Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Anatomic and functional discordance among patients with non-obstructive coronary disease

Background

Non-obstructive coronary artery disease (CAD) is associated with increased adverse cardiovascular (CV) events. However, it is unclear if functional stenosis, as assessed by FFRCT <0.80, further stratifies risk among patients with non-obstructive CAD and which factors contribute to this anatomic-functional discordance (stenosis <50% and FFRCT <0.80).

Purpose

We hypothesized that patients with anatomically non-obstructive CAD by CTA and an abnormal FFRCT value of ≤0.80 have a phenomenon termed anatomic-functional discordance, and this discordance would be associated with increased adverse outcomes.

Methods

Patients in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) Registry who had exclusively non-obstructive CAD (anatomic stenosis <50%) were stratified by FFRCT >0.80 in all coronary vessels (concordant) vs. FFRCT <0.80 in at least one vessel (discordant). Baseline patient demographics, coronary computed tomography angiography findings, downstream testing and clinical outcomes were compared between groups. The primary composite endpoint included revascularization, CV hospitalization, heart failure, arrhythmia, non-fatal myocardial infarction, unplanned hospitalization for an acute coronary syndrome leading to urgent revascularization, and all-cause death.

Results

Among 1,261 patients with non-obstructive CAD, 543 (43.1%) had functional stenosis with FFRCT <0.80. Patients in the discordant group were older, more likely to have hypertension, hyperlipidemia, and had significantly higher indexed left ventricular (LV) mass and significantly lower coronary volume-to-mass ratios when compared with patients in the concordant group. Downstream non-invasive testing was more common among patients with discordance (35.9% vs 20.2%, p<0.0001) and more frequently resulted in a positive downstream test (10.3% vs. 3.3%, p<0.0001). Invasive angiography was also more common among patients with discordance (25.2% vs. 11.6%, p<0.0001). Anatomic-functional discordance was associated with higher rates of CV hospitalization and percutaneous coronary intervention (both p<0.0001), but no significant difference in all-cause death. After adjustment, anatomic-functional discordance was associated with a significantly higher risk of the composite endpoint (adjusted HR 2.79, 95% CI 1.67–4.65), Figure 1. As shown in Figure 2, the more vessels with anatomic-functional discordance, the higher the rate of adverse cardiac events.

Conclusion

Anatomic-functional discordance was present in nearly half of patients with exclusively non-obstructive CAD. The lower coronary volume: LV mass ratio may reflect abnormal coronary physiology at lower thresholds of anatomical stenosis among those with discordance. Compared to patients with concordance, patients with discordance had worse clinical outcomes suggesting that anatomic-functional discordance may stratify risk for adverse CV events among patients with non-obstructive CAD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The analysis was an investigator-initiated analysis sponsored by Heart Flow.

Tricuspid regurgitation: frequency, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP valvular heart disease II survey

Background

Tricuspid regurgitation (TR) is frequent among patients with severe left-sided valvular heart disease (LS-VHD).

Objectives

This study sought to assess TR frequency, management and outcome in this population.

Methods

Among 6883 patients with severe LS-VHD or previous valvular intervention in the EURObservational Research Programme prospective VHD II survey, we analyzed frequency and grade of TR according to LS-VHD, and 6-month survival according to TR grade. Among 2081 patients who underwent an intervention for severe LS-VHD, we analyzed frequency and outcome of concomitant TV intervention, and concordance between Class I indications for concomitant TV surgery (patients with severe TR) and real-practice decision-making.

Results

Moderate to severe TR was very frequent among patients with severe mitral VHD (≥30%), especially in patients with secondary mitral regurgitation (46%), and rare among patients with aortic VHD (<5%). Higher TR grade was associated with a poorer 6-month survival (P<0.001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (more than 40%). Concomitant TV intervention at the time of left-sided heart valve surgery (LS-HVS) was not associated with an increase in-hospital mortality (P=0.93). Concordance between Class I indications for concomitant TV surgery at the time of LS-HVS according to guidelines and real-practice decision-making was very good (88% overall).

Conclusion

TR was frequent in patients with mitral VHD and was associated with a poorer outcome as TR grade increased. Compliance to guidelines for Class I indications for concomitant TV surgery at the time of LS-HVS was very good. With the trend toward more transcatheter treatment for left-sided VHD, there is a critical need for safe and efficient tricuspid valve transcatheter treatment for patients with concomitant TR.

Funding Acknowledgement

Type of funding sources: None.

The impact of chronic obstructive pulmonary disease on right ventricular dysfunction and remodeling after aortic valve replacement

Background

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in patients with aortic stenosis (AS) and has been associated with a poor prognosis after both transcatheter and surgical aortic valve replacement (AVR). Since COPD is associated with an increase in right ventricular (RV) afterload, some studies already suggested that COPD causes RV dysfunction (RVD) and dilatation. On the other hand, RVD and remodeling can also occur due to chronic pressure overload secondary to the AS itself. However, there is no data that studied RVD and remodeling in AVR recipients in terms of COPD severity.

Purpose

We aimed to evaluate the impact of COPD on RVD and remodeling in patients with severe AS undergoing AVR before AVR and at 1-year follow-up, as well as the association between COPD severity and all-cause mortality.

Methods

Patients with severe AS who received either transcatheter or surgical AVR were included. Patients' demographic data, medical history and documented spirometry data were carefully collected, while two-dimensional and speckle tracking echocardiography measurements were performed according to recommended guidelines to evaluate RV systolic function and RV size. RVD was defined as tricuspid annular plane systolic excursion (TAPSE) ≤17mm. RV dilatation was defined by RV mid cavity >35 mm, RV basal diameter >42mm, and RV longitudinal diameter >83mm. RV wall thickness above 5mm was considered as RV hypertrophy. Diagnosis of COPD was determined by the Society of Thoracic Surgeons' definition based on forced expiratory volume in first second (FEV 1<75%, cut-off for COPD). The primary outcome was all-cause death at 1-year.

Results

A total of 293 patients (78.0 years, 58.4% male) were included. RVD was detected in 54 (18.4%) patients, while 55 (18.8%) patients had mild COPD and 43 (14.7%) patients had moderate or severe COPD. At 1-year follow-up, the prevalence of RVD significantly increased (18.4% versus 23.6%, p=0.004). Compared to baseline, RV free wall strain of lateral basal segment (p=0.046), TAPSE (p<0.0001) and tricuspid regurgitation gradient (p=0.018) impaired whereas RV wall thickness (p=0.014), RV diameter index of lateral basal segment (p<0.0001), and RV diameter index of lateral mid segment (p<0.0001) increased, respectively. At 1-year follow-up, 33 patients died (Figure 1). On multivariate cox regression analysis, RVD (hazard ratio (HR) 2.781, 95% confidence interval (CI) 1.172–6.598; p=0.020) as well as mild (HR 4.695, 95% CI 1.787–12.336; p=0.002) and moderate-severe COPD (HR 4.725, 95% CI 1.717–13.006; p=0.003) were significantly associated with the endpoint (Table 1).

Conclusions

The prevalence of RVD significantly increased and it deteriorated at 1-year after AVR. RV remodeling observed more at lateral basal and mid segments of RV as well as wall thickness. RV dysfunction and COPD were the strongest predictors of mortality in this population.

Funding Acknowledgement

Type of funding sources: None.

Association between chronic obstructive pulmonary disease and all-cause mortality after aortic valve replacement for aortic stenosis

Introduction

Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in aging population that their prevalence and percental change in mortality increase over the years. In severe AS, aortic valve replacement (AVR) is the only treatment that has demonstrated to improve survival, however the presence of comorbidities increases the operative risk and influences negatively on the outcomes after AVR. Therefore, the definition of COPD varies across the studies and is not always based on the use of pulmonary functional tests. Accordingly, the aim of the present study is to evaluate the association between pulmonary functional parameters and all-cause mortality after AVR in a large cohort of patients with severe AS.

Methods

Total of 400 patients (78.0 year-old, 56.7% men) with severe AS and documented preoperative pulmonary functional test (PFT) were retrospectively analyzed. Demographic and clinical characteristics were collected from electronic medical records while echocardiography was performed and measured according to the recommendations. PFTs were performed prior to AVR and categories defined in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database: normal pulmonary function was defined by an FEV1 >75% of predicted; mild COPD if FEV1 was 60–75% of predicted; moderate COPD if FEV1 was 50–59% of predicted and severe COPD when FEV1 <50% of predicted.

Results

Mild, moderate and severe COPD were documented in 75 (19%), 31 (8%) and 22 (5%) while the remaining 68% had normal PFTs. Patients with moderate and severe COPD had significantly larger LV mass and LV end-systolic volume whereas LV ejection fraction was significantly lower. The FVC, FEV1, Tiffeneau index, VC, PEF, and IC were the worst among patients with moderate and severe COPD (per definition) (p<0.0001). Over a median follow-up of 32 months, 92 (23%) patients died. The survival rates were significantly lower in patients with moderate and severe COPD (Log rank p=0.003, Figure 1). In multivariable Cox regression analysis, some clinical factors and COPD were independently associated with all-cause mortality (table 1). Remarkably, any grade of COPD was associated with 2-fold increased risk of all cause-mortality (HR 1.933; 95% CI 1.166–3.204; p=0.011 for mild COPD and HR 2.028; 95% CI 1.154–3.564; p=0.014 for moderate/ severe COPD, separately).

Conclusion

Patients with moderate and severe COPD had higher LV hypertrophy and reduced LV ejection fraction while PFT parameters were the worst among these patients. The survival rates were significantly lower in patients with moderate and severe COPD compared with patients without COPD. In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all cause-mortality.

Funding Acknowledgement

Type of funding sources: None.

Mesenchymal stromal cell therapy with early tacrolimus withdrawal prevents left atrial remodelling in renal transplant recipients: an analysis of the TRITON trial

Background

After renal transplantation, there is a need for immunosuppressive regimens that effectively prevent allograft rejection, while minimizing cardiovascular side effects. The TRITON study is the first randomized clinical trial that tested a strategy with autologous bone marrow derived mesenchymal stromal cell (MSC) therapy and complete withdrawal of calcineurin inhibitors (CNIs). The combination of MSC therapy and CNIs discontinuation was associated with improved blood pression control and regression of left ventricular hypertrophy. Nevertheless, the impact of this immunosuppressive strategy on left atrial (LA) structural and functional remodelling, which has been proven as an independent predictor of cardiovascular outcomes, has not been investigated.

Purpose

To assess the effects of MSC therapy combined with CNIs withdrawal on longitudinal changes of LA structure and function, evaluated by two-dimensional transthoracic echocardiography.

Methods

The TRITON trial randomized renal transplant recipients to MSC therapy – infused at week 6 and 7 after transplantation, with complete withdrawal at week 8 of tacrolimus (MSC group) – or standard tacrolimus dose (control group). Patients who underwent transthoracic echocardiography with speckle-tracking analysis at week 4 and 24 after renal transplantation were included in this sub-analysis. Changes in echocardiographic variables between 4 and 24 weeks post-transplantation were evaluated and compared between randomization arms using an analysis of covariance model, adjusted for baseline variable.

Results

54 patients (MSC group =27; control group =27) were included. Between 4 and 24 weeks after transplantation, an increase in indexed minimal LA volume (LAVImin) was observed in the control group, whereas in the MSC group there were no changes in LAVImin over the time, leading to a significant difference between groups (p=0.021). Moreover, patients randomized to MSC therapy showed a benefit in LA function, assessed by a significant interaction between changes in LA emptying fraction (LAEF) and LA reservoir strain and the treatment group (p=0.012 and p=0.027, respectively) (Table 1).

The association between changes in LA structural and functional parameters and the randomization arm remained significant after adjustment for changes in systolic blood pressure, diastolic blood pressure and estimated glomerular filtration rate over the time (Figure 1).

Conclusion

The combination of MSC therapy and early CNIs withdrawal prevents LA structural and functional remodelling in the first six months after renal transplantation. MSC therapy appears a promising approach in renal transplant recipient, effective in the prevention of graft rejection, while exerting potential cardioprotective effects.

Funding Acknowledgement

Type of funding sources: None.

Evolution of functional mitral regurgitation and left atrial function in patients receiving cardiac resynchronization therapy

Background

Left atrial (LA) function is a strong prognostic marker in patients with heart failure and patients with functional mitral regurgitation (MR). Although cardiac resynchronization therapy (CRT) has shown to improve MR severity, the interaction between a reduction in MR severity and an improvement in LA function, as well as their association with outcomes, has not been investigated.

Purpose

To investigate the association between a reduction in MR severity and an improvement in LA function, as well as their association with outcomes.

Methods

LA reservoir strain (RS) was evaluated with speckle tracking echocardiography in patients with moderate and severe functional MR. MR improvement was defined as at least 1 grade improvement in MR severity at 6 months after CRT implantation. The association between MR improvement and change in LARS was evaluated using multivariable logistic regression analysis. Patients were dividing into 3 groups: MR non-improvers; MR improvers with no LARS improvement; and MR improvers with LARS improvement. The primary endpoint was all-cause mortality.

Results

A total of 340 patients (mean age 66±10 years, 73% male) were included, of whom 200 (59%) showed MR improvement after CRT implantation. On multivariable analysis, an improvement in MR was independently associated with an improvement in LARS (OR 1.008; 95% CI 1.003–1.013; p=0.002) (Table 1). MR improvers showing LARS improvement had the lowest mortality rate, whereas outcomes were not significantly different between MR non-improvers and MR improvers showing no LARS improvement (p=0.236) (Figure 1).

Conclusion

In patients with HF and significant functional MR, an improvement in MR after CRT implantation is independently associated with an improvement in LARS, which in turn, is associated with better survival.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

The impact of atrial fibrillation on prognosis in aortic stenosis

Background

Atrial fibrillation (AF) and aortic stenosis (AS) are both highly prevalent and increasing with age. Various studies have focused on the complex relationship between these entities that frequently coexist. AS might induce adverse cardiac remodelling, which is associated with poor prognosis in severe AS. Left atrial remodelling, especially left atrial enlargement, is also an important risk factor for AF.

Purpose

To evaluate the additive prognostic value of AF besides markers of left atrial and left ventricular remodelling in patients with AS, irrespective of severity of AS and left ventricular ejection fraction (LVEF).

Methods

Patients with moderate and severe AS were selected and history of AF was assessed. Subgroups were defined according to LVEF (reduced (<50%) vs. preserved (≥50%)) and severity of AS (moderate vs. severe). The endpoint was all-cause mortality. Unadjusted Kaplan-Meier survival curves were plotted. Four multivariable Cox regression models were constructed.

Results

In total, 2849 patients with moderate and severe AS (mean age 72±12 years, 54.7% men) were evaluated of whom 686 (24.1%) had a history of AF. Regarding the defined subgroups, 1091 (38.3%) patients had severe AS and 2207 (77.5%) patients had preserved LVEF. During a median follow-up time of 60 months (interquartile range 30 to 97), 1182 (41.5%) patients died. Ten-year mortality rate in patients with AF was 46.8% compared with 36.8% in patients with sinus rhythm (SR) (Figure 1) (p<0.001). In subgroup analysis, patients with AF and severe AS, moderate AS or preserved LVEF had worse survival than those who maintained SR (p=0.015, p<0.001 and p<0.001 respectively). On univariable (HR: 1.42; 95% CI: 1.25 to 1.62; p<0.001) and multivariable Cox regression analysis (HR: 1.19; 95% CI: 1.02 to 1.38; p=0.026) adjusting for age, body mass index, hypertension, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, kidney function, New York Heart Association class, aortic valve replacement as a time-dependent covariate, left ventricular mass index, left ventricular end-diastolic volume index, LVEF, mean aortic valve gradient, tricuspid annular plane systolic excursion, AF is independently associated with mortality (Table 1; model 1). However, when correcting for LAVI, E/e' or both, AF is no longer independently associated with all-cause mortality (Table 1; model 2–4).

Conclusion

Patients with moderate or severe AS and AF have a significantly higher 10-year mortality rate than patients with SR. This finding is irrespective of AS severity and also apparent in the subgroup with preserved LVEF. Nonetheless, when correcting for markers of diastolic dysfunction, AF is not independently associated with outcome in patients with moderate or severe AS.

Funding Acknowledgement

Type of funding sources: None.

Coronary computed tomography angiography based endothelial wall shear stress in normal coronary arteries

Background

Endothelial wall shear stress (ESS) is a biomechanical force which plays a key role in the formation and evolution of atherosclerotic lesions.

Purpose

This study aims to evaluate ESS in coronary arteries without atherosclerosis, and to assess various factors affecting ESS values.

Methods

Coronary computed tomography angiography (CCTA) images from patients with suspected coronary artery disease were analyzed to identify coronary arteries without atherosclerosis. Minimal and maximal ESS values were calculated for 3-mm segments with dedicated software. Segments were categorized according to lumen diameter tertiles into small (<2.6 mm), intermediate (2.6–3.2 mm) or large (≥3.2 mm) size classes. Normal ranges of minimal and maximal ESS values were calculated per vessel and vessel size.

Results

A total of 349 normal vessels from 168 patients (mean age 59.4±9.2 years, 39% men) were included. ESS was highest in the left anterior descending artery compared to the left circumflex and the right coronary arteries (2.3 Pa vs. 1.9 Pa vs. 1.6 Pa for minimal ESS, p<0.001 and 3.7 Pa vs. 3.0 Pa vs. 2.5 Pa for maximal ESS, p<0.001). ESS values were highest in small vessel segments compared to intermediate or large segments (3.8 Pa vs. 1.7 Pa vs. 1.2 Pa for minimal ESS, p<0.001 and 6.0 Pa vs. 2.6 Pa vs. 2.0 Pa for maximal ESS, p<0.001). Weak to moderate correlation was found between ESS and the distance from the ostium (ρ values ranging from 0.22 to 0.62 for different vessels).

Conclusion

We derived ESS values from the CCTA images for visually normal coronary arteries. ESS values depend strongly on the lumen diameter of the coronary vessel. The normal ranges of minimal and maximal ESS can be used in future studies, where ESS values in stenotic lesions are compared to the normal values derived in the present analysis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Finnish Foundation for Cardiovascular Research

Staging heart failure patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge repair

Background

Heart failure with reduced ejection fraction (HFrEF) and secondary mitral regurgitation (SMR) are closely related. Progression of HFrEF-SMR is associated with characteristic pathophysiological changes. Recently, staging of HFrEF-SMR patients showed prognostic value in a SMR cohort on medical therapy. Whether these stages are prognostic for SMR patients undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) in addition to drug therapy is unknown.

Purpose

The present study aimed at classifying HFrEF-SMR patients undergoing M-TEER into progressive disease stages based on cardiac and extracardiac involvement. We sought to evaluate the impact of the disease stages on survival outcome and symptomatic improvement after M-TEER

Methods

Based on echocardiographic transthoracic evaluation, patients were assigned into one of the following subsequent HFrEF-SMR stages representing disease progression (Figure 1): left ventricular (LV) dysfunction alone (Stage 1, LV end diastolic volume ≥159 ml and/or LV ejection fraction <50%); left atrial (LA) involvement (Stage 2, history of atrial fibrillation and/or indexed LA volume >34 ml/m2); right ventricular (RV) pressure/volume overload (Stage 3, tricuspid regurgitation ≥3+ and/or systolic pulmonary artery pressure >65 mmHg); biventricular failure (Stage 4, RV to pulmonary artery coupling <0.274 mm/mmHg). A Cox regression model was implemented to investigate the impact of HFrEF-SMR stages on two-year all-cause mortality and symptomatic outcome was assessed with New York Heart Association (NYHA) functional class at follow-up.

Results

Among a total of 849 included patients who underwent M-TEER for symptomatic MR from 2008 until 2019, 9.5% (n=81) presented with LV dysfunction alone, 46% (n=393) with LA involvement, 15% (n=129) with pressure/volume overload and 29% (n=246) with biventricular failure. At baseline and follow-up, successive HFrEF-SMR stages were associated with more severe heart failure symptoms as expressed by NYHA functional class. An increase in HFrEF-SMR stage was associated with increased two-year all-cause mortality rates after M-TEER (Hazard ratio 1.39, confidence interval 1.23–1.58, p<0.01, Figure 2).

Conclusions

Classifying HFrEF-SMR patients undergoing M-TEER into subsequent disease stages provides prognostic value regarding heart failure symptoms and survival.

Funding Acknowledgement

Type of funding sources: None.

Prognostic relevance of left ventricular global longitudinal strain in patients with heart failure and reduced ejection fraction

Background

Patients with heart failure (HF) and reduced ejection fraction (HFrEF) are complex patients who often have a high prevalence of comorbidities and cardiovascular risk factors. However, risk stratification and treatment decision in these patients mainly depend on simple measurements of left ventricular (LV) ejection fraction (EF). In the present study, we investigated the prognostic significance of LV global longitudinal strain (GLS) along with important clinical and echocardiographic risk factors in patients with HFrEF.

Methods

Patients who had a first echocardiographic diagnosis of LV systolic dysfunction, defined as LVEF ≤45%, were identified. LV GLS was measured with speckle-tracking echocardiography and represented by a positive value. To divide the study population into 2 groups, spline curve analysis was used to derive the optimal threshold value of LV GLS (i.e. where the predicted hazard ratio for the endpoint was ≥1) (Figure 1). Patients were followed up for worsening HF, as well as the composite endpoint of worsening HF and all-cause mortality.

Results

A total of 2394 patients (mean age 63±12 years, 75% men) were analyzed. During a median follow-up of 60 months (interquartile range [IQR] 31–60 months), 306 patients (13%) experienced worsening HF and the composite endpoint of worsening HF and all-cause mortality occurred in 673 patients (28%). The 5-year event-free survival rates for the primary and secondary endpoint were significantly lower in the patients who had LV GLS ≤10% compared to the patients who had LV GLS >10% (Figure 2A for worsening HF and Figure 2B for the composite endpoint of worsening HF and all-cause mortality). After adjustment for important clinical and echocardiographic risk factors, including HF treatments and baseline LVEF, baseline LV GLS remained independently associated with a higher risk of worsening HF (HR=0.95, 95% CI 0.90–0.99, p=0.029) and the composite of worsening HF and all-cause mortality (HR=0.94, 95% CI 0.90–0.97, p=0.001).

Conclusions

Baseline LV GLS is associated with long-term prognosis in patients with HFrEF, independently from various clinical and echocardiographic risk factors.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of left ventricular myocardial work indices in patients undergoing transcatheter aortic valve replacement

Introduction

Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess LV function using pressure-strain loops taking LV afterload into account. In patients with aortic stenosis (AS), this approach was shown to improve assessment of LV performance as compared to conventional and advanced parameters of LV systolic function, but data on its prognostic value are lacking.

Purpose

To evaluate the prognostic value of LVMW indices in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).

Methods

LVMW indices, including LV global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were calculated in 281 patients with severe AS (age 82, IQR 78–85 years, 52% male) prior to the TAVR procedure. As previously validated, LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure. LV global longitudinal strain and LV systolic pressure were then incorporated to construct pressure-strain loops to determine the LVMW indices. The study endpoint was all-cause mortality.

Results

In the total population average GWI was 1872±753 mmHg%, GCW 2240±797 mmHg%, GWW 200 (IQR 127–306) mmHg% and GWE 89 (IQR 84–93)%. During a median follow-up of 52 (IQR 41–67) months, 64 patients died. These patients showed lower values of GWI (1644 vs 1940 mmHg%, p=0.006) and GCW (2010 vs 2307 mmHg%, p=0.009) as compared to patients who survived while GWW (197 vs 200 mmHg%, p=0.794) and GWE (88% vs 90%, p=0.102) were similar. While LV GCW, GWW and GWE did not show a significant association with the study endpoint, GWI was independently associated with all-cause mortality (HR per-tertile-increase 0.639; 95% CI 0.463–0.883; P=0.007), and the patients in the lowest GWI tertile showed the worst survival rates (Figure 1). Of interest, patients in the lowest GWI tertile were more likely to be male (63% vs 56% and 37% from the lowest to the highest tertile, P=0.001), had a higher prevalence of atrial fibrillation (26% vs 19% and 8% from the lowest to the highest tertile, P=0.006), worse renal function (53 mL/min/1.73 m2 vs 64 mL/min/1.73 m2 and 62 mL/min/1.73 m2 from the lowest to the highest tertile, P=0.038) and larger LV dimension (LVEDD 52 mm vs 47 mm and 46 mm from lowest through highest tertile, p<0.001). Importantly, when added to a basal model, LVGWI yielded a higher increase in predictivity compared to both conventional and advanced parameters of LV systolic function (Figure 2). Also, in a model corrected for the hemodynamic class of AS (high-gradient, low-flow low-gradient), GWI also showed a significant independent association (P=0.003) with all-cause mortality.

Conclusions

LVGWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.

Funding Acknowledgement

Type of funding sources: None.

Left atrial reservoir strain and long-term prognosis in patients with heart failure and reduced ejection fraction

Background

Cardiac damage in heart failure (HF) with reduced ejection fraction (HFrEF) often involves structural and functional left atrial (LA) abnormalities. Speckle-tracking echocardiography derived LA reservoir strain (LARS) is a sensitive measurement for early detection of LA dysfunction. However, the prognostic value of LARS is not well established in patients with HFrEF.

Methods

LARS was measured with speckle tracking echocardiography in patients who had a first echocardiographic diagnosis of reduced LVEF (≤45%). Patients with prior history of atrial fibrillation (AF) were excluded. The primary endpoint was newly onset AF, while the composite endpoint of newly onset AF and all-cause mortality was chosen as the secondary endpoint. The study population was divided into two groups according to the optimal threshold value of baseline LARS (derived from spline curve analysis) (Figure 1) and event-free survival rates were compared by the Kaplan-Meier method.

Results

A total of 997 patients (mean age 62±13 years, 73% men) were analyzed. At baseline, LA volume index was significantly larger (41±17 vs. 32±12 ml/m2, p<0.001), and LA reservoir function significantly more impaired (9±3.1 vs. 21±6.3%, p<0.001) in patients with LARS ≤14% compared to patients with LARS >14%. During a median follow-up of 60 months (interquartile range [IQR] 29–60 months), newly onset AF occurred in 75 patients (7.5%), while 254 patients (25.5%) experienced the composite endpoint of newly onset AF and all-cause mortality. The 5-year event-free survival rates for both endpoints were significantly lower in the LARS ≤14% group compared to LARS >14% group (Figure 1A for new onset AF and Figure 2B for the composite endpoint of newly onset AF and all-cause mortality). After adjustment for important risk factors, including HF treatments and echocardiographic predictors, baseline LARS remained independently associated with a higher risk of development of AF (HR=0.89, 95% CI 0.85–0.94, p<0.001) and the composite of newly onset AF and all-cause mortality (HR=0.93, 95% CI 0.91–0.96, p<0.001).

Conclusions

Baseline LARS is associated with long-term prognosis in patients with HFrEF and the association is independent from various clinical and echocardiographic predictors.

Funding Acknowledgement

Type of funding sources: None.

Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) diastolic dysfunction (DDF) has shown to carry an unfavorable prognosis in severe AS, the prognostic value of LV DDF in MAS has not been investigated.

Purpose

To investigate the prognostic impact of LV DDF in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV diastolic function was evaluated in patients with MAS (aortic valve area >1.0 and ≤1.5cm2)  and preserved LVEF (≥50%) using echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1247 patients (age 74 ± 10 years, 47% men) with MAS and preserved LVEF, 396 (32%) had normal diastolic function, 316 (25%) had indeterminate diastolic function and 535 (43%) had DDF. Patients with DDF were more likely to be female, had more comorbidities (hypertension, atrial fibrillation, chronic kidney disease) and were more symptomatic (NYHA ≥2) than patients with normal diastolic function. Patients with DDF also had smaller aortic valve area and higher peak aortic velocities than patients with normal/indeterminate diastolic function. During a median follow-up of 53 (26 – 81) months, 484 (39%) patients died. For the composite endpoint, 770 patients (62%) underwent AVR (n = 376) or died (n = 394) during a median follow-up of 37 (IQR 15 – 62) months. Patients with DDF had significantly lower survival rates (p <0.001) and event-free survival rates (p = 0.015) compared to patients with normal/indeterminate diastolic function (Figure 1). On multivariable analysis, DDF was independently associated with all-cause mortality (HR: 1.368; 95% CI: 1.085 – 1.725; p = 0.008) and the composite endpoint of all-cause mortality and AVR (HR: 1.241; 95% CI: 1.035 – 1.488; p = 0.020) (Figure 2).

Conclusion

LV DDF is associated with worse outcomes in patients with MAS. Assessment of LV diastolic function may contribute significantly to risk stratification of patients with MAS. Abstract Figure.  Abstract Figure.

Prognostic value of left ventricular global longitudinal strain in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Impaired left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis, but its prognostic value in patients with moderate aortic stenosis (MAS) is largely unknown.

Purpose

To investigate the prognostic implications of LV GLS in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV GLS was evaluated by speckle tracking echocardiography in 621 patients (age 71 ± 12 years, 59% men) with MAS (aortic valve area 1.0 – 1.5cm2) and preserved LVEF (≥50%). Impaired LV GLS was defined as an LV GLS value <16%, based on spline curve analysis (i.e. where the hazard ratio for all-cause mortality was ≥1). Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement.

Results

Patients with LV GLS <16% (n = 282) were significantly older, more likely to be male and had more comorbidities (diabetes mellitus, atrial fibrillation, more impaired renal function) compared to patients with LV GLS ≥16% (n = 339). In terms of echocardiographic data, patients with LV GLS <16% had larger LV volumes, lower LVEF and higher E/e’. During a median follow-up of 53 (27 – 102) months, 199 (32%) patients died. For the composite endpoint, 409 patients (66%) underwent AVR (n = 290) or died (n = 119) during a median follow-up of 29 (IQR 14 – 54) months. Patients with LV GLS <16% experienced significantly lower survival rates (p < 0.001) and event-free survival rates (p = 0.001) compared to patients with LV GLS ≥16% (Figure 1). On multivariable analysis, LV GLS was independently associated with all-cause mortality (HR 2.442; 95% CI: 1.762 – 3.384; p < 0.001) and the composite endpoint of all-cause mortality and aortic valve replacement  (HR 1.862; 95% CI: 1.498 – 2.315; p = 0.040) (Figure 2).

Conclusions

In patients with MAS and preserved LVEF, reduced LV GLS is associated with an increased risk of all-cause mortality and the composite endpoint of all-cause mortality and AVR. Assessment of LV GLS may be useful in the risk stratification of these patients. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Non-invasive left ventricular myocardial work in patients with chronic aortic regurgitation and preserved left ventricular ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

 Left ventricular global longitudinal strain (LV GLS) has been proposed as sensitive marker of myocardial damage in patients with chronic severe aortic regurgitation (AR) and preserved left ventricular ejection fraction (LVEF). However, LV GLS does not take into account the afterload.

Non-invasive LV myocardial work is a novel parameter of LV myocardial performance, which integrates measurements of myocardial deformation and non-invasive blood pressure (afterload).

Purpose

The aims of this study were: 1) to assess non-invasive LV myocardial work in patients with chronic AR and preserved LVEF and its correlation with other echocardiographic parameters, 2) to evaluate changes of LV myocardial work after aortic valve replacement or repair (AVR) and 3) to assess the relationship between LV myocardial work and post-operative LV reverse remodeling.

Methods

This retrospective study included fifty patients (53 ± 16 years; 68% men) with moderate or severe chronic AR and preserved LVEF, who underwent AVR. Non-invasive LV myocardial work indices were measured at baseline and post-operatively (between 2 and 12 months after surgery) and compared with previously reported normal reference ranges.

Results

Based on normal reference values, patients with chronic AR and preserved LVEF had preserved or increased values of LV global work index (LV GWI) (84% and 16%, respectively) and LV global constructive work (LV GCW) (78% and 22%, respectively) (Figure 1). In addition, LV global work efficiency (LV GWE) was preserved in all patients, despite 16 (32%) subjects had impaired values of LV GLS (<16.7.% in men and <17.8% in women). LV GWI and GCW showed a positive correlation with markers of AR severity and parameters of LV systolic function. AVR results in a significant reduction of myocardial work indices (p < 0.0001), with the exception of LV global wasted work, that did not change (p = 0.29). According to normal reference ranges, 15 (30%) patients had impaired values of LV GWI and LV GCW post-operatively, while LV GLS was impaired in 37 (74%) patients. The post-operative impairment of LV GWI demonstrated a stronger association with reduced LV reverse remodeling, as compared to the impairment of LV GLS (Figure 2).

Conclusions

Compared to afterload-dependent echocardiographic parameters, non-invasive LV myocardial work indices allow a better understanding of myocardial performance and energetics in the setting of chronic AR with preserved LVEF and could improve risk stratification. Abstract Figure.  Abstract Figure.

Right ventricular remodelling in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Inconsistent changes in right ventricular (RV) dimensions and function have been observed after tricuspid valve (TV) surgery and their associations with long-term outcomes have not been explored.

Purpose

To evaluate RV remodelling and RV function in patients with significant (moderate or severe) tricuspid regurgitation (TR) undergoing TV surgery and their association with outcome.

Methods

A total of 121 patients (mean age 63 ± 12 years, 47% male) with significant TR treated with TV surgery and who had an echocardiogram between 3 months and 1 year of follow-up, were included for this analysis. Remodelling was assessed by comparing dimensions and function at follow-up to baseline values. The population was stratified by tertiles of percentage reduction of RV end-systolic area (RVESA) and absolute change of RV fractional area change (RVFAC). Five-year mortality rates were compared across the tertiles of RV remodelling and the independent associates of mortality were investigated.

Results

Reduction in RVESA and improvement in RVFAC were significantly associated with better survival after TV surgery, whereas reduction in RV end-diastolic area was not (Figure 1). One third of the patients presented with a reduction in RVESA of at least 17.2% and improvement in RVFAC of at least 2.3%, constituting the third tertiles for comparison. Kaplan-Meier curves for overall survival according to RVESA- and RVFAC-tertiles are shown in Figure 2. Cumulative survival rates were significantly better in patients in the third tertile of RVESA reduction: 49%, 69%, and 90% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 12.526; p = 0.002); as well as according to RVFAC improvement: 57%, 65%, and 87% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 7.784; p = 0.02). Tertile 3 of RVESA-reduction as well as tertile 3 of RVFAC-change were both independently associated with better survival after TV surgery compared to tertile 1 (hazard ratio: 0.221 [95% CI: 0.074 to 0.658] and 0.327 [95% CI: 0.118 to 0.907], respectively).

Conclusion

The magnitude of RV reverse remodelling (based on reduction in RVESA) and improvement in RVFAC were associated with better survival at 5 years’ follow-up after TV surgery for significant TR. Abstract Figure 1: Spline curves  Abstract Figure 2: KM curves for overal survival

Left atrioventricular coupling index in hypertrophic cardiomyopathy and risk of new-onset atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

 In patients with hypertrophic cardiomyopathy (HCM) accurate risk stratification for new onset atrial fibrillation (AF) has important prognostic implications. Left atrioventricular coupling index (LACI) has been recently associated with the occurrence of AF in patients without history of cardiovascular disease.

Purpose

The objective of this study was to investigate the association between LACI and new onset AF in HCM patients and its incremental value over conventional left atrial (LA) parameters.

Methods

A total of 373 HCM patients without history of AF (48 ± 17 years, 66% men) were evaluated by transthoracic echocardiography. LACI was defined by the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. The cut-off value for LACI (≥40%) to identify LA-left ventricular (LV) uncoupling was chosen based on the risk excess of new-onset AF described with a spline curve analysis. Cox proportional hazard models were used to evaluate the association between LACI and the occurrence of AF.

Results

The median LACI was 38% (interquartile range: 24-56) and LA-LV uncoupling (LACI ≥40%) was observed in 171 (45.8%) patients. During a mean follow-up of 11.0 ± 5.6 years, 118 subjects (31.6%) developed new-onset AF. The cumulative event-free survival at 10 years was 53% for patients with LA-LV uncoupling (LACI ≥40%) versus 94% for patients without LA-LV uncoupling (LACI <40%) (p < 0.0001; Figure 1). Multivariable analysis showed an independent association between new-onset AF  and LA maximum volume indexed (LAVImax) (hazard ratio [HR], 1.03; 95% CI, 1.02–1.04), LA minimum volume indexed (LAVImin) (HR, 1.04; 95% CI, 1.03–1.05), LA emptying fraction (HR, 0.97; 95% CI, 0.96–0.98) and LACI (HR, 1.02; 95% CI, 1.01–1.02; all p < 0.0001). The inclusion of LACI in the multivariate model provided larger improvement in the risk stratification for new-onset AF, as compared to conventional LA parameters (Figure 2). Furthermore, the likelihood ratio test demonstrated incremental value of LACI assessment on the top of the multivariate model including LAVImin to predict new-onset AF (p = 0.02), while the addition of LAVImin did not improve the risk discrimination of the multivariate model including LACI (p = 0.36).

Conclusion

Greater LACI, indicative of LA-LV uncoupling, was independently associated with the occurrence of new-onset AF in patients with HCM and demonstrated a stronger risk discrimination power compared to conventional LA parameters. This simple ratio may be easily implemented in clinical practice to improve risk stratification for new-onset AF in HCM. Abstract Figure. Incident AF according to LACI  Abstract Figure.

Let atrial dysfunction is an independent predictor of mortality in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt

Funding Acknowledgements

Type of funding sources: None.

Background

 Transjugular intrahepatic portosystemic shunt (TIPS) is widely used to treat portal hypertension-related complications in patients with liver cirrhosis. Left ventricular diastolic dysfunction (LVDD) is associated with an increased risk of cardiac decompensation after TIPS, but its predictive value on long-term survival of TIPS candidates is currently unknown. In addition, the assessment of left atrial (LA) reservoir function, which recently emerged as sensitive marker of LVDD, has never been studied in this population.

Purpose

The main objectives were 1) to evaluate the association between LVDD, assessed according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium (revised from the 2016 ASE/EACVI guidelines), and long-term survival in cirrhotic patients undergoing TIPS 2) to investigate the additive prognostic value of LA reservoir strain, measured by speckle-tracking echocardiography.

Methods

Patients with liver cirrhosis treated by TIPS were retrospectively evaluated. All subjects received an echocardiographic examination few weeks before the procedure. Threshold for LA reservoir strain (≤35%) to identify LA dysfunction was chosen based on the median value in the current population and on previously suggested cut-off value from the literature. The primary endpoint of the study was all-cause mortality.

Results

A total of 129 patients (61 ± 12 years; 61 % men) were included. According to the algorithm of the Cirrhotic Cardiomyopathy Consortium, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (LA reservoir strain ≤35%) was found in 67 (52%) patients. After a median follow-up of 36 months (interquartile range: 12-80), 65 (50%) patients died. Kaplan–Meier analysis for all-cause mortality at 4 years demonstrated a significant reduction in survival for more advanced grades of LVDD (log-rank p = 0.007) (Figure 1A). Furthermore, patients with LA dysfunction (LA reservoir strain ≤35%) had a higher cumulative event rate versus patients with preserved LA function (log-rank p = 0.001) (Figure 1B). Multivariable Cox regression analysis identified MELD (model for end-stage liver disease) score (Hazard ratio:1.06; p = 0.003), hemoglobin (Hazard ratio:0.74; p = 0.022) and LA reservoir strain (Hazard ratio:0.96; p = 0.005) as independent predictor of mortality (Figure 2). Excluding LA reservoir strain from the model, more advanced grades of LVDD (grade 2 and indeterminate function) became associated with the outcome. Of note, LA reservoir strain provided incremental prognostic value to the model including MELD score, hemoglobin and grades of LVDD (p = 0.004).

Conclusions

LA dysfunction, assessed by LA reservoir strain with speckle-tracking echocardiography, is an independent predictor of long-term mortality in in cirrhotic patients treated with TIPS. Abstract Figure.  Abstract Figure.

Left ventricular remodeling patterns in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) adverse remodeling is associated with worse outcomes in patients with severe AS, the prognostic significance of different patterns of LV remodeling in MAS has not been investigated.

Purpose

To investigate the association between different patterns of LV remodeling on outcomes in patients with MAS.

Methods

Patients with MAS (aortic valve area >1.0 and ≤1.5cm2) were stratified into 4 groups according to the pattern of LV remodeling: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) or eccentric hypertrophy (EH). Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1931 patients (age 73 ± 10 years, 52% men) with MAS, 344 (18%) had NG, 469 (24%) CR, 698 (36%) CH and 420 (22%) EH. Patients with CH were more likely to be female, had more hypertension, were more symptomatic (NYHA ≥III) and had more pronounced LV diastolic dysfunction, whereas patients with EH had more coronary artery disease, were more symptomatic (NYHA ≥III) and had lower LV ejection fraction than patients with NG. Patients with CH had higher aortic mean pressure gradients and peak aortic jet velocities than patients with NG. During a median follow-up of 51 (IQR 25 - 83) months, 833 (43%) patients died. For the composite endpoint, 1286 (67%) patients underwent AVR (n = 613) or died (n = 673) during a median follow-up of 35 (IQR 14 - 60) months. Patients with CH and EH had significantly lower survival rates (p < 0.001; Figure 1) and event-free survival rates (p = 0.004) compared to patients with NG/CR. On multivariable analysis, CH was independently associated with all-cause mortality (HR:1.267; 95% CI:1.024 – 1.568; p = 0.029), whereas both CH (HR:1.293; 95% CI:1.090 – 1.533; p = 0.003) and EH (HR:1.222; 95% CI:1.013 – 1.474; p = 0.036) were associated with the composite endpoint of AVR and all-cause mortality (Figure 2).

Conclusions

In patients with MAS, different patterns of LV remodeling are observed with CH being independently associated with an increased risk of all-cause mortality. Risk stratification according to the different patterns of LV remodeling may help to identify patients with MAS who are at increased risk of adverse events and may benefit from closer follow-up. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Prognostic value of three dimensional-vena contracta area in patients with secondary mitral regurgitation

Background

Effective regurgitant orifice area (EROA) is an important quantitative measurement for mitral regurgitation (MR) grading. Yet, the accuracy of this method is limited in patients with secondary mitral regurgitation (SMR). Three-dimensional (3D) color Doppler echocardiography allows for the direct assessment of the vena contracta area (VCA). The prognostic value of 3D-VCA in patients with secondary MR has not been investigated.

Purpose

The aim of the present study was to assess the association between 3D-VCA and prognosis of patients with SMR.

Methods

A total of 218 patients (69% men, median age 74 years) with significant SMR were retrospectively analyzed. 3D-VCA was measured offline with dedicated software, from restored 3D color Doppler full volume datasets of the mitral valve (Figure 1). The population was divided according to the American College of Cardiology expert recommendation for the grading of severe MR (VCA ≥50 mm2 and VCA <50 mm2). Patients were followed up for the combined end point of all-cause mortality or heart failure hospitalization.

Results

Of the total population, 63% had an ischemic etiology, 60% had atrial fibrillation and 25% cardiac resynchronization therapy. Patients with 3D-VCA ≥50 mm2 needed more diuretic therapy, had a larger left ventricle and atrium, and had more post-procedural residual MR. A total of 82% of patients underwent MitraClip device implantation, 17% had mitral valve repair and 1% had mitral valve replacement. During a median follow-up of 28 months, 130 (60%) met the combined end point (101 (46%) patients died and 81 (37%) were hospitalized due to heart failure). When dividing the population according to the cut-off of 3D-VCA, patients with a 3D-VCA≥50 mm2 had a worse prognosis compared with their counterparts (Figure 2). In a multivariable Cox regression analysis, 3D-VCA≥50 mm2 remained independently associated with the composite endpoint of all-cause mortality or heart failure hospitalization (HR=1.454, 95% CI 1.020–2.072, p=0.038).

Conclusion

In patients with SMR, a 3D-VCA ≥50 mm2 was independently associated with a combined endpoint of death or heart failure hospitalization.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Method of 3D-VCA measurementFigure 2. Kaplan-Meier survival curve

Sex differences in left ventricular remodeling in patients with severe aortic valve stenosis

Background

Women with severe aortic valve stenosis (AS) have better long-term outcomes after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared to men. Whether this is related to sex differences in left ventricular (LV) remodeling is unknown.

Purpose

To examine sex differences in LV remodeling and outcomes in patients with severe AS undergoing TAVI.

Methods

Patients with severe AS who underwent TAVI between 2007 and 2018 with a pre-procedural multidetector row computed tomography (MDCT) scan were included. LV volumes, mass and function were analyzed with MDCT. Patients were classified into 4 LV remodeling patterns based on LV mass index and LV mass-to-volume ratio: 1) normal geometry, 2) concentric remodeling, 3) concentric hypertrophy and 4) eccentric hypertrophy. The primary endpoint was all-cause mortality after TAVI.

Results

A total of 289 patients (age 80±6 years, 54% male) were included. Women showed smaller LV volumes and mass compared to men. Concentric hypertrophy (50%) was the most frequent pattern of LV remodeling followed by eccentric hypertrophy (33%), normal geometry (13%) and concentric remodeling (4%). Concentric remodeling was more frequently observed in men compared to women (91% vs. 9% respectively, p=0.011). However, no sex differences were observed in the remaining LV remodeling patterns (Figure 1). During a median follow-up of 3.8 (IQR 2.2–5.1) years after TAVI, 87 patients died. Women demonstrated better outcome after TAVI compared to men (log-rank χ2=4.29, p=0.038). The survival benefit of women over men was mainly present among patients with concentric hypertrophy (log-rank χ2=4.91, p=0.027, Figure 2).

Conclusion

LV concentric and eccentric hypertrophy are similarly observed in men and women with severe AS. Women demonstrated better outcome after TAVI as compared to men, particularly among those with LV concentric hypertrophy. However, the outcome benefit of females after TAVI seems not to be related to sex-differences in LV remodeling.

Funding Acknowledgement

Type of funding sources: None. Distribution of sex in LV remodelingAll-cause mortality after TAVI

Right ventricular myocardial work characterisation in patients with pulmonary hypertension: association with invasive haemodynamic parameters

Background

Non-invasive evaluation of indices of right ventricular (RV) myocardial work derived from RV pressure-strain loops may provide novel insights into RV function in pre-capillary pulmonary hypertension.

Purpose

This study was designed to evaluate the association between the indices of RV myocardial work and invasive haemodynamic parameters in a patient cohort with pulmonary arterial hypertension (Group I) or chronic thromboembolism pulmonary hypertension (Group IV).

Methods

The non-invasive analysis of echocardiography-derived RV myocardial work (Figure 1, upper panel) was completed in 51 patients (mean age 58.1±12.7 years, 31% male) with Group I (78%) or Group IV (22%) pulmonary hypertension. Conventional echocardiographic measurements of RV systolic function, RV global work index (RV GWI), RV global constructive work (RV GCW), RV global wasted work (RV GWW) and RV global work efficiency (RV GWE) were compared with parameters derived invasively during right heart catheterisation (RHC).

Results

The median RV GWI, RV GCW, RV GWW and RV GWE were 620 (443 to 857) mmHg%, 830 (650 to 1206) mmHg%, 105 (54 to 169) mmHg% and 87 (82 to 93)%, respectively. Compared to pulmonary artery systolic pressure and conventional echocardiographic parameters of RV systolic function (RV global longitudinal strain [GLS], tricuspid annular plane systolic excursion and RV fractional area change), RV GCW and RV GWI correlated more closely with invasively-derived RV stroke work index (R=0.63, P<0.001 and R=0.60, P<0.001, respectively) (Figure 1, lower panels). Invasively-derived pulmonary vascular resistance (PVR) correlated with RV GWW (R=0.63, P<0.001), RV GWE (R=0.48, P<0.001) and RV GLS (R=0.58, P<0.001). RV GLS correlated more closely with invasively-derived stroke volume index (R=−0.57, P<0.001) than RV GCW, RV GWI and RV GWE (R=0.34, P=0.016, R=0.48, P<0.001 and R=0.47, P<0.001, respectively).

Conclusions

In a patient cohort with Group I and Group IV pulmonary hypertension, indices of RV myocardial work were more closely correlated with invasively-derived RV stroke work index and PVR than conventional echocardiographic parameters of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Method and correlations

Prognostic value of left atrial function in patients with severe primary mitral regurgitation undergoing mitral valve repair

Background

Timing of mitral valve surgery for primary mitral regurgitation (MR) remains challenging. Since MR has a significant hemodynamic impact on the left atrium (LA), assessment of LA function may have prognostic value in these patients which is incremental to LA volume and left ventricular (LV) remodeling parameters.

Purpose

This study sought to investigate whether preoperative assessment of LA reservoir strain (LASr) by speckle tracking echocardiography is associated with long-term outcome in patients undergoing mitral valve repair for severe primary MR.

Methods

Echocardiography was performed prior to mitral valve surgery in 566 patients (age 64±12 years, 66% men) with severe primary MR. Complete clinical information was collected and the endpoint was all-cause mortality after operation. The study population was divided based on a cut-off value of LASr (22%) derived from a spline curve analysis (hazard ratio for all-cause mortality >1).

Results

Patients with LASr ≤22% (n=277) were significantly older, had more impaired renal function and were more symptomatic (NYHA functional class III to IV) compared to patients with LASr >22% (n=289). In terms of echocardiographic data, patients with LASr ≤22% had significantly lower LV ejection fraction and LV global longitudinal strain (LV-GLS) and significantly higher systolic pulmonary artery pressures and LA volume index compared with patients with LASr >22%.

During a median follow-up of 95 (56 – 147) months, 129 patients (22.8%) died. Patients with LASr ≤22% experienced significantly higher mortality rates compared to patients with LASr >22% (log rank chi-square 35.1; p<0.001) (Figure). On multivariable analysis, age (hazard ratio (HR): 1.06; 95% confidence interval (CI): 1.03 to 1.09; p<0.001), LV-GLS (HR: 1.08; 95% CI: 1.02 to 1.15; p=0.014) and LASr (HR: 0.96; 95% CI: 0.93 to 0.99; p=0.014) were independently associated with all-cause mortality. The addition of LASr to a clinical model (including: age, coronary artery disease, estimated glomerular filtration rate, NYHA class III-IV, atrial fibrillation, LV end-diastolic volume index, LV ejection fraction, LV-GLS, LA volume index and systolic pulmonary artery pressure) showed a significant increase in the chi-square value (chi-square differences = 6.9; p=0.011), demonstrating the incremental prognostic value of LASr in patients with primary MR.

Conclusions

Preoperative LASr is independently associated with all-cause mortality in patients undergoing mitral valve repair for primary MR, has incremental prognostic value over LA volume and LVEF and might therefore be helpful to guide surgical timing.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Jan Stassen has received an ESC training grant (Appehab724.011364741) Association of LASr and outcome

Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Introduction

Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated.

Purpose

To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery.

Methods

Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality.

Results

A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4.

The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages.

During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021).

Conclusion

Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Stages of right heart failureFigure 2. Kaplan-Meier curves for overall survival

Prevalence, echocardiographic profile and clinical outcomes of patients with paradoxical low-gradient rheumatic mitral stenosis

Introduction

Rheumatic mitral stenosis (MS) has been conventionally defined by the mitral valve area (MVA), and associated with an elevated mean pressure gradient (PG) across the valve. However, there may be discrepancies between MVA and PG. We compared the clinical and echocardiographic parameters, as well asoutcomes of those with consistent (normal-gradient, NG) versus discrepant (Low-gradient, LG) grading between MVA and PG.

Methods

Consecutive patients (n=452) with index echocardiographic diagnosis of rheumatic MS (MVA <1.5cm2) were examined. Patients were matched by MVA and divided based on mean PG (LG <10mmHg or HG ≥10mmHg). The groups were compared using appropriate univariable, multivariable and survival analyses. Patients were followed up prospectively for clinical outcomes (admission for congestive heart failure, stroke or death).

Results

There were 226 patients (50.0%) with LGMS despite MVA<1.5cm2. They had similar age and body mass index. The LG group had higher prevalence of atrial fibrillation (62.4% vs 45.1%, p<0.001), hypertension (31.4% vs 18.8%, p<0.001) and lower heart rate during echocardiography (74.3±16.6 vs 82.5±20.2 beats per minute, p<0.001). LG MS patients had lower incidence of adverse events (log-rank 4.62, p=0.032). On multivariable Cox regression adjusting for age, left ventricular ejection fraction, MVA, pulmonary artery systolic pressure and mitral valve procedure, LG MS remained protective for adverse events (adjusted HR 0.58, 95% CI 0.38–0.89, p=0.013).

Conclusions

There was significant prevalence of paradoxical LG MS. Despite similar MVA, these patients had lower PASP and had fewer adverse outcomes on follow-up.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Dr Jan Stassen is supported by an ESC Training Grant (Appehab724.169164741)

Impact of left atrial strain assessed with feature-tracking computed tomography on long-term mortality after transcatheter aortic valve implantation

Background

Aortic stenosis (AS) induces left atrial (LA) remodeling through the increase of left ventricular (LV) filling pressure. Peak left atrial longitudinal strain (PALS) has been proposed as a prognostic marker in patients with AS. Novel feature-tracking (FT) software allows to assess LA strain from multidetector computed tomography (MDCT) dataset.

Purpose

To investigate the association between PALS using FT MDCT and moratlity in patients who underwent transcatheter aortic valve implantation (TAVI).

Methods

A total of 369 Patients (mean 80±7 years, 51% male) who underwent preprocedual MDCT before TAVI and had suitable data for measureing PALS using dedicated FT software were included. Patients were classified into 4 groups according to PALS quartiles; PALS more than 19.3% (Q1), 19.3% or less to more than 15.0% (Q2), 15.0% or less to more than 9.1% (Q3), and 9.1% or less (Q4). The primary outcome was all-caurse mortality.

Results

During median follow-up of 45 [22 - 68] months, 124 patients (34%) were died. On multivariable Cox regression analysis, PALS is an independently associated with all-cause mortality (HR: 0.958 [95% CI: 0.925–0.993], P=0.006). Kaplan-Meier analysis showed the worse outcome of the quatile with more impaired PALS (Logrank P<0.001). Compared to Q1, Q3 and Q4 had higher risk of mortality after TAVI (HR: 2.475 [95% CI: 1.411–4.340] for Q3, HR: 3.253 [95% CI: 1.878–5.633] for Q4).

Conclusion

In this retrospective study, PALS measured with FT MDCT was strongly associated with all-cause mortality after TAVI. LA functial assessment using MDCT may have a importan role for risk stratification in patients referred to TAVI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 K-M curve according to PALS quartiles

Left atrial appendage size is a marker of atrial fibrillation recurrence after radiofrequency catheter ablation in patients with persistent atrial fibrillation

Background

Catheter ablation is an established therapy for rhythm control in patients with drug-refractory atrial fibrillation (AF), however, recurrence is frequent particularly in persistent AF. There are no consistently confirmed predictors of AF recurrence after catheter ablation. The left atrial appendage (LAA) potentially plays an important role in AF recurrence, although the exact mechanism and pathophysiology are still unclear.

Purpose

We aimed to study whether LAA volume (LAAV) and function influence the long-term recurrence of AF after point-by-point radiofrequency catheter ablation, depending on AF type.

Methods

AF patients who underwent point-by-point radiofrequency catheter ablation after preprocedural cardiac computed tomography (CT) and transthoracic and transesophageal echocardiography (TEE) were included in this retrospective analysis. LAAV and LAA orifice area were measured by CT and LAA flow velocity assessed by TEE and was used as a surrogate marker of LAA function. Uni- and multivariable Cox proportional hazard regression models were performed to determine the predictors of AF recurrence.

Results

In total, 561 AF patients (61.9±10.2 years, 34.9% females) were included in the study. Recurrence of AF was detected in 40.8% of the cases (34.6% in patients with paroxysmal and 53.5% in those with persistent AF) with a median recurrence-free time of 22.7 [9.3–43.1] months. Patients with AF recurrence had significantly higher body surface area-indexed left atrial volume (iLAV), LAAV and LAA orifice area, as compared to those without recurrence. Moreover, patients with persistent AF had significantly higher iLAV, LAAV, LAA orifice area and lower LAA flow velocity, than those with paroxysmal AF. After adjustment for the main cardiovascular risk factors and comorbidities left ventricular ejection fraction (LVEF) <50% (HR=2.17; 95% CI=1.38–3.43; p<0.001) and LAAV (HR=1.06; 95% CI=1.01–1.12; p=0.029) were independently associated with AF recurrence in persistent AF, while no independent predictors could be identified in paroxysmal AF.

Conclusions

The current study demonstrates that beyond left ventricular systolic dysfunction, LAA enlargement is associated with higher rate of AF recurrence after catheter ablation in persistent AF, but not in patients with paroxysmal AF. Our results suggest that preprocedural assessment of LVEF and LAAV might contribute to optimal patient selection and aid to improve long-term results of ablation procedures in patients with persistent AF.

Funding Acknowledgement

Type of funding sources: None.

Sex-differences in left ventricular remodeling and mechanics after aortic valve surgery in patients with severe aortic valve disease

Background

Sex-differences in left ventricular (LV) remodeling in patients with aortic valve disease have been reported. However, sex-differences in LV remodeling and mechanics in response to aortic valve replacement (AVR) remained largely unexplored.

Purpose

The present study aimed to evaluate the sex-differences during the time course of LV remodeling and LV mechanics (by LV global longitudinal strain (GLS)) after aortic valve replacement.

Methods

Patients with severe aortic valve disease (aortic stenosis (AS) or aortic regurgitation (AR)) undergoing AVR with echocardiographic follow-up at 1,2, and/or 5 years were evaluated. LV mass index, LV ejection fraction, LV GLS and stroke volume (SV) were measured. Linear mixed models analyses were used to assess changes in LV mass index, LVEF, LV GLS and SV between time points. The models were corrected for age, LV end-diastolic diameter at baseline and time between echocardiograms.

Results

A total of 211 patients (61±14 years, 61% male) with severe aortic valve disease (AS 63% or AR 39%) were included. Before AVR, men had larger LV mass index and higher SV compared to women. Both men and women had a preserved LV ejection fraction (54±12 and 56±9, P=0.102, respectively), but moderately impaired LV GLS (14.6±4.1 and 16.1±4.1, P=0.009, respectively). After AVR, both groups showed LV mass regression, improvement in LV ejection fraction and LV GLS. LV mass index and SV remained higher in men. During follow-up women showed significantly better LV GLS compared to men (P=0.030, figure 1).

Conclusion

In men and women with severe aortic valve disease undergoing AVR, the time course of changes in LV mass regression, LV ejection fraction, LV GLS and SV are similar. During follow-up LV mass index remained larger in men and women showed significantly better LV GLS.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The department of Cardiology received unrestricted research grants from Abbott Vascular, Bayer, Bioventrix, Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic. Victoria Delgado received speaker fees from Abbott Vascular, Edwards Lifesciences, GE Healthcare, MSD and Medtronic. Nina Ajmone Marsan received speakers fees from Abbott Vascular and GE healthcare. Jeroen J Bax received speaker fees from Abbott Vascular. The remaining authors have nothing to disclose.

Impact of tricuspid annular shape on late worsening tricuspid regurgitation after transcatheter aortic implantation: insight from multidetector row computed tomography assessment

Background

Worsening of tricuspid regurgitation (TR) in patients undergoing transcatheter aortic valve implantation (TAVI) is associated with adverse clinical outcomes. The geometrical factors that determine the occurrence of significant TR after TAVI are uncertain. Multi-detector row computed tomography (MDCT) may provide additional geometrical insights in the pathophysiology of worsening TR after TAVI.

Purpose

To investigate the impact of right atrial and tricuspid annular (TA) geometryassessed by MDCT on the occurrence of significant TR (≥ moderate) at 1-year after TAVI.

Methods

Patients without significant TR who had undergone a full-beat MDCT prior to TAVI were included. Right and left atrial and ventricular volumes and TA parameters including the anterior-posterior (AP) and septal-lateral (SL) diameters, area and circularity (AP/SL ratio) were measured and correlated to the occurrence of significant TR at 1-year after TAVI.

Results

A total of 205 patients (80±7 years, 51% male) who underwent TAVI for severe aortic stenosiswere included. Moderate or severe TR at 1-year follow-up occurred in 59 patients (29%). Patients who developed significant TR were more likely to have atrial fibrillation and lower left ventricular (LV) volumes, but larger right and left atrial volumes and TA dimensions at baseline. After adjusting for atrial fibrillation and LV and right atrial volumes, larger end-diastolic TA SL diameter (odds-ratio 1.182 95% CI 1.047–1.334, P=0.007) and more circular TA shape were independently associated with the occurrence of significant TR.

Conclusion

In patients without significant TR prior to TAVI, TA dilation and loss of the elliptical shape of the TA at baseline are associated with of the occurrence of significant TR 1-year after TAVI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 Representative cases

Sex-specific difference in cardiac function in patients with systemic sclerosis: association with cardiovascular outcomes

Background

Cardiac involvement is an important cause of hospitalization and mortality in patients with systemic sclerosis (SSc) and advanced echocardiographic measures such as left ventricular (LV) global longitudinal strain (GLS) have already demonstrated to improve risk-stratification. However, possible sex differences in echocardiographic parameters including LV GLS have not been explored so far.

Purpose

To compare standard and advanced echocardiographic parameters between men and women with SSc and evaluate their association with cardiovascular outcomes.

Methods

A total of 746 SSc patients from four different centers were included of which 628 (84%, 54±13 years) women and 118 (16%, 55±15 years) men. Baseline transthoracic echocardiographic (TTE) data with standard and advanced (LV GLS) measurements as well as clinical characteristics were analysed. The study endpoint was the composite of all-cause mortality and cardiovascular hospitalisations.

Results

Men and women showed several differences in terms of disease characteristics: greater modified Rodnan skin score, higher prevalence of diffuse cutaneous SSc, lung fibrosis and myositis, more impaired pulmonary function (DLCO) and higher creatine phosphokinase were observed in men, while women were characterized by longer disease duration, higher NT-proBNP and lower glomerular filtration rate. By TTE, men showed larger LV indexed volumes, lower LV ejection fraction and more impaired LV GLS [−19% (IQR −20% to −17%) vs. −21% (IQR: −22% to −19%, p<0.001)]. Considering the significant differences in clinical characteristics between men and women, a propensity matching score was applied to explore whether sex-differences in TTE parameters were maintained. The matching was performed according to age, disease duration, presence of diffuse SSc, lung fibrosis, DLCO and NT-proBNP (n=140); after matching, LV GLS still showed significant difference between men and women [−19% (IQR −20% to −18%) vs. −20% (IQR −22% to −18%, p=0.03)] while LV volumes and ejection fraction did not. After a median follow-up of 48 months (IQR: 26–80), the combined endpoint occurred in 182 patients and Kaplan-Meier survival analysis (Figure) showed that men experienced higher cumulative event rates as compared to women (Chi-square 8.648; Log rank 0.003) even after matching for clinical characteristics (Chi-square 7.211; Log rank 0.007); however, sex difference in outcomes was neutralized after matching groups according to LV GLS. Furthermore, LV GLS showed a significant association with prognosis in the overall group (HR: 1.173; 95% CI: 1.106–1.244, p<0.001) without significant interaction with sex (p=0.373), indicating a consistent prognostic value of LVGLS for both men and women.

Conclusions

Among patients with SSc, LV GLS is more impaired in men as compared to women even after matching for clinical characteristics, and its impairment is associated with higher prevalence of death and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Calcified versus non-calcified plaque volume fraction in patients with coronary artery disease and their association with outcome

Background

The amount of coronary artery calcification is a general marker of coronary atherosclerosis and has been associated with increased risk of adverse cardiac events. On the other hand, calcification of coronary artery plaques has also been considered as a marker of plaque stabilization.

Purpose

We hypothesized that the fraction of the non-calcified volume of the total plaque volume in patients with coronary artery disease (CAD) is associated with abnormal myocardial perfusion and increased risk of future cardiac events.

Methods

Consecutive patients with suspected CAD undergoing sequential coronary computed tomography angiography (CCTA) with selective positron emission tomography (PET) perfusion imaging between 2007 and 2011 were selected. The total, calcified and non-calcified plaque volume (PV) were defined at patient-level. The non-calcified plaque volume fraction was calculated by dividing the non-calcified PV by the total PV, and expressed as percentage. Patients were divided into three groups: patients with 1) non-obstructive CAD (<50% diameter stenosis), 2) suspected coronary stenosis but normal PET perfusion and 3) suspected stenosis and abnormal regional PET perfusion. Difference between high vs. low PV was based on the median value. Clinical outcomes including all-cause mortality and myocardial infarction were recorded for 6.1 [SD 5.3–7.5] years.

Results

In total, 494 patients (age 63±9 years, 55% male) with documented atherosclerosis on CCTA were included. Total PV, calcified PV and non-calcified PV were all significantly larger in patients with abnormal myocardial perfusion compared to patients with non-obstructive CAD (370 [197–739] mm3 vs. 108 [59–177] mm3, 84 [23–220] mm3 vs. 9 [1–34] mm3 and 274 [157–500] mm3 vs. 94 [53–140] mm3, respectively, p<0.001 for all). However, the non-calcified fraction was smaller in patients with reduced myocardial perfusion (75 [63–86]% vs. 89 [76–98]%, p<0.001, Figure 1). During follow-up 35 events occurred. Patients with higher total PV, calcified PV and non-calcified PV showed worse outcome compared to patients with lower PV (log-rank p<0.001, Figure 2). In contrast, patients with a lower non-calcified plaque volume fraction showed poorer outcome (log-rank χ2=5.54; p=0.019) even after adjusting for statin therapy or revascularization.

Conclusion

We observed that higher volumes of any plaque component in general are associated with abnormal perfusion and increased risk of future cardiac events. In contrast, patients with a lower non-calcified plaque volume fraction showed poorer outcome.

Funding Acknowledgement

Type of funding sources: None. Non-calcified plaque volume fractionKaplan-Meier survival analysis

Left atrial remodeling after mitral valve repair for primary mitral regurgitation: evolution over time and prognostic significance

Background

Although preoperative left atrial (LA) dilation is a well-known predictor of adverse cardiovascular events in patients with severe, primary mitral regurgitation (MR), little is known about LA reverse remodeling after mitral valve (MV) surgery and its prognostic value.

Purpose

This study sought to systematically investigate the changes in LA volume in patients undergoing MV repair for severe, primary MR and the association between LA volume after surgery and long-term outcome.

Methods

In patients undergoing MV repair for severe, primary MR, echocardiography was evaluated at three different time points: pre-operatively, immediate postoperatively (5 [4–6] days) and within 1–3 years (19 [14–24] months) follow-up. Outcome was all-cause mortality happening after the third echocardiographic evaluation.

Results

A total of 226 patients (mean age 62±13 years, 66% male) were included. Mean pre-operative LA volume index (LAVi) was 56±28 ml/m2 and significantly decreased immediately after surgery (to 38±21 ml/m2; p<0.001) as well as at long-term follow-up (to 32±17 ml/m2; p<0.001). Significant correlations were found between reduction in LAVi at long-term follow-up and age (R=−0.139; p=0.037), pre-operative left ventricular end-diastolic volume index (R=0.199; p=0.003), preoperative LAVi (R=0.498; p<0.001), preoperative effective regurgitant orifice area (R=0.205; p=0.004), preoperative regurgitant volume (R=0.222; p=0.002) and postoperative transmitral mean pressure gradient at long-term follow-up (R=−0.150; p=0.026). Patients were subsequently divided into 3 groups: patients with a preoperative LAVi <42 ml/m2 (n=68), based on the definition of moderately dilated LA; patients with a LAVi 42–59 ml/m2 (n=88) and patients with a LAVi ≥60 ml/m2 (n=70), based on the current class IIaC indication for intervention in primary MR. Although patients with a LAVi ≥60 ml/m2 at baseline showed the most pronounced reduction in LAVi, their values of LAVi at long-term follow-up remained above the range of normality (figure 1). During a median follow-up of 72 (40–114) months, 43 (19.0%) patients died. Patients who had a LAVi ≥42 ml/m2 at long-term follow-up (3rd echocardiographic evaluation) showed significantly higher mortality rates as compared to patients with a LAVi <42 ml/m2 (p<0.001) (figure 2). Multivariable Cox regression analysis showed that, after adjusting for age, sex and coronary artery disease, postoperative LAVi ≥42ml/m2 at long-term follow-up remained independently associated with all-cause mortality (HR 2.494; CI 1.292 to 4.815; p=0.006).

Conclusions

In patients with severe primary MR, LA reverse remodeling occurs immediately after MV repair, with a further reduction in LAVi during follow-up. Patients in whom LAVi does not remodel to normal values present worse long-term prognosis as compared to patients who achieve normal LAVi values.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant (Appehab724.011664741). Changes in LA volume over timeKM curve for all-cause mortality

Renal function in patients with significant tricuspid regurgitation: pathophysiological mechanisms and prognostic implications

BACKGROUND

The pathophysiological mechanisms linking tricuspid regurgitation (TR) and chronic kidney disease (CKD) remain unknown. This study aimed to determine which pathophysiological mechanisms related to TR are independently associated with renal dysfunction and to evaluate the impact of renal impairment on long-term prognosis in patients with significant (≥ moderate) secondary TR.

METHODS

A total of 1234 individuals (72 [IQR 63-78] years, 50% male) with significant secondary TR were followed up for the occurrence of all-cause mortality and the presence of significant renal impairment (eGFR of <60 mL min-1  1.73 m-2 ) at the time of baseline echocardiography.

RESULTS

Multivariable analysis demonstrated that severe right ventricular (RV) dysfunction (TAPSE < 14 mm) was independently associated with the presence of significant renal impairment (OR 1.49, 95% CI 1.11 to 1.99, P = 0.008). Worse renal function was associated with a significant reduction in survival at 1 and 5 years (85% vs. 87% vs. 68% vs. 58% at 1 year, and 72% vs. 64% vs. 39% vs. 19% at 5 years, for stage 1, 2, 3 and 4-5 CKD groups, respectively, P < 0.001). The presence of severe RV dysfunction was associated with reduced overall survival in stage 1-3 CKD groups, but not in stage 4-5 CKD groups.

CONCLUSIONS

Of the pathophysiological mechanisms identified by echocardiography that are associated with significant secondary TR, only severe RV dysfunction was independently associated with the presence of significant renal impairment. In addition, worse renal function according to CKD group was associated with a significant reduction in survival.

Reclassification of aortic stenosis by fusion of echocardiography and computed tomography in low-gradient aortic stenosis

Background

The integration of computed tomography (CT)-derived left ventricular outflow tract area into the echocardiography-derived continuity equation results in the reclassification of a significant proportion of patients with severe aortic stenosis (AS) into moderate AS based on aortic valve area indexed to body surface area determined by fusion imaging (fusion AVA_i). The aim of this study was to evaluate AS severity by a fusion imaging technique in patients with low-gradient AS and to compare the clinical impact of reclassified moderate AS versus severe AS.

Methods

We included 359 consecutive patients who underwent transcatheter aortic valve implantation for low-gradient, severe AS at two academic institutions and created a joint database. The primary endpoint was a composite of all-cause mortality and rehospitalisations for heart failure at 1 year.

Results

Overall, 35% of the population (n = 126) were reclassified to moderate AS [median fusion AVAi 0.70 (interquartile range, IQR 0.65–0.80) cm²/m²] and severe AS was retained as the classification in 65% [median fusion AVAi 0.49 (IQR 0.43–0.54) cm²/m²]. Lower body mass index, higher logistic EuroSCORE and larger aortic dimensions characterised patients reclassified to moderate AS. Overall, 57% of patients had a left ventricular ejection fraction (LVEF) <50%. Clinical outcome was similar in patients with reclassified moderate or severe AS. Among patients reclassified to moderate AS, non-cardiac mortality was higher in those with LVEF <50% than in those with LVEF ≥50% (log-rank p = 0.029).

Conclusions

The integration of CT and transthoracic echocardiography to obtain fusion AVAi led to the reclassification of one third of patients with low-gradient AS to moderate AS. Reclassification did not affect clinical outcome, although patients reclassified to moderate AS with a LVEF <50% had worse outcomes owing to excess non-cardiac mortality.

P5582Predicting the clinical outcomes in moderate aortic stenosis: implementation of the newly proposed staging classification

Background

While symptomatic severe aortic stenosis (AS) carries a worse prognosis and early intervention is favoured, it is always assumed that patients with moderate AS are more stable and their disease progression can be monitored yearly. However, it is known that patients with moderate AS have a higher risk of cardiovascular events but is unclear if other factors may also affect the overall prognosis.

Purpose

In this multicentre registry of patients with moderate AS, the prognostic value of a new staging classification on the extent of cardiac damage was examined.

Methods

Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into five stages depending on the extra-aortic valvular cardiac damage: no signs of cardiac damage (Stage 0), left ventricular (LV) damage [LV ejection fraction <50%, LV mass index >95 g/m2 for women or >115 g/m2 for men or E/e' >14] (Stage 1), mitral valve or left atrial (LA) damage [LA volume index >34 ml/m2 or mitral regurgitation ≥grade 3 or presence of atrial fibrillation] (Stage 2), tricuspid valve or pulmonary artery vasculature damage [systolic pulmonary arterial pressure ≥60 mmHg or tricuspid regurgitation ≥grade 3] (Stage 3), or right ventricular damage [tricuspid annular plane systolic excursion <17 mm] (Stage 4). The clinical endpoint was all-cause mortality. The association between the extent of cardiac damage and all-cause mortality was assessed by the Kaplan Meier method using log-rank test.

Results

Of the included 522 patients with moderate AS (age 71±11 years, 54% males), 12% (63) of patients were re-classified as Stage 0, 30% (157) in Stage 1, 47% (245) in Stage 2, 6% (31) in Stage 3 and 5% (26) in Stage 4. During follow-up, 43% (226) of patients underwent surgical or transcatheter aortic valve replacement. Over a median follow-up of 6.2 [interquartile range 3.2–9.0] years, 254 (49%) patients died. The cumulative event rates for all-cause mortality increased with increasing stage, particularly for Stages ≥2: 39% for Stage 0, 55% for Stage 1, 67% for Stage 2, 68% for Stage 3 and 57% for Stage 4, respectively (Figure, log-rank test p=0.001).

Cumulative death rates after re-staging

Conclusion

In a real-world registry of patients with moderate AS patients, worsening extra-aortic valvular cardiac damage portends a worse long-term prognosis.

P5973Regional left ventricular myocardial work and response to cardiac resynchronization therapy

Background

Myocardial work, assessed by speckle tracking echocardiography, reflects mechanical efficiency of the left ventricle. In heart failure patients, characterization of acute changes in regional (septal and lateral) left ventricular (LV) myocardial walls after cardiac resynchronization therapy (CRT) may enhance understanding of CRT response.

Objective

To evaluate the interaction between CRT response and components of myocardial work of the lateral wall and septum in patients with heart failure.

Methods

Regional LV myocardial work was calculated by integrating non-invasive blood pressure measurements, timing of mitral and aortic valve opening and closure and speckle tracking-derived LV longitudinal strain. From pressure-strain loops, constructive work (CW) and wasted work (WW) were calculated. CRT response was defined as a decrease in LV end-systolic volume ≥15% at 6 months follow-up. Changes in CW and WW of the septal and lateral walls prior to (baseline) and within the first 5 days after CRT implantation were compared between CRT responders and non-responders.

Results

At baseline, measurement of regional CW and WW was performed in 168 patients treated with CRT (71% men, 66±10 years). At 6 months, 59% of patients were CRT responders. CRT responders more frequently had non-ischemic heart failure than non-responders (54% vs 36%; p=0.027). At baseline, CRT responders were characterized by a significantly higher septal WW (270.5 [160.0; 451.5] mmHg% vs. 210.5 [106.3; 336.5] mmHg%; p=0.038) and lateral CW (989.5 [574.0; 1439.0] mmHg% vs. 689.0 [463,3; 1140.0] mmHg%; p=0.005). On multivariable analysis, only CW of the lateral wall at baseline was independently associated with CRT response (HR 1.001; 95% CI, 1.000–1.001; p=0.048).

Immediately after CRT implantation, measurement of regional CW and WW was feasible in 115 patients. CRT responders showed improvement in CW (433.0 [254.5; 686.5] mmHg% to 664.5 [424.5; 977.8] mmHg%; p<0.001) and WW (305.0 [169.0; 461.3] mmHg% to 145.0 [80.0; 306.3] mmHg%; p=0.005) of the septum whereas the lateral wall demonstrated a significant decrease in CW (1036.5 [561.0; 1402.0] to 818.0 [491.0; 1154.3] mmHg%; p=0.005) and increase in WW (132.5 [80.3; 269.3] to 198.5 [107.5; 331.0] mmHg%; p=0.025). Non-responders showed only a decrease in WW of the septum (202.8 [102.9; 332.5] to 168.5 [67.6; 258.4] mmHg%; p=0.049).

Conclusion

CRT responders are characterized by increased WW of the septum and CW of the lateral wall at baseline, which are corrected immediately after CRT implantation. Constructive work of the LV lateral wall at baseline is independently associated with CRT response.

Acknowledgement/Funding

Study was supported by ESC Research grant 2018

P1473Global work efficiency 3 months after ST-segment elevation myocardial infarction: prevalence and characteristics of patients with reduced global work efficiency

Background

Global work efficiency (GWE) is an index of left ventricular function derived from echocardiographic speckle tracking derived strain-pressure loops. GWE is calculated as constructive work divided by the sum of constructive and wasted work and expressed as a percentage. The prevalence of reduced GWE after ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) is unknown.

Aims

To assess GWE in STEMI patients 3 months after the index admission and report on the prevalence and characteristics of patients with impaired GWE.

Methods and results

This retrospective study included 150 patients (111 men, mean age: 60±10 years) with STEMI. They were divided into GWE normal and GWE reduced groups, based on reference values from the EACVI NORRE study. Reduced GWE was observed in 23% of patients. Those with reduced GWE had significantly higher values of CK [3033.62 U/L (±2003.47) vs. 1308.47 U/L (±1309.07); P<0.001] and troponin T [8.43 μg/L (±6.73) vs. 3.49 μg/L (±4.36); P<0.001)] at baseline, as well as significantly higher left ventricular end-diastolic volume [112 ml (±32) vs. 90 ml (±30); P<0.001] and left ventricular end-systolic volume [62 ml (±21) vs. 39 ml (±17); P<0.001] and significantly lower values of left ventricular ejection fraction [46% (±8) vs. 59% (±8); P<0.001] and impaired global longitudinal strain [−13.03% (±2.54) vs. −18.04% (±2.75); P<0.001] at 3 months (Table 1).

Table 1. Patient characteristics GWE normal (N=116) GWE reduced (N=34) P value Age (years) 60 (±10) 58 (±11) 0.224 HR (bpm) 69 (±13) 74 (± 13) 0.063 SBP (mmHg) 138 (±17) 138 (±21) 0.920 DBP (mmHg) 81 (±12) 84 (±15) 0.214 Maximum CK value at baseline (U/L) 1308.47 (±1309.07) 3033.62 (±2003.47) <0.001 Maximum Troponin at baseline (μg/L) 3.49 (±4.36) 8.43 (±6.73) <0.001 Left ventricular end-systolic volume (ml) 39 (±17) 62 (±21) <0.001 Left ventricular end-diastolic volume (ml) 90 (±30) 112 (±32) <0.001 LVEF (%) 59 (±8) 46 (±8) <0.001 GLS (%) −18.04 (±2.75) −13.03 (±2.54) <0.001

Conclusions

Almost one fourth of STEMI patients treated with primary PCI have impaired GWE at 3 months follow-up. Patients with reduced GWE had larger myocardial damage than those with preserved GWE at 3 months.

P2465Assessment of left atrial electro-mechanical delay to predict atrial fibrillation in hypertrophic cardiomyopathy

Background

Left atrial remodelling in hypertrophic cardiomyopathy (HCM) is recognized as the main contributor to the development of atrial fibrillation (AF). It is well reported that the occurrence of AF in HCM increases both morbidity and mortality. Therefore, early recognition of AF is essential. Due to its often silent and paroxysmal nature, the diagnosis can be missed.

Purpose

PA-TDI, representing total atrial conduction time, reflects the left atrial structural and electrical remodelling. We sought to evaluate the association between this novel non-invasive echocardiographic parameter and AF in patients with HCM.

Methods

The electronic charts of patients with HCM and no previous history of AF from 1993 to 2018 were retrospectively analysed. PA-TDI was measured offline using pulsed wave tissue Doppler imaging with the sample volume placed on the lateral wall of the left atrium just above the mitral annulus in an apical 4-chamber view. The time interval was determined from the onset of P wave on surface ECG to the peak of the a' wave of the left atrial tissue Doppler tracing.

Results

There were 208 patients (64% male) with a mean age of 53±14 years in this study. The incidence of AF was 20% over a median follow-up of 56.3 (IQR 18.4–84.5) months. Patients who developed AF, had higher baseline PA-TDI intervals when in sinus rhythm (134±23 ms vs 111±30 ms, P<0.001) than those who remained free from AF. The cut-off value of PA-TDI duration was the median at 115 ms. A PA-TDI ≥115 ms was independently associated with new onset AF (HR: 2.5, 95% CI: 1.1–5.5, P=0.02) after correcting for age, left atrial diameter and E/e'.

Conclusion

A prolonged PA-TDI was strongly associated with the development of AF in patients with HCM. This parameter may be useful to risk-stratify patients with HCM who are at risk of having AF.

P6165Sex differences in compositional plaque volume progression in patients with stable coronary artery disease: observations from a serial CCTA registry

Background

It is unclear whether sex impacts the plaque volume (PV) progression in patients with stable coronary artery disease (CAD).

Purpose

To explore whether the total and compositional PV progression rate differ according to sex.

Methods

We performed a prospective multinational registry of consecutive patients who underwent serial CCTA at ≥2-year interval. Total and compositional PV at baseline and follow-up were quantitatively analysed and normalized using the analysed total vessel length. Multivariate linear regression models were constructed for each women and men.

Results

Of the 1,255 patients included (median CT interval 3.8 years), 543 were women and 712 were men. Women were older (62±9 years vs. 59±9 years, p<0.001) and had higher total cholesterol level (195±41mg/dL vs. 187±39mg/dL, p=0.002). Prevalence of hypertension, diabetes, and family history of CAD were not different (all p>0.05).

At baseline, men possessed greater total PV (131.5±230.5mm3 vs. 97.7±193.6mm3, p=0.005) and a higher prevalence of high-risk plaques (HRP) than women (31% vs. 20%, p<0.001). Annual total PV progression rate was greater in men, driven by the greater non-calcified PV progression (TABLE).

In multivariate analysis (TABLE), although total PV progression rate was not different, women were associated with greater calcified PV progression (β=2.83, p=0.004) but slower non-calcified PV progression (β=-3.39, p=0.008) and less development of HRP (β=-0.18, p=0.049) than men.

CCTA findings according to sex Univariate analysis Female Sex in Multivariable Analysis Women (n=543) Men (n=712) P β SE P Agatston CACS, /year 0.44±0.7 0.4±0.7 0.332 0.106 0.04 0.006 Total PVnormalized, mm3/year 14.7±23.4 17.8±26.2 0.026 -0.56 1.33 0.677 Calcified PVnormalized, mm3/year 10.5±21.5 10.0±19.1 0.670 2.83 0.98 0.004 Non-calcified PVnormalized, mm3/year 4.2±17.3 7.8±21.2 0.001 -3.39 1.28 0.008 Development of high-risk plaque*, n (%) 86 (15.8) 139 (19.5) 0.092 -0.18 0.09 0.049 In linear multivariate regression analysis adjusted with age, race, HTN, DM, family history, smoking, LDL, statin, anti-platelets, beta-blockers, and PV at baseline, women were associated with greater calcified PV progression and slower non-calcified PV progression. (High-risk plaque was defined as ≥2 of low-attenuation plaque, spotty calcification, and positive remodelling.)

Conclusion

In this large CCTA cohort, we found that the compositional PV progression differs according to sex. These findings, which are hypothesis generating, suggest that comprehensive plaque evaluation may contribute to further refine risk stratification according to sex.

Acknowledgement/Funding

This work was supported by the National Research Foundation of Korea funded by the Ministry of Science and ICT (Grant No. 2012027176).

P1783Prognostic implications of significant tricuspid regurgitation in patients with atrial fibrillation in the absence of left-sided heart disease or pulmonary hypertension

Background

Tricuspid regurgitation (TR) can be caused by atrial fibrillation (AF) in the absence of left-sided heart disease or pulmonary hypertension. The prognostic impact of AF-TR has not been investigated.

Purpose

The aim of this study was to investigate the prognostic significance of TR in AF patients who do not show left-sided heart disease, pulmonary hypertension or primary structural abnormalities.

Methods

A total of 63 AF patients with moderate and severe TR were identified and matched by age and gender to 116 patients with AF without significant TR, resulting in a total study population of 179 patients (mean age 71±7 years, 59% male). As per design of the study, patients with primary TR, significant (moderate or severe) aortic and/or mitral valve disease, previous valvular surgery, congenital heart disease, left ventricular ejection fraction <50%, systolic pulmonary artery pressure >40mmHg, pacemaker or implantable cardioverter defibrillator leads in situ were excluded as well as patients with AF de novo. Patients were followed for the combined endpoint of all-cause mortality, hospitalization for heart failure and stroke.

Results

Patients with AF-TR had more often paroxysmal AF as compared to patients without TR (60% vs. 43%, p=0.028). In addition, right atrial volumes and the tricuspid annulus diameter (TAD) were significantly larger in patients with AF-TR compared to their counterparts (p<0.001 for all). Furthermore, tricuspid annular plane systolic excursion was significantly lower in patients with AF-TR (17±5 mm vs. 21±6 mm, p<0.001). During follow-up (median 62 [32–95] months) 55 events for the combined endpoint occurred. One- and 5-year event-free survival rates for patients with TR were 71% and 53%, compared to 92% and 85% for patients without TR, respectively (Log rank Chi-Square p<0.001; Figure). In the multivariable Cox proportional hazard model adjusted for age, gender, NYHA functional class >2, renal function, right ventricular (RV) function and TAD, the presence of significant TR was independently associated with the combined endpoint (HR, 2.495; 95% CI, 1.167–5.335; p=0.018), while RV function was not (HR, 1.026; 95% CI, 0.971–1.085; p=0.364).

Figure 1. Kaplan-Meier curves

Conclusion

In the absence of left-sided heart disease and pulmonary hypertension, significant TR is independently associated with worse event-free survival in patients with AF.

P3694Discordant criteria in moderate aortic stenosis patients: prognostic implications

Background

The frequency of discordant mean valve gradient (MG) and aortic valve area (AVA) in patients with moderate aortic stenosis (AS) has not been investigated.

Objectives

Determine the occurrence of discordant gradient in patients with moderate AS (defined by MG <20 mmHg), and how these patients compare with concordant gradient moderate AS (MG >20 mmHg) in terms of patients' characteristics and the impact on long term prognosis.

Methods

Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into discordant or concordant gradients, MG <20 mmHg or >20 mmHg, respectively. The clinical endpoint was all-cause mortality.

Results

Of 522 patients with moderate AS, 95 (18.2%) had discordant gradient moderate AS (MG <20 mmHg). Patients with discordant mean gradient were older, had higher prevalence of previous myocardial infarct, larger left ventricular (LV) end-diastolic volume index, lower LV ejection fraction (EF), stroke volume index and higher LV filling pressure. Compared to patients with concordant gradients, these patients had higher mortality rates (57.9% vs 46.6%, p=0.05) and lower aortic valve replacement rates (33.7% vs 54.9%, p<0.001) during a median follow-up of 6.2 [IQR 3.2–9.0] years. The results of Cox regression analysis are shown on the table.

Cox proportional hazard analysis All-cause mortality Univariate analysis Multivariate analysis Hazard ratio (95% CI) P value Hazard ratio (95% CI) P value Age (per 1 year increase) 1.05 (1.03–1.06) <0.001 1.04 (1.02–1.06) <0.001 Diabetes (yes/no) 1.34 (1.03–1.74) 0.031 1.33 (0.97–1.82) 0.072 Previous myocardial infarction (yes/no) 1.73 (1.29–2.34) <0.001 1.01 (0.70–1.46) 0.980 eGFR <60 ml/min/1.73m2 (yes/no) 2.15 (1.68–2.76) <0.001 1.71 (1.25–2.33) 0.001 Left ventricular hypertrophy (yes/no) 1.74 (1.31–2.30) <0.001 1.50 (1.07–2.09) 0.018 Indexed LA volume (per 1 mL/m2 increase) 1.005 (1.001–1.009) 0.008 1.006 (1.001–1.012) 0.040 Tricuspid regurgitation >moderate (yes/no) 2.02 (1.29–3.16) 0.002 1.36 (0.73–2.54) 0.337 Discordant moderate AS (yes/no) 1.81 (1.34–2.45) <0.001 1.42 (1.01–2.01) 0.049 AS, aortic stenosis; CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; LA, Left atrial.

Conclusion

Discrepant aortic mean gradient in moderate AS is not uncommon and occurs more often in older patients, with higher LV filling pressure and lower EF and stroke volume index. The lower gradient values lead to underestimation of AS severity, and is associated with greater cardiac extra-valvular damage and higher mortality.

P6162Difference in progression to obstructive lesions according to the presence of high-risk plaque features

Background

It is still debatable whether the so-called high-risk plaque (HRP) simply represents a certain phase during the natural history of coronary atherosclerotic plaques or the disease progression would differ according to the presence of HRP.

Purpose

We determined whether the pattern of non-obstructive lesion progression into obstructive lesions would differ according to the presence of HRP.

Methods

Patients with non-obstructive coronary artery disease, defined as % diameter stenosis (%DS) ≥50%, were enrolled from a prospective, multinational registry of consecutive patients who underwent serial coronary computed tomography angiography at an inter-scan interval of ≥2 years. HRP was defined as lesions with ≥2 of positive remodelling, spotty calcification, and low-attenuation plaque. The total and compositional percent atheroma volume (PAV) at baseline and annualized PAV change were compared between non-HRP and HRP lesions.

Results

A total of 1,115 non-obstructive lesions were identified from 327 patients (61.1±8.9 years old, 66.0% male). There were 690 non-HRP and 425 HRP lesions. HRP lesions possessed greater PAV and %DS at baseline compared to non-HRP lesions. However, the annualized total and non-calcified PAV change were greater in non-HRP lesions than in HRP lesions. On multivariate analysis, addition of baseline PAV and %DS to clinical risk factors improved the predictive power of the model (Table). When clinical risk factors, PAV, %DS, and HRP were all adjusted on Model 3, only baseline PAV and %DS independently predicted the development of obstructive lesions (hazard ratio (HR) 1.046 [95% confidence interval (CI): 1.026–1.066] and HR 1.087 [95% CI: 1.055–1.119], respectively, all p<0.001), while HRP did not (p>0.05).

Comparison of C-statistics of per-lesion analysis to predict progression to obstructive lesion C-statistics (95% CI) P Model 1: Baseline PAV 0.880 (0.879–0.884) – Model 2: Model 1 + baseline %DS 0.938 (0.937–0.939) vs. Model 1: <0.001 Model 3: Model 2 + HRP 0.935 (0.934–0.937) vs. Model 2: 0.004 Adjusted for age, male sex, hypertension, diabetes mellitus, hyperlipidemia, family history of coronary artery disease, smoking, body mass index, and statin use.

Conclusion

The pattern of individual coronary atherosclerotic plaque progression differed according to the presence of HRP. Baseline PAV was the most important predictor for lesions developing into obstructive lesions rather than the presence of HRP features at baseline.

Acknowledgement/Funding

This work was supported by the National Research Foundation of Korea funded by the Ministry of Science and ICT (Grant No. 2012027176).

P1785Whole exome sequencing unravels new genes associated with mitral valve prolapse

Background

Several studies have suggested a familial clustering of mitral valve prolapse (MVP), especially for Barlow disease (BD), which is regarded as the effect of genetic or developmental errors. However, the genetic etiology of MVP, in particular BD, is largely unknown. So far only three genes have been identified: FLNA, DCHS1 and PLD1.

Purpose

The aim of this study was to identify genes associated with MVP using whole exome sequencing (WES).

Methods

Patients with MVP, who were classified as BD and/or had a positive family history for MVP, were referred for genetic counseling and WES. In total, 106 unrelated probands were included to identify potentially pathogenic variants in a set of 551 genes associated with cardiovascular development and/or diseases. The population databases Genome Aggregation and WES data from 110 parents of children with mental retardation were used as controls. Variants were analyzed using prediction programs, frequency in the population database and literature search. Variants were divided into the following categories: likely benign, variant of unknown significance or likely pathogenic.

Results

Thirteen percent (14/106) of the probands had a likely pathogenic variant in seven different genes: DCHS1 (1x), DSP (1x), HCN4 (2x), MYH6 (1x), TMEM67 (1x), TRPS1 (1x) and TTN (7x); the DSP, MYH6 and HCN4 variants cosegregated in affected relatives. None of the 110 parents of children with mental retardation had a likely pathogenic variant in these seven genes. In addition, 31% (33/106) of the probands harbored a variant of unknown significance in 23 different genes, including the genes DSP, FLNA, MYH6 and TTN (Fig). Remarkable, one variant of unknown significance in the FBN2 gene was shared among three unrelated probands and did not occur in population databases.

Conclusion

WES analysis conducted in probands with MVP using a large panel of genes associated with cardiac development and/or disease confirmed previously known causative genes (DCHS1) and expanded the cardiac phenotype of genes originally associated with cardiomyopathy (DSP, HCN4, MYH6 and TTN). This study is the first study that described the association between MVP and the genes DSP, MYH6 and TTN although the pathogenesis is still unknown. This high yield of likely pathogenic variants emphasizes the importance of genetic screening in MVP patients.

P919Ventricular arrhythmias in patients with mitral valve prolapse and severe mitral regurgitation

Background

Mitral valve prolapse (MVP) is known to be associated with ventricular arrhythmias (VA), from symptomatic premature ventricular contractions (PVCs) to malignant ventricular tachycardia (VT) and sudden cardiac death (SCD). Previous studies identified risk factors for VA in these patients such as young woman, bileaflet prolapse and inverted T-waves, but they included only specific cohort of patients who experienced SCD or who had only trivial or mild mitral regurgitation (MR). The prevalence of VA and their potential risk factors in a population of MVP patients with severe MR are unknown.

Purpose

The aim of our study was to describe the prevalence of VA in patients who underwent mitral valve surgery for moderate to severe MR due to MVP and to identify clinical, electrocardiographic and echocardiographic parameters associated with VA.

Methods

797 patients (65±12 years, 65% male) who underwent surgery for MVP were included from 2000 until 2018. The presence of VA was defined as symptomatic and frequent PVCs (Lown grade ≥2), non-sustained ventricular tachycardia (nsVT), VT or ventricular fibrillation (VF) documented before surgery and without an ischemic cause. The echocardiogram and electrocardiogram (ECG) prior to operation were used for the specific analysis. ECGs were checked for rhythm, conduction times, QRS morphology and inferior T-wave inversion. The origin of the PVCs was derived from a 12-lead ECG when available and divided in 5 groups; mitral annulus, papillary muscle (PM), left ventricle (LV, including outflow tract), right ventricle (including outflow tract) and other. By echocardiography, several parameters such as LV thickness and volumes, LV ejection fraction (EF), global longitudinal strain (GLS) and MR grade were obtained.

Results

A total of 99 (12%) patients showed VA; 70% (69/99) of the patients had symptomatic PVCs, 36% (36/99) had nsVT, 12% (12/99) VT and 3% (3/99) VF. 21 patients had more than one type of VA, of which the combination PVCs and nsVT was the most common (19/99, 19%). In addition, 6 patients experienced an out of hospital cardiac arrest of a non-ischemic cause. When comparing the clinical characteristics (Table), patients with VA were significantly younger (and with better renal function), more frequently diagnosed with Barlow's disease and experienced more palpitations as compared to patients without VA. The ECG analysis showed that patients with VA more often had inferior T-wave inversions and that the PVCs predominantly originated from the PM whereas in patients without VA the PVCs originated from different regions. Echocardiography showed that patients with VA had a thinner posterior wall, reduced LV EF and worse GLS; more severe MR was not associated with VA.

Conclusion

In MVP patients with moderate to severe MR undergoing surgery, Barlow's disease, inferior T-wave inversions, thinner posterior wall and LV systolic dysfunction are associated with the presence and development of VA.

P1237Left ventricular myocardial work characteristics and CRT response in patients with LBBB according to Strauss criteria and ESC 2013 definition

Background

The impact of left bundle branch block (LBBB) on left ventricular (LV) myocardial work may vary according to the specific definition of a LBBB. Quantification of the interplay between LV myocardial work and the underlying electrical dyssynchrony may improve our understanding of cardiac resynchronization therapy (CRT) response.

Objective

To evaluate the impact of LBBB, defined according to Strauss and ESC 2013 ECG criteria, as well as non-LBBB morphologies on different LV myocardial work indices and response to CRT.

Methods

LBBB was defined according to the Strauss criteria and ESC 2013 guidelines on heart failure. LV myocardial constructive and wasted work (CW and WW) were derived from pressure-strain loop analysis integrating valvular opening and closing times, speckle tracking strain echocardiography and noninvasive blood pressure measurement. LV myocardial work efficiency (WE) was calculated from the ratio of constructive work, divided by the sum of constructive and wasted work. CRT response was defined as a decrease in LV end-diastolic volume (EDV) ≥15% at 6 months' follow-up.

Results

Patients were divided into 3 groups: 1) LBBB according to Strauss criteria (group 1, n=109, age 64±10 years), 2) LBBB according to ESC 2013 criteria (group 2, n=22, age 64±10 years) and 3) non-LBBB (group 3, n=44, age 69±10 years). Patients from group 1 were 4.2 times more likely to respond to CRT than patients from group 3 (odds ratio [OR] 4.182; 95% confidence interval [CI], 1.999–8.750; p<0.001), whereas CRT response between groups 2 and 3 did not differ significantly (OR 1.100; 95% CI 0.387–3.124; p=0.859). Patients in group 1, were characterized by significantly lower WE, compared to groups 2 and 3 (67.6±9.9 mmHg% vs. 72.7±9.7 mmHg% and 75.4±9.6 mmHg%, respectively; p<0.001) as well as higher WW (313.2±144.9 mmHg% vs. 215.1±102.5 mmHg% and 229.0±113.5 mmHg%, respectively; p<0.001). There was no significant difference in CW between any of the groups (811.6±353.4 mmHg% vs. 798.6±440.6 mmHg% and 893.6±420.2 mmHg% respectively for groups 1, 2 and 3; p=0.447).

Conclusion

Patients with a LBBB according to Strauss criteria had a higher probability of response to CRT, compared to those with a LBBB defined by ESC 2013 guidelines criteria or with non-LBBB morphology. This is reflected in a greater amount of wasted work and more impaired LV myocardial work efficiency at baseline in patients with LBBB satisfying Strauss criteria, compared to the other two groups, representing the substrate for CRT.

Acknowledgement/Funding

Study was supported by ESC Research grant 2018

P868Temporal remodeling of coronary arteries during progression of atherosclerosis with serial coronary CT angiography using 3D metrics: results from the PARADIGM study

Aim

To determine compensatory enlargement and luminal reduction of coronary arteries during the progression of atherosclerosis with serial coronary computed tomography angiography (CCTA) by using volumetric measurements. To date, the impact of coronary plaque progression on temporal remodeling, as opposed to the static remodeling, has only been studied with invasive imaging modalities and primarily two-dimensional areas rather than three-dimensional volumes.

Methods

In total, 1,245 patients with suspected coronary artery disease (CAD) at 13 sites (61±9 years, 39% women) underwent serial CCTA with interscan interval of ≥2 years. The primary objective was to assess volumetric temporal remodeling, defined as the linear association between the change in coronary plaque, lumen and vessel volume at follow-up CCTA on a per-segment level. Temporal remodeling was determined in strata of low and high baseline plaque burden as well as different coronary segments at baseline. Linear regression analysis and Pearson's correlation coefficients were calculated to assess associations.

Results

Amongst 1,245 patients with 19,920 segments, the median interscan interval was 3.3 (IQR 2.6–4.8) years. For each 1 mm3 increase in plaque volume, the increase in vessel volume was 0.72 mm3 and the decrease in lumen volume was 0.28 mm3 (Figure 1, both p<0.001). Volumetric temporal remodeling was similar in low versus high PAV [0.70 mm3 vs 0.73 mm3 (p for interaction=0.491)] and left-main arteries versus all other segments [0.78 mm3 vs. 0.72 mm3 (p for interaction=0.336)], but not in proximal versus distal segments at baseline [0.75 mm3 vs. 0.61 mm3 (p for interaction=0.020)].

Figure 1. Volumetric temporal remodeling

Conclusion

In general, coronary plaque grows approximately 70% outward and 30% into the coronary lumen during the progression of atherosclerosis. Volumetric temporal remodeling is not limited by baseline plaque burden, but is potentially dependent on its location within the coronary artery tree.

Acknowledgement/Funding

NRF of Korea (Grant No. 2012027176); Dalio Institute of Cardiovascular Imaging and Michael J. Wolk Foundation

4182Sex specific patterns in the onset and manifestation of coronary atherosclerotic plaque; insights from the multi-center CCTA CONFIRM registry

Background

Pathobiologic data support varied atherosclerotic plaque characteristics which uniquely define risk in women as compared to men (i.e., plaque erosion versus rupture). The advent of noninvasive coronary computed tomographic angiography (CCTA) allows for further exploration as to a sex-specific signature of atherosclerotic plaque features unique to women and different from that of men. In this analysis, we compared sex differences in the age of onset of coronary atherosclerosis and varied plaque findings between women and men.

Methods

From the multicenter CONFIRM registry, the Leiden CCTA score (based on segmental plaque extent, location, severity, and composition) was calculated in women and men without prior CAD, with imputation for missing plaque data. First, women and men were matched on the Leiden CCTA score to allow assessment of differences in atherosclerotic profile. Second, the earliest age of women and men to display a median Leiden CCTA score >0, >2, >6, >8 was evaluated. Third, the prognostic value of previously established thresholds of the Leiden CCTA score was examined for all-cause mortality with Cox-proportional hazard analysis, and specifically a sex interaction.

Results

In total, 11,678 women (age 58.5±12.4 years) and 13,272 men (age 55.6±12.5 years) were included. Of the patient subset matched on Leiden CCTA score (10,266 women, score 4.1±6.0 and 10,266 men, Leiden score 4.1±6.0, P=0.589), women were characterized by less obstructive CAD (≥50% stenosis) (17.5% vs 19.1%, P=0.003), more frequent non-obstructive left main plaque (10.1% vs 8.9%, P=0.004) and a lower number of segments with non-calcified or mixed plaque, but an equal number of calcified plaques. The earliest age when women and men have a median Leiden CCTA score above 0, 2, 4, 6, or 8 was consistently 14 to 16 years later for women. A visual representation of the CAD development delay is shown in Figure 1. Adjusted for age, the hazard ratio for death (827 events) for a score 6–20, and >20 (compared with 0–6) was 1.95 (95% CI 1.56–2.42), and 3.44 (95% CI 2.40–4.93) for women, respectively, and 1.63 (95% CI 1.31–2.03), 2.22 (95% CI 1.64–3.00) for men, respectively (P-interaction 0.006). Despite the low number of events, women <50 years with a score >20 were at 12.8 (95% CI 3.58–45.73) times increased risk.

Conclusion

There is an approximate 15-year delay in onset of coronary atherosclerosis for women compared to men. The burden of atherosclerotic plaque is associated with a higher relative hazard for death among women than men. The pattern of more nonobstructive CAD, especially in the left main coronary artery, but also less non-calcified plaque supports a sex-specific plaque signature which may uniquely define risk among women as compared to men.

Acknowledgement/Funding

The research reported in this manuscript was funded, in part, by the National Institute of Health (Bethesda, MD, USA) under award number R01 HL115150.