.22). In a statistically significant multiple regression model (p&lt;0.001, R2 = 0.697), although VTI reverse flow in DA correlated strongly with RF at valve level (p&lt;0.001; beta = 0.733), it was also influenced by DA distensibility (p&lt;0.001; beta = 0.197) and aortic root diameter (p&lt;0.001; beta= 0.140).

Conclusions

VTI reverse flow in DA correlates strongly with the degree of AR and may be useful in the assessment of its severity. Neverthless, owing to the influence of other factors (aortic distensibility and aortic root diameter), it cannot be used as a single parameter in the quantification of AR severity by CMR.

Scatter Plot graphs

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): research grant provided by the Cardiopath PhD program

Orthodontic treatment need and timing: Assessment of evolutive malocclusion conditions and associated risk factors

AIM

Orthodontic treatment need indexes are indispensable tools for collecting aepidemiological information, to define the need for clinical intervention on a graduated risk scale and to monitor the evolution of clinical conditions over time. The purpose of this research is to evaluate the prevalence of malocclusion and associated risk factors, and to compare the prevalence of malocclusion related to children's growth. Investigating the correlation between malocclusion and dental occlusion development is crucial to define orthodontic timing and the most suitable treatment modalities.

MATERIALS AND METHODS

A cross-sectional, multi-center, observational study was carried out throughout Italy: 4,422 patients aged between 2 and 13 years were visited. The patients were divided into two age groups: one composed of patients aged 2 -7 years, and one of children between 8 and 13 years of age. The prevalence data were classified according to the items of the Baby ROMA (first group, deciduous/early mixed dentition) and ROMA Index (second group, late mixed/permanent dentition). Pearson's Chi-square test was applied for the calculation of statistical significance in the comparison of prevalence data between the two age groups (P <0.05).

RESULTS

The need for orthodontic treatment among Italian children is high. In the sample aged between 2 and 7 years, the most frequent malocclusions are the moderate and severe open bite (23%), moderate and severe Class II (21.2%), deep bite (18.8%), cross bite (16.5%), Class III (7.7%), and crowding (5.1%). In the sample aged between 8 and 13 years the most frequent malocclusions are crowding (50.8 %), Class II (33.1%), deep bite (19.2%) crossbite (18.1%), Class III (9.1%), open bite (6.6%), facial or mandibular asymmetries (3.3%), and functional asymmetries (3.2%). It was found a statistically significant variation of the different malocclusion conditions according to age.

CONCLUSION

The study confirms that some risk factors occur during growth, and worsen the malocclusion. Therefore, it is important to reduce this risk of worsening by counteracting those factors with an early orthodontic intervention. Some malocclusions are less affected by environmental risk factors. In these case it would be better defer treatment until adolescence.

P372 Aortic stiffness in Loeys-Dietz syndrome: a comparison with Marfan syndrome patients and healthy volunteers

Funding Acknowledgements

ISCIII PI14/0106 and PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

Genetic syndromic aortic diseases are rare, with Marfan syndrome (MFS) being the most common. However, less is known of Loeys-Dietz syndrome (LDS) which has much lower prevalence and presumed worse prognosis. Increased aortic stiffness in MFS has been previously described but no studies have evaluated aortic biomechanics in LDS. Pulse wave velocity (PWV) is the gold standard measure for arterial stiffness and can be quantified by 4D flow MRI. We aim to evaluate regional aortic PWV by 4D flow MRI in LDS compared to MFS and healthy volunteers.

METHODS

Sixteen LDS patients with a pathogenic mutation, 76 MFS and 49 healthy volunteers were prospectively and consecutively included. No patient had previous aortic dissection or surgery. All underwent a 4D flow MRI study in a 1.5 T clinical scanner. Ascending (AAo) and descending (DAo) aorta PWV were computed using wavelet analysis of the systolic upslope for transit time calculation (Figure). Statistical comparison was made with non-parametric analysis to account for the non-normality of data and multivariate analysis was evaluated separately for AAo and DAo PWV.

RESULTS

Ascending and descending aortic PWV revealed stiffer aortas in LDS patients than in healthy volunteers, even after adjustment for diameter of sinus of Valsalva (SoV) and sex. Conversely, no differences in aortic stiffness were found between LDS and MFS patients (Table).

CONCLUSIONS

Abnormally high regional aortic stiffness was observed in LDS patients when compared with controls. The severity of increased regional aortic stiffness was found similar to the one affecting MFS patients.

Table Controls (N = 49) LDS (N = 16) MFS (N = 76) LDS vs. HV LDS vs. MFN Parameter Unadjusted p-value Adjusted p-value Unadjusted p-value Adjusted p-value Age [years] 39 ± 12 39 ± 16 36 ± 12 0.903 0.599 Men 32 (65%) 6 (37%) 34 (45%) 0.079 0.782 Weight [kg] 72 ± 11 69 ± 13 74 ± 16 0.288 0.194 Height [cm] 172 ± 8 172 ±12 181 ± 11 0.834 0.008 Systolic BP [mmHg] 126 ± 18 125 ± 14 127 ± 17 0.957 0.523 Diastolic BP [mmHg] 70 ± 11 77 ± 6 75 ± 12 0.011 0.318 SoV diameter [mm] 30.6 ± 3.9 35.4 ± 4.6 38.1 ± 5.9 0.001 0.060 AAo diameter [mm] 27.7 ± 3.8 29,0 ± 5.0 29.7 ± 5.4 0.458 0.579 DAo diameter [mm] 20.0 ± 2.0 21.3 ± 3.6 22.9 ± 3.8 0.546 0.124 AAo PWV [m/s] 5.2 ± 1.9 7.6 ± 2.4 7.3 ± 2.8 0.001 0.050* 0.534 NS DAo PWV [m/s] 7.1 ± 2.2 9.4 ± 2.6 10.7 ± 4.6 0.003 0.025** 0.493 NS

Abstract P372 Figure

P1601 Relationship between aortic distensibility and aortic regurgitation assessed by CMR in bicuspid valve patients

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

The severity of aortic regurgitation can be evaluated with cardiac magnetic resonance (CMR) through calculation of regurgitant fraction (RF) in phase contrast sequences acquired at the aortic root (as close as possible to the aortic valve). However, the impact of aortic distensibility in this evaluation remains unkown.

PURPOSE

The aim of the study was to evaluate the relation between aortic distensibility and RF valve in bicuspid aortic valve patients.

METHODS

We enrolled bicuspid aortic valve patients without significant aortic stenosis (maximum velocity &lt;2.5 m/s) and connective tissue disease. All patients underwent a CMR study with phase contrast sequences for evaluation of regurgitant fraction at the level of the aortic valve. Aortic regurgitation was considered as mild, moderate or severe depending on RF value (mild &lt;15%; moderate 15-30%; severe &gt;30%). Furthermore we used cine-sequences of aortic root, ascending and proximal descending aorta to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

RESULTS

A total of 98 bicuspid aortic valve patients were included (30% female, 49.7 ± 14.5 years). 75 (76,5%) AR was mild, 17 (17,4%) moderate and 6 (6,1%) severe. RF valvewas significantly correlated with aortic root diameter (r= 0.430 y p &lt; 0.001 )and aortic distensibility at the level of the ascending (r = 0.273 p =0.016) and descending aorta (r = 0.502 and p&lt; 0.001). Aortic distensibility was positively correlated with RFvalve even after adjustment for aortic diameter ( p = 0.002 and p &lt;0.001 respectively) . (Table) (IMG)

CONCLUSIONS

In our study, aortic regurgitation in bicuspid valve patients, evaluated by CMR using RF valve, is related to aortic distensibility. Thus, aortic distensibility should be included in the evaluation of aortic regurgitation by CMR as additional parameter. However, longitudinal studies are needed to evaluate the impact of including aortic distensibility in the evaluation of AR severity by CMR.

AR SEVERITY MILD MODERATE SEVERE Descending aorta distensibility(mean ± std. deviation) 2693,68 ± 997,5 3285,8 ±1952,7 5042,99 ±2873,44 Correlation between AR severity (by RFvalve) and descending aorta distensibility

Abstract P1601 Figure.

P1447 Ascending aorta longitudinal strain in bicuspid aortic valve patients: a comparison with healthy volunteers and patients with degenerative aortic aneurysm

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

Background

Histological findings of fibrillin-1 deficiency in bicuspid aortic valve (BAV) ascending aorta (AAo), as observed in Marfan (MFS), supported the existence of intrinsic aortic wall abnormalities, but recent studies reported the absence of an intrinsic impairment in stiffness. A recent study in MFS showed that AAo longitudinal strain was reduced in MFS and predicted dilation and aortic events. This parameter has not been studied in BAV.

Purpose

We investigated whether ascending aorta longitudinal strain is intrinsically altered in BAV with respect to tricuspid aortic valve (TAV) individuals.

Methods

80 BAV, 31 healthy volunteers (HV) and 29 TAV with AAo aneurysm, all without moderate valvular disease, were consecutively included. AAo dilation was defined as a z-score &gt; 2. The 1.5T CMR protocol included a set of 2D cine CMR stacks covering the proximal aorta in saggital, coronal and axial views. AAo longitudinal strain was computed by an in-house Matlab code performing a feature tracking of the aortic valve in each of the cine images.

Results

Twenty (25%) of BAV had AAo dilation. AAo longitudinal strain was lower in non-dilated BAV compared to HV, but the difference was not significant in multivariate analysis adjusted for AAo diameter and systolic blood pressure. Similarly, the difference between dilated BAV and dilated TAV found in univariate analysis was not confirmed by multivariate analysis. On the other hand, both dilated BAV and TAV showed decreased AAo longitudinal strain compared to HV, which were confirmed in multivariate analyses.

Conclusions

AAo longitudinal strain, a marker of aortic stiffness with predictive value in MFS, is not altered in BAV patients compared to TAV matched for dilation prevalence. Reduced AAo longitudinal strain was independently associated with dilation in both BAV and TAV.

Table 1 HV vs. NON-DILATED BAV DILATED BAV vs DILATED TAV HV vs. DILATED BAV HV vs. DILATED TAV HV NON-DILATED BAV Univariate /multivariate p-value DILATED TAV DILATED BAV Univariate /multivariate p-value Univariate/ Multivariate p-value Univariate p-value N 31 20 29 60 Age [years 35 ± 8 49 ± 16 &lt;0.001/ NS 66 ± 13 49 ± 14 &lt;0.001 / &lt;0.001 &lt;0.001 / 0.052 &lt;0.001 / NS Sex [% male] 42 35 0.629 24 42 0.097 / NS 0.969 0.149 BSA [m2] 1.83 ± 0.17 1.81 ± 0.14 0.702 1.95 ± 0.24 1.82 ± 0.22 0.015 / &lt;0.001 0.881 0.030 / NS SBP [mmHg] 119 ± 11 132 ± 16 0.002 / 0.029 133 ± 17 138 ± 19 0.304 &lt;0.001 / NS &lt;0.001 / NS DBP [mmHg] 69 ± 11 73 ± 6 0.099 / NS 77 ± 9 79 ± 11 0.455 &lt;0.001 / 0.016 0.004 / 0.023 Ascending aorta diameter [mm] 26 ± 4 33 ± 3 &lt;0.001 / 0.006 46 ± 7 43 ± 6 0.032 / NS &lt;0.001 / 0.001 &lt;0.001 /0.007 AAo long strain [%] 10.5 ± 3.6 8.4 ± 4.1 0.067/ NS 5.9 ± 2.7 7.7 ± 3.6 0.023 / NS 0.001 / 0.002 &lt;0.001 / 0.023 Demographics and uni- and multivariate analyses of AAo longitudinal strain

Decreased rotational flow and circumferential wall shear stress as early markers of descending aorta dilation in Marfan syndrome: a 4D flow CMR study

BACKGROUND

Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined.

METHODS

Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed.

RESULTS

In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter.

CONCLUSIONS

Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients.

P4131Abnormal flow pattern in the main pulmonary artery of Marfan patients is related to local dilation

Introduction

Marfan syndrome (MFS) is a hereditary connective tissue disorder caused by mutation in the FBN1 gene. Main pulmonary artery (MPA) dilation is very prevalent in MFS patients. Indeed, the old Ghent nosology considered main pulmonary artery (MPA) dilation as diagnostic criterion of MFS patients. Although clinical complications related to pulmonary dilation in MFS are rare, this may potentially lead to MPA dissection or be a marker of vascular disease in MFS. Studies regarding potential causes of MPA dilation in MFS patients are very scarce.

Purpose

Through 4D flow CMR, we aimed to assess whether flow abnormalities exist in the MPA of MFS patients and their relation to local diameter.

Methods

Fifty-five consecutive Marfan syndrome adults (MFS) and 22 healthy volunteers (HV) were prospectively enrolled. All subjects underwent non-contrast-enhanced 4D flow-MRI, obtaining 4D flow field and a 3D angiography. The MPA was segmented from the 3D angiography, and the segmentation was used to mask 4D velocity data. Four, equidistant analysis planes were placed in the MPA between the pulmonary valve and the pulmonary artery bifurcation. Common descriptors of large arteries hemodynamics were computed at each plane: maximum velocity, systolic flow reversal ratio (a descriptor of the amount of systolic backward flow) and circumferentially-averaged axial and circumferential wall shear stress (WSS). Pulmonary artery diameters were measured on axial images. MPA dilation was defined as a diameter larger than 27 mm in women and 29 mm in men. Systolic (SBP) and diastolic (DBP) systemic blood pressure were measured at the brachial artery with a calibrated cuff immediately after the scan.

Results

Compared with HV, MFS patients presented similar age, BSA, SBP and maximum blood velocity, but had larger MPA diameter (27.8 vs 25.1 mm, p<0.001) and higher DBP (75.5 vs 66.8 mmHg, p=0.003). According to the used threshold, 45% (27) of MFS patients had MPA dilation. Compared with HV, Marfan patients presented an increased systolic flow reversal ratio in the proximal part of the MPA (Figure 1). In MFS patients axial WSS was reduced in central sections of the MPA, while the circumferential component was not difference with respect to HV. All these flow abnormalities were also present in the subset of 28 MFS patients without pulmonary artery dilation. In multivariable analysis, MPA diameter was independently related to age (B=0.056; p=0.032), sex (B=−2.3; p=0.02) and axial (B=6.4; p=0.039) and circumferential (B=33.9; p<0.001) WSS.

Figure 1

Conclusions

Dilation of the main pulmonary artery is prevalent in Marfan syndrome patients. Abnormal increase in systolic vortexes and reduction in axial WSS were present in dilated and non-dilated MPA in MFS patients. Axial and circumferential WSS were independently related to MPA diameter. The eventual predictive role of abnormal pulmonary flow pattern in pulmonary artery dilation in MFS patients remain to be established

Acknowledgement/Funding

Instituto de Salud Carlos III (PI14/0106), La Maratό de TV3 (20151330), CIBERCV and FP7/People (267128)

P1821Proximal aorta longitudinal but not circumferential strain predicts aortic events and aortic root dilation rate in marfan syndrome patients

Background

The most common cardiovascular complications in Marfan syndrome (MFS) are aortic root dilation and type A aortic dissections. Elective aortic root surgery is indicated when maximum aortic diameter is larger than a defined threshold or in the case of fast-progressing dilation. However, maximum aortic diameter is limited for the prediction of aortic events. Indeed, a large international registry of acute aortic syndromes reported that as much as 40% of aortic dissections happen with maximum aortic diameter lower than 50 mm. Consequently, there is a need for new, non-invasive biomarkers to improve the prediction of aortic complications.

Purpose

The aim of the present study was to assess if proximal aorta circumferential and longitudinal strain and ascending aorta distensibility were associated with progressive aortic dilation and incidence of aortic events in Marfan syndrome patients.

Methods

Eighty seven Marfan syndrome patients free from previous cardiac/aortic surgery or dissection, were prospectively included in a multicenter follow-up. Patients were diagnosed by original Ghent criteria. Proximal aorta longitudinal and circumferential strain and distensibility were computed from baseline cine CMR images by means of feature-tracking. The predictive capacity of each stiffness biomarkers was separately tested with multivariable linear regression analysis (aortic growth) and with Cox logistic regression analysis (aortic events), both corrected for clinical and demographic variables, including baseline maximum aortic diameter.

Results

During a follow-up of 81.6±17 months, mean diameter growth-rate was 0.65±0.67 mm/year and z-score growth rate was 0.07±0.13 / year. Elective aortic root replacement was performed in 11 patients while two patients presented type A aortic dissection.Baseline proximal aorta longitudinal strain was independently related to diameter growth-rate (p=0.001), z-score growth-rate (p=0.018) and aortic events (p=0.018). Conversely, neither circumferential strain nor distensibility were independent predictors of diameter growth-rate (p=0.385 and p=0.381, respectively), z-score growth-rate (p=0.515 and p=0.484, respectively) and aortic events (p=0.064 and p=0.205, respectively).

Conclusions

Proximal aorta longitudinal strain predicts aortic root dilation and major aortic events in Marfan syndrome patients beyond aortic root diameter and clinical and demographic characteristics.

Acknowledgement/Funding

ISCIII PI14/0106, La Maratό de TV3 (20151330) and CIBERCV. Guala A. FP7/People n° 267128

P1475Risk stratification after STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance

Introduction

Cardiac magnetic resonance (CMR) has emerged as the most potent non-invasive imaging technique for risk stratification after ST-segment elevation myocardial infarction (STEMI) but an indiscriminate use in all patients is unfeasible. Echocardiography (Echo) has been universally used for prognostication in this scenario. We hypothesized that left ventricular ejection fraction (LVEF) by Echo can represent the gatekeeper for selecting those patients who benefit most from CMR for prognostic purposes.

Methods

Data were obtained from a large prospective registry of reperfused STEMI patients (n=516) in whom Echo (2D and Doppler variables) and CMR (cine images, microvascular obstruction and infarct size) were simultaneously recorded at pre-discharge (7±2 days). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (whichever occurred first). Patients were categorized in reduced LVEF (r-LVEF, <40%), mid-range LVEF (mr-LVEF, 40–49%) and preserved LVEF (p-LVEF, ≥50%). Hierarchical multivariate Cox regression analyses including first clinical+Echo variables and then CMR variables where carried out. C-statistics, “net reclassification” (NRI) and “integrated discrimination” (IDI) indexes were obtained.

Results

During a mean and median follow-up of 4 years, 86 first MACE (17%) were registered (39 deaths and 47 re-admissions for acute heart failure). In the whole study group (n=516), the independent predictors of MACE were time to revascularization (min), GRACE score, CMR-LVEF (%) and CMR-microvascular obstruction (% of LV mass); C-statistic 0.82 (p<0.001). The MACE rate in patients with r-LVEF, mr-LVEF and p-LVEF was 47%, 23% and 11% by Echo-LVEF and 45%, 17% and 8% by CMR-LVEF. LVEF was lower by CMR than by Echo (51±13 vs. 54±10, p<0.001) and r-LVEF was more frequently detected by CMR (n=94, 18%) than by Echo (n=48, 9%), p<0.001. CMR significantly improved clinical+Echo stratification in those 112 patients (22%) with mr-Echo-LVEF (C-statistitics 0.74 vs 0.82; NRI and IDI: p<0.05) but it did not in those 355 patients (69%) with p-Echo-LVEF (C-statistitics 0.75 vs 0.76; NRI and IDI: non-significant) and in those 49 patients (9%) with r-Echo-LVEF (C-statistitics 0.77 vs 0.77; NRI and IDI: non-significant).

Figure 1. Risk stratification after STEMI

Conclusions

Applied in an individualized manner, Echo-LVEF appears as a useful gatekeeper for a selective use of CMR soon after STEMI for prognostic purposes. The event rate is high in patients with reduced Echo-LVEF and low in those with preserved Echo-LVEF; CMR does not seem to significantly improve risk stratification in these scenarios. Nevertheless, the occurrence of mid-range Echo-LVEF permits discriminating the specific subset of STEMI patients (less than a quarter) who really benefit from pre-discharge CMR in terms of risk assessment.

Acknowledgement/Funding

Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).

477Partial fusion of two aortic valve leaflets is related to alterations in ascending aorta flow: 4D flow CMR study

Introduction

Bicuspid aortic valve (BAV) is the most common congenital valve defect. It consists in the fusion of two aortic valve leaflets, and it is associated with a high prevalence of proximal aorta dilation. Dilation is highly prevalent (around 30%) in BAV patient relatives with a tricuspid valve (TAV) identified by echocardiography. However, the presence of partial aortic valve leaflet fusion (also called mini-raphe or forme fruste BAV, see figure 1A) is easily missed by echocardiography. A recent study reported that 44% of patients from a small cohort of BAV patient relatives with aortic dilation followed by CT showed mini-raphe.

Purpose

We aimed to use 4D flow CMR to assess if the presence of mini-raphe is associated with aortic flow alterations, which may be concurs in the etiology of aortic dilation in BAV patient relatives.

Methods

Twenty BAV patients first-degree relatives with partial fusion (<50%) of aortic valve leaflets and proximal aorta dilation were identified by CT or cine CMR and prospectively included. One-hundred twenty-five BAV and 95 patients with TAV from our prospective dataset of 4D flow CMR were included for comparison. Propensity score matching was used throughout the study to correct the comparisons between mini-raphe and BAV and mini-raphe and TAV patients for differences in age, maximum aortic diameter, sex, height, weight, proximal aortic pulse wave velocity and, only for BAV, fusion pattern. The hemodynamic parameters previously related to aortic dilation were computed. They were jet angle, normalized flow displacement and systolic flow reversal ratio (SFRR, identifying through-plane vortexes) were computed and compared in the ascending aorta and in the aortic arch.

Results

The presence of mini-raphe was statistically-significantly associated with increase in jet angle (Figure 1B), flow displacement (Figure 1C) and vortexes (Figure 1D) in most of the ascending aorta and aortic arch when mini-raphe patients were compared with TAV patients. The severity of flow asymmetry found in mini-raphe patients was lower than the one characteristic of BAV patients, but vortexes were even higher in a small region at the distal ascending aorta.

Figure 1

Conclusion

Partial fusion of the aortic valve leaflets is related to increase in proximal aorta flow eccentricity and vorticity. These flow abnormalities are not as marked as those associated with BAV. Data regarding prevalence of mini-raphe as evaluated with CT or cine CMR are needed, especially in familiar of BAV patients.

Acknowledgement/Funding

European FP7/People 267128; Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1 and Instituto de Salud Carlos III PI14/0106