What Do We Know So Far About Ventricular Arrhythmias and Sudden Cardiac Death Prediction in the Mitral Valve Prolapse Population? Could Biomarkers Help Us Predict Their Occurrence?

PURPOSE OF THE REVIEW

To summarize currently available data on the topic of mitral valve prolapse (MVP) and its correlation to the occurrence of atrial and ventricular arrhythmias. To assess the prognostic value of several diagnostic methods such as transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance, cardiac computed tomography, electrocardiography, and electrophysiology concerning arrhythmic episodes. To explore intra and extracellular biochemistry of the cardiovascular system and its biomarkers as diagnostic tools to predict rhythm disturbances in the MVP population.

RECENT FINDINGS

MVP is a common and mainly benign valvular disorder. It affects 2-3% of the general population. MVP is a heterogeneous and highly variable phenomenon with three structural phenotypes: myxomatous degeneration, fibroelastic deficiency, and forme fruste. Exercise intolerance, supraventricular tachycardia, and chest discomfort are the symptoms that are often paired with psychosomatic components. Though MVP is thought to be benign, the association between isolated MVP without mitral regurgitation (MR) or left ventricle dysfunction, with ventricular arrhythmia (VA) and sudden cardiac death (SCD) has been observed. The incidence of SCD in the MVP population is around 0.6% per year, which is 6 times higher than the occurrence of SCD in the general population. Often asymptomatic MVP population poses a challenge to screen for VA and prevent SCD. Therefore, it is crucial to carefully assess the risk of VA and SCD in patients with MVP with the use of various tools such as diagnostic imaging and biochemical and genetic screening.

Lip print evidence: Poland as the Last Bastion of Practical Cheiloscopy

Cheiloscopic examinations have long been conducted, and many scientists have reported the usefulness of cheiloscopy for personal identification with a characteristic and individual pattern of furrows on the vermilion lip. For almost 40 years, research conducted in Poland has determined the patterns of these furrows and the separation and development of their individual features. This was the basis for forming expert opinions and presenting them in court as evidence. In Poland, cheiloscopic expertise is performed and the results of precise procedures that are accredited and assessed serve as evidence. Although the legal system in Poland (continental system) is completely different from the American system, cheiloscopic expertise was also assessed in detail according to the American standards of evidence. This narrative review presents the problem of cheiloscopic expertise as a scientific and practical issue and provides a brief historical overview of this field and the foundations of the Polish cheiloscopic identification method. We conclude that Poland has sufficient historical background and a robust development of cheiloscopy in the field on a scientific and legal basis; however, due to its reports being in the Polish language, its absence from the most relevant specialized literature, or simply a lack of cooperation between countries and experts, the country has unfairly been left out of the discussion. We believe that a new look at the Polish contribution to lip print identification is necessary to reinsert this topic into the current discussion of a new identification paradigm.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Deep learning for evaluating left atrium stress echocardiography: a proof of principle study

Introduction

Left atrial (LA) size is a dynamic variable that changes during stress echocardiography (SE) and provides valuable information within and beyond coronary artery disease. However, its measurement remains subjective, time-consuming and based on manual tracings.

Recent advances in deep learning might save analysis time and deflate variability by removing the subjectivity of LA assessment.

Purpose

In this proof of principle study we aim to validate the potential of an automated machine learning system for the evaluation of LA in SE.

Methods

From the image data bank of Stress Echo 2030 study, we selected 20 consecutive patients who underwent SE (using a variety of stress methods) in 2 recruiting centers. Imaging data was acquired in DICOM format and anonymized. The studies were reviewed by an expert cardiologist trained in SE evaluation who selected apical four chamber (A4Ch) view images during stress and rest phases and marked end-systolic (ES) and end-diastolic frames to be used in further evaluation. Endocardial borders for LA were traced in ES. The tracings were repeated by three different evaluators (expert cardiologist [C1], cardiologist from external center [C2] and a machine learning [ML] model – a convolutional neural network trained on an unrelated set of images). LA area (LAA), volume (LAV) using area-length formula and proportional LAV changes between stress and rest (ΔLAV = [rest − stress] / rest) were calculated. Each evaluator was blinded from each other's measurements.

Results

In total, 40 A4Ch images were acquired (20 at rest and 20 at stress) of which all were of sufficient quality for performing LA measurements using an automated system. Pearson correlation coefficients (R) for LAA were 0.95 (C1-ML), 0.96 (C2-ML) at rest and 0.88 (C1-ML), 0.79 (C2-ML) at stress. The C1-C2 pair had R of 0.98 and 0.86 for LAA at rest and stress.

LAV also showed good correlation between different raters with R values of 0.90 (C1-ML), 0.94 (C2-ML), 0.94 (C1-C2) at rest and 0.86 (C1-ML), 0.87 (C2-ML), 0.84 (C1-C2) at stress. Root mean squared errors (RMSEs) for LAV were 13.48 ml (C1-ML), 7.44 ml (C2-ML), 10.26 ml (C1-C2) at rest and 14.03 ml (C1-ML), 8.53 ml (C2-ML), 13.69 ml (C1-C2) at stress.

There were high level correlations between all raters for ΔLAV with R values of 0.93, 0.94 and 0.95 for C1-ML, C2-ML and C1-C2 pairs respectively. Mean (95% CI) ΔLAV values were −20.1 (−51.59 to +11.39), −14.95 (−43.77 to +13.87) and −14.37 (−34.46 to +5.72) for ML, C1 and C2. Comparison with one-way ANOVA did not show significant differences in mean ΔLAV values between operators (p=0.94).

Conclusions

Automated ML based system produces LA measurements that are comparable to human operators and can reduce the need for manual tracing. There was a tendency for all operators to have lower levels of agreement in stress images compared to rest, further showing the need for additional standardization of SE evaluation for machine and human operators.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking-derived left atrial strain rate – undervalued and useful predictor of adverse events

Background

Strain rate reflects the rate of change of the distance between two points of the myocardium occurring in the cardiac cycle. It is a time-dependent parameter requiring higher temporal resolution than standard strain assessment. Because of this limitation, speckle tracking-derived left atrial (LA) strain rate analysis is of less interest in the literature.

Purpose

To analyze the prognostic value of LA strain rate during 2-years follow-up in patients with atrial fibrillation (AF).

Methods

The prospective study involved 80 patients with nonvalvular AF scheduled for elective electrical cardioversion (mean age 63.5±13 years, 60% male). All patients underwent echo before cardioversion and 24 hours after conversion to sinus rhythm. We analyzed standard echocardiographic parameters. Using the speckle-tracking method, we assessed LA strain rate during ventricular systole LA-SSR, in the early stage of ventricular diastole LA-ESR, and during atrial active pump phase LA-ASR. The last one is possible to measure only in the sinus rhythm. The analysis included 4-chamber and 2-chamber views. The clinical endpoint was predefined as AF recurrence.

Results

Median time of the current AF episode was 2.1 (IQR 0.5–5) months. Standard echo measurements revealed a median left ventricular ejection fraction of 55% (IQR 46–58) and the median of LA volume indexed to body surface area 42 ml/m2 (IQR 33–51). The successful cardioversion rate was 90%. During follow-up, we noticed AF recurrence in 49 (68%) patients. The median time-to-event was 2 (IQR 1 to 6.9) months. Receiver operating characteristic curve analysis revealed that LA-SSR <−0.73 s–1 (AUC=0.745; p=0.0004) and LA-ESR >−1 s–1 (AUC=0.703; p=0.0015) assessed during AF as well as LA-ESR >−0.88 s–1 (AUC=0.644; p=0.04) and LA-ASR >−1 s–1 (AUC=0.837; p<0.0001) measured in sinus rhythm were the optimal cut-off values for predicting AF recurrence. The figure presents Kaplan-Meier survival analysis for AF recurrence.

Conclusions

Speckle tracking-derived LA strain rate predicts the recurrence of AF after successful electrical cardioversion.

Funding Acknowledgement

Type of funding sources: None.

Supra-normal values of resting left ventricular systolic function are associated with decreased survival: to good to be normal?

Background

Hyper-contractile phenotype of the left ventricle (LV) is generally considered prognostically benign, but recent data challenge this intuitive assumption.

Aim

To assess the effects of resting LV function on survival.

Methods

In a prospective, observational, multicenter study, we recruited 5,122 patients (age 65±11.1 years, 2974 males, 58%) with chronic coronary syndromes referred for resting transthoracic echocardiography with technically successful volumetric echocardiography in 14 accredited laboratories. All recruiting centers had a structured follow-up program with >90% follow-up rate. In each patient, we quantitatively assessed (by Simpson's biplane, apical single-plane or parasternal linear method) LV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). As a load-independent index of LV contractility, LV force was estimated as systolic blood pressure by cuff sphygmomanometer/ESV. All-cause death was the only considered outcome end-point.

Results

EF was 59±11% (normal reference sextile = 58.0–59.9%). Force was 4.51±2.11 mmHg/ml (normal reference sextile = 3.50–4.27 mmHg/ml). The correlation between EF and force was linear (r=0.585, p<0.001). After a median follow-up of 862 days, there were 265 all-cause deaths. Considering EF values, mortality was lowest in the highest sextile (>67%) and significantly higher in the lowest sextile (EF <52%): see figure, left panel. A U-shaped curve was found with force, with mortality values being lowest in the middle sextile and significantly higher in the lowest sextile (<2.59 mmHg/ml) and in the highest sextile (>6.36 mmHg/ml): see figure, right panel. At multivariable analysis, after adjustment for age, diabetes, EF, and prior myocardial infarction, both the highest sextile of force (HR 1.84, 95%, confidence intervals 1.12–3.03 p=0.015), and the lowest sextile of force (HR 1.77, 95%, confidence intervals 1.08–2.90 p=0.024) were associated with decreased survival.

Conclusion

Sub-normal values of resting ejection fraction and super- and sub-normal values of the force are associated with worse survival in patients with chronic coronary syndromes. This U-shaped curve of mortality is detectable only with the force, a load independent index of LV contractility: too much of a good thing such as LV contractility can be dangerous on the long-run.

Funding Acknowledgement

Type of funding sources: None.

Misconception in patients with cardiovascular implantable electronic device as a factor of anxiety and depression – how to design optimal educational approach?

Purpose

The aim of this study is to assess the level of knowledge of safety and awareness about daily living in patients with cardiac implantable electronic devices (CIED) and potential impact upon anxiety and depression.

Methods

Data were collected in consecutive patients visiting pacemaker clinic for regular CIED follow-up. Demographic, clinical and psychological data were collected: Hospital Anxiety and Depression Scale-Modified (HADS-M) and a custom self-reported questionnaire was used (CIED-SRQ, 18 questions regarding daily activities, medical procedures and the safe use of electronic devices) to assess the knowledge regarding CIED. Dedicated questions referred to the preferences for CIED education channels in various age groups.

Results

We studied 186 patients (36,6% women, mean age 66,7±10,8) with CIED (63,5% pacemaker, 17,7% cardioverter defibrillator, 18,8% cardiac resynchronization therapy) in their first year following the implantation. In the CIED-SRQ the mean score of correct answers related to knowledge of CIED 13,25±2,86 (with 18 as the maximum possible score). The knowledge of CIED was correlated with the patients' level of education (p<0,001) and inversely correlated with age (rho=−0443; p<001). In the anxiety subscale of HADS-M, normal scores were noted in 75,8% patients, 13,5% cases were borderline, and abnormalities were observed in 10,7% patients. In the depression subscale, 70,4% were recognized as normal, 21,5% as borderline, and 8,1% as abnormal. As the knowledge of patients about CIED increased, there was a significant decrease in their depression level (rho=−0,149; p=0,042) and in the anxiety level (rho=−0,193; p=0,008). Anxiety level was higher in patients with CIED experiencing complications from the implantation (15,6% of patients in total experienced complications), both the mild (hematoma, bruising) and the severe (tamponade, lead dislocation, pneumothorax), when compared to the group without complications (p<0,001). Conversely, no statistically significant difference between these groups was found as to their level of depression (p=0,051). The younger patients (≤64 years) were more often in favour of remote education on CIED (p=0,025), while the elder (≥65 years) most often preferred to be personally informed by the attending physician.

Conclusions

Lack of information and misinformation in patients with CIED may result in self-imposed restrictions, which could in turn result in higher levels of anxiety and depression. Patients experiencing CIED complications should be offered increased psychological care as well as more intense education about CIED, due to higher anxiety levels. Age influences the preferences for CIED education channels, thus educational approach must be individualized and age-appropriate. These findings may help health care professionals to provide holistic care to help patients manage to live with CIED and optimize postprocedural quality of life.

Funding Acknowledgement

Type of funding sources: None.

Left atrial volume, function and B-lines at rest and during vasodilator stress echocardiography

Background

Left atrial volume index (LAVi), left atrial reservoir function assessed with global peak amplitude longitudinal strain (PALS), and B-lines at lung ultrasound are supplementary markers of left ventricular filling pressures.

Aim

To assess the relationship between LAVi, PALS and B-lines at rest and peak vasodilator stress.

Methods

A comprehensive dipyridamole stress echo was completed in 266 patients (187 male, 71%, age 65±10 years) with chronic coronary syndromes. LAVi was measured with the biplane disk summation method. PALS was measured from a single vendor with 2-dimensional speckle tracking echocardiography and expressed in % values as the mean of the 12 atrial segments from 4- and 2-chamber values. B-lines were assessed with the simplified 4-site scan in the third intercostal space, with global score from 0 to 40, and considered significant with global score ≥2 units.

Results

During dipyridamole, LAVi decreased (rest= 26±14 ml/m2 vs stress= 24±12 ml/m2, p<0.001), PALS increased (rest= 33±8 vs stress= 38±10%, p<0.001), and B-lines were more frequent (rest= 0.4, median interquartile range 0–30, vs stress= 0.7, median interquartile range 0–30, units, p<0.001). There was a significant, linear, inverse correlation between LAVi and PALS both at rest (r=−0.301, p<0.001) and at peak stress (r=−0.279, p<0.001, see figure). At group analysis, peak B-lines were directly correlated with peak LAVi (r=0.151, p=0.017) and inversely correlated with peak PALS (r=−0.234, p<0.001). At individual patient analysis, 4/93 patients (4.3%) showed stress B-lines (black dots in figure) with normal LAVi (<34 ml/m2) and preserved PALS (>42%).

Conclusion

Vasodilator stress echocardiography with combined assessment of left atrial volume, function and pulmonary congestion is feasible with high success rate in patients with chronic coronary syndromes. Pulmonary congestion is more frequent with dilated left atrium with reduced atrial contractile reserve, but it may occur in a minority of patients with normal LAVi and normal PALS.

Funding Acknowledgement

Type of funding sources: None.

Anxiety and depression among ambulatory and hospitalized patients with cardiovascular long-COVID-19 presentation referred to cardiology consultation after COVID-19 infection

Introduction

COVID-19 is connected with varying degrees of emotional stress. Patients (pts) who are hospitalized with severe COVID-19 (C19) are located in single rooms without a permanent attendant to prevent contamination. All personnel serving these pts come into contact with patients with personal full-body protective garment. Ambulatory C19 pts, usually with less severe presentation, are treated in more comfortable conditions.

Purpose

To evaluate the impact of the psychosocial changing conditions on individuals' psyche and to analyse the differences in terms of experienced anxiety and depression among the ambulatory and hospital patients referred to post-C19 cardiology consultation.

Methods

The study involved 388 pts with persistent cardiovascular symptoms, including 198 ambulatory patients (130 females and 68 males) and 190 hospital patients (128 females and 62 males) referred to the cardiology consultation (mean age 4.9±12.9 and 50.5±14.4 years, respectively). The data were collected using the specially designed questionnaire related to descriptive characteristics of the patients and to standardized questionnaires: the State-Trait Anxiety Inventory (STAI) and Beck's Depression Inventory (BDI).

Results

Abnormal psychological metrics was common in the study pts. Indicators of anxiety were lower in the ambulatory than in hospitalized pts (p<0.001). Depression level was also lower in the ambulatory pts (p<0.001). The same differences were statistically significant in both female and male pts subsets. However, anxiety and depression were more pronounced among female than male pts. Very strong positive correlation was observed between anxiety - state and depression among ambulatory patients, both females and males (p<0.05).

Conclusions

C19 convalescents with persistent symptoms of presumed cardiovascular origin present with abnormal psychological traits including increased anxiety and depression especially in individuals requiring hospital treatment. For this reason, it is necessary to plan the interventions particularly in hospitalized pts to reduce their anxiety and depression levels and to create psychological support programs.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemics upon nationwide pulmonary hypertension cohort: 18-months analysis of BNP-PL national database

Introduction

Pulmonary hypertension (PH) patients may be vulnerable to SARS-CoV-2 infection, but large analytic studies on morbidity and mortality risks are limited.

Aim

Assessment of the incidence and course of COVID-19 among patients (pts) diagnosed with PH, treated under the NFZ program, registered in the national BNP-PL database with the assessment of the impact of the SARS-CoV-2 pandemic on the care of patients with pulmonary hypertension in Poland.

Methods

We analyzed the records of the complete population of Polish pts treated under the National Drug Program of PH (PAH and CTEPH), registered in the national database of BNP-PL, and updated on an ongoing basis by all PH centers. The frequency of SARS-CoV-2 infections, clinical severity of COVID-19 course and mortality were reviewed. Clinical characteristics of infected and deceased patients were compared to the remaining patients registered in the BNP-PL database. The rate of increase of new diagnoses ended with inclusion in the Drug Program between 01 March 2020 and 31 August 2021, compared to the pre-pandemic year 2019, and the change in the treatment profile were reviewed.

Results

The analysis included 1923 pts (PAH 1292, CTEPH 631). The incidence of SARS-CoV-2 infections was 7.4% (n=143) and similar to general population (7.6%), with a slight preponderance in PAH 8.1% (n=105) vs. CTEPH 6.0% (n=38) (p=0.099). 47 patients (33%) required hospitalization. Mortality rate was 24% (34/143) vs. 2.6% for general population – including 19/34 outside of hospital. Those who died due to COVID-19 were older (mean age 56±17.6 vs. 70.5±12.8 yrs; p<0.0001) and had more cardiovascular comorbidities (1.35 vs. 1.97; p=0.01). Systemic arterial hypertension was the strongest unique risk factor for mortality, present in 71% decedents vs. 45% of survivors, and the only independent risk factor in multivariate logistic regression analysis (OR 2.94, 95% CI 1.28–6.73). Moreover, there was a trend towards a higher incidence of diabetes and coronary artery disease in the group of non-survivors (Table 1). The number of new diagnoses of PH decreased during the pandemic compared to 2019 (new diagnoses rate in 2019 was 28.2/month vs. 19.2/month during COVID). A significant increase in total mortality was also observed in the PH group (11.1/month in 2019 vs. 13.7/month during COVID). Escalation of specific PH therapy also reduced (rate of specific therapy escalation in 2019 was 30.4/month vs. 20.5/month during COVID).

Conclusions

The COVID-19 pandemic has deeply affected the care of patients with pulmonary hypertension by reducing the number of new diagnoses, escalation of therapy, and increasing overall mortality in this population, and this impact continues into second year of pandemics. Pulmonary hypertension is associated with a more severe course and higher mortality in COVID-19.

Funding Acknowledgement

Type of funding sources: None.

The use of handheld ultrasound device in cardiac examination of patients with history of COVID-19

Background

Clinical usefulness of Handheld Ultrasound Device [HUD] was previously confirmed in numerous clinical scenarios. During the previous two years Covid-19 patients become a focal point of healthcare worldwide. The assessment of long term consequences of this infection is bound to overload already burdened healthcare system.

Purpose

To assess clinical usefulness of HUD as an adjunct to physical cardiac examination of patients with history of COVID-19.

Methods

Study population consisted of randomly selected patients with no symptoms of cardiovascular pathology, who had been hospitalized due to COVID-19 one year prior to examination. Physical examination and clinical assessment was augmented with short examination with the use of HUD, which included: visual evaluation of the global and regional LV function, measurement of RV size, screening for the significant valve defects and the presence of pericardial effusion. Subsequently full echocardiographic examination with the use of high-end workstation was performed, which results were treated as reference.

Results

54 patients (35 men, mean age 63±13 years) were enrolled into the study. In clinical examination no significant cardiovascular abnormalities were discovered. In 30 [56%] of patients cardiac abnormalities in HUD examination were detected. In 18 patients [33%] LV function assessment was not performed, due to insufficient quality of registered view. In the remaining group significant impairment of LV ejection fraction (<50%) was detected in HUD examination in 3 [6%] patients (2 confirmed in full examination, positive predictive value [PPV] 57%, negative predictive value [NPV] 97%, AUC 0,82±0,17, P 0,057). WMA were diagnosed in 6 [11%] patients (4 confirmed in full examination, PPV 84% NPV 78%, AUC 0,69±0,17, P 0,02). RV enlargement was identified in 21 [39%] patients (PPV 57%, NPV 97%, AUC 0,85±0,05, P<0,0001), mild pericardial effusion in 3 [6%] patient (1 confirmed in full echocardiographic examination; 2 false positive, no false negative), at least moderate mitral/tricuspid/aortic valve insufficiency in 7 [13%] patients (3 confirmed, 4 false positive cases, no false negative). A total mean time of the heart and lungs HUD examination was 2,1±0,6 minute.

Conclusion

Cardiac abnormalities exposed in brief assessment with the use HUD are a relatively common finding in asymptomatic patients previously hospitalized due to COVID infection in a 1-year follow-up, despite normal physical examination. Normal HUD examination excludes the presence of significant cardiac abnormalities with high probability. However one should keep in mind a relatively high percentage of false positive results, which may lead to an exceeding number of patients referred for a full echocardiographic examination.

Funding Acknowledgement

Type of funding sources: None.

Predictors and clinical consequences of heart damage in CMR in patients after COVID-19

Methods

Out-hospital clinic patients (pts) recovered from COVID-19 were prospectively recruited and underwent cardiac magnetic resonance (CMR) examination with a protocol including: edema, hyperemia, and necrosis or scar-derived from signal intensity assessment in T2-weighted, early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) CMR images.

Results

A total of 702 patients (mean age 50±12 years, 62% female) were included. The median (IQR) time interval between COVID-19 diagnosis and CMR was 13 (8–22) weeks. In none pts signs of edema, hyperemia and necrosis derived from signal intensity assessment in T2-weighted and early gadolinium enhancement was found. LGE was found in 152 (22%). LGE+ patients had significantly lower left ventricular (LV) ejection fraction (58.5±7.7 vs 61.1±7.9%, p&lt;0.001) and greater LV end-diastolic (117.0±52.2 vs 103,0±36.3 ml, p=0.023) and end-systolic (50.3±28.0 vs 41.0±17.5 ml, p=0.010) volumes when compared with LGE− patients. In the resting electrocardiogram (ECG) fragmented QRS was observed significantly more frequently (46% vs 25%, p&lt;0.001) in LGE+ group, whereas in 24h Holter ECG neither single premature, nor complex ventricular extrasystole burden did not differ between groups (p&gt;0.05). There were observed no differences between symptoms of COVD-19 and comorbidities between LGE+ and LGE− pts. In the multivariable logistic regression analysis: fragmented QRS [OR and 95% CI: 2.85 (1.93–4.21)] and any ST-T segment deviation in resting ECG [OR: 1.93 (1.15–3.25)] were identified as independent predictors of LGE, even after adjustment for comorbidities and COVID-19 symptoms.

Conclusions

1. In patients with fibrosis after COVID-19 reduced left ventricular ejection fraction and greater volume of the heart was found.

2. Fragmented QRS and ST-T abnormalities were independent predictors for LGE in patients after COVID-19.

Funding Acknowledgement

Type of funding sources: None.

The prognostic value of speckle tracking echocardiography in patients hospitalized with COVID-19

Introduction

In COVID-19 patients, both preexisting cardiovascular disease as well as cardiac injury resulting from SARS-CoV-2 infection are associated with increased mortality. We hypothesized that novel parameters of myocardial function may be useful in the assessment of in-hospital and long-term prognosis.

Aim

The aim of study was to determine the prevalence of myocardial dysfunction revealed by speckle tracking echocardiography and its association with in-hospital and one-year mortality.

Methods

The study group comprised 192 patients hospitalized in the cardiology department due to COVID-19. All patients underwent transthoracic echocardiographic examination with off-line analysis. Using speckle tracking technique, we measured the following parameters: left ventricular global longitudinal strain (GLS), right ventricular global longitudinal strain (RV-GLS), right ventricular free wall strain (RV-FWS) and myocardial work parameters – global work index (GWI), global wasted work (GWW), global constructive work (GCW) and global work efficiency (GWE). The primary outcome was in-hospital and one-year mortality.

Results

112 patients (mean age 68±14 years, 76 (68%) male) had adequate image quality to evaluate strain-derived parameters. 27 patients died during hospitalization and 44 patients died within one-year after discharge. In-hospital non-survivors were older, had lower baseline oxygen saturation (SpO2) and had higher NTproBNP (Table 1). In non-survivors speckle-tracking echocardiography revealed significant impairment of left and right ventricular function compared to the group of survivors (Table 1). The independent predictors of in-hospital death were GWE (OR 0.85; 95% CI 0.78–0.93) and SpO2 on admission (OR 0.91; 95% CI 0.86–0.96). Based on the ROC curve analysis, the optimal cut-off points for predicting in-hospital death were identified: GWE ≤87% (sensitivity 63%, specificity 89%) and baseline SpO2 value ≤88% (sensitivity 81%, specificity 71%).

The independent predictors of one-year mortality were: age (OR 1.28 [1.13–1.46]), NTproBNP (OR 1.002 [1.001–1.003]), baseline SpO2 (OR 0.71 [0.59–0.86]) and RV-GLS (OR 1.32 [1.12–1.55]). Based on the ROC curve analysis, the cut-off points optimal for predicting death within 12 months after COVID-19 were also identified: baseline SpO2 value ≤88% (sensitivity 69.8%, specificity 77.3%), age >60 years (sensitivity 90%, specificity 43%), NTproBNP >500 pg/ml (sensitivity 95%, specificity 41.8%), RV-GLS >−18.5 (sensitivity 93%, specificity 64.2%).

Conclusions

Two-dimensional speckle tracking echocardiography is a useful technique to evaluate myocardial function in COVID-19 patients and provides good prognostic value for identifying patients at risk of death during hospitalization and in long term follow-up.

Funding Acknowledgement

Type of funding sources: None.

Long-term clinical outcome in patients with isolated chronic total occlusion treated percutaneously or pharmacologically

Purpose

Chronic Total Coronary Occlusion (CTO) is defined as the total obstruction of coronary blood flow for at least 3 months duration. The aim of this study was to compare the long-term clinical outcome in patients with stable angina (CCS I-III) and isolated CTO treated with successful percutaneous coronary intervention (PCI) or conservative management (a priori pharmacologically or after failed PCI) and to detect potential risk factors of unsuccessful PCI.

Methods

The inclusion criteria were: isolated CTO of one CA, previously confirmed viability of myocardium in the area of occluded CA, stable coronary disease, absence of significant valve disease resulting in predicted survival below 1 year. Choice of management was based on individualized risk/benefit analysis encompassing ischemia assessment and angiographic considerations. Clinical follow-up of 24 months duration was conducted with regard to occurrence of major adverse cardiac events (MACE) including death, acute myocardial infarction (MI), need for repeat revascularization (surgical or PCI), major bleeding and hospitalization for angina.

Results

The study group consisted of 119 pts with isolated CTO (88 males, mean age 60.7±9.6 years)– 75 (63%) in the right CA, 28 (23,5%) in the left anterior descending CA, 16 (13,5%) in the circumflex CA. The history of MI was revealed in 37 pts in medically treated group, 10 pts in PCI group and 7 pts after failed PCI. Successful PCI was performed in 39 (33%) pts while 80 (67%) pts were treated pharmacologically (16 after failed PCI). Over a mean 24-months follow-up there were 58 MACE in all groups, including: 2 cardiac deaths (1 in medically treated group and 1 in PCI group), hospitalization due to angina in 17 pts (10 in medically treated group, 6 in PCI group, 1 after failed PCI), 4 repeated revascularizations (1 in PCI group, 3 after failed PCI), 33 pts developed unstable angina (25 medically treated, 6 in PCI group, 2 after failed PCI), major bleeding occurred in 2 pts in medically treated group. The risk of MACE was lower in pts after successful PCI comparing both with patients treated medically as well as those with failed PCI (p=0.05 for both). Univariate analysis showed that left ventricular endsystolic (p=0.001) and enddiastolic diameter (p=0.01), left ventricular ejection fraction (p=0.03), higher NYHA class (p=0.002) and duration of angina (p=0.05) were significant predictors of MACE. Multivariate analysis identified two independent predictors of MACE: absence of effective PCI (as an intention-to-treat and per protocol) (OR 3.6, 95% CI 1.6–8.3) and larger left ventricular systolic diameter (OR=1.16, 95% CI 1.04–1.29). The independent negative predictors of procedural success were severity of calcification (p=0.001) and length of occlusion (p=0.02).

Conclusions

Successful PCI of CTO leads to a significant reduction in MACE in 24 months follow-up. Failed PCI is predicted by the occlusion length and extent of calcification.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Echocardiographic assessment of pulse wave velocity in psoriatic patients with and without psoriatic arthritis

Funding Acknowledgements

Type of funding sources: None.

Background

Psoriasis (PSO) is an inflammatory disorder which in its more severe form affects cardiovascular system (CVS) leading to more rapid atherosclerosis progression. Moreover, some data suggested that the presence of psoriatic arthritis (PSA) may further increase CVS deterioration.

Purpose

Our aim was to compare the pulse wave velocity (PWV) between psoriatic patients without and with psoriatic arthritis (PSA 0 and 1 group, respectively).

Methods

We examined 31 consecutive patients (20 males and 11 females) with moderate to severe PSO taking systemic anti-inflammatory medications (TNF-alpha inhibitor, IL-17 inhibitor, IL-23 inhibitor or IL12/23 inhibitor) with transthoracic echocardiography with the evaluation of PWV

The group was divided into two

17 patients without PSA (PSA 0) and 14 with concomitant PSA (PSA 1). To achieve PWV value the time from R wave in ECG to the onset of arterial flow was measured respectively in carotid (T1) and femoral artery (T2) with further calculation of time difference (delta T). The distance between supraclavicular area and groin was measured during physical examination of patient. PVW was expressed as the ratio between assessed distance (in meters) and time difference (in seconds).

Results

Patients with psoriatic arthritis (PSA 1) had more frequently hypertension and higher BMI but did not differ significantly from the group without joints involvement regarding other demographics, risk factors and basic echocardiographic data. They also showed similar PSO severity as assessed with PASI score, see Table. The PWV assessment was feasible in all patients and the respective mean values achieved 9.2 ± 3.7 m/s in PSA 0 vs 10 ± 2.8 m/s in PSA 1 group, p = ns.

Both T1 and T2 correlated significantly with duration of PSO, see Figure, and even better with patient’s age r = -0.61, p = 0.0003 for T1 and r = -0.77, p &lt; 0.0001 for T2, whereas PWV correlated significantly only with patient’s age.

In the model of 12 variables only older age was the independent predictor of PWV &gt;10 m/s in multivariate logistic analysis, OR 1.08 95% CI 1.003- 1.165.

Conclusions

Patients with PSA showed tendency to the higher prevalence of obesity and hypertension when compared with patients with skin PSO only. Measurement of PWV during echocardiography or even more simple times to flow spectrum onset in carotid or femoral arteries provided quantitative parameters reflecting cardiovascular impairment in PSO and PSA. Abstract Table. Group comparison.  Abstract Figure. PSO duration, T1, T2 and PVW.

Predicting maintenance of sinus rhythm after cardioversion - novel versus conventional left atrial parameters

Funding Acknowledgements

Type of funding sources: None.

Background

 The successful electrical cardioversion (EC) in patients with atrial fibrillation (AF) improves cardiac mechanical function and enables early assessment of atrial activity by echocardiography.

Purpose

 To analyze conventional and novel parameters characterizing left atrium (LA) within 24 hours after the restoration of sinus rhythm (SR) and their prognostic value during 2-years follow-up.

Methods

 Prospective study involved 71 patients with nonvalvular AF (mean age 64 ± 13 years, 61% male). All patients underwent echo 24 hours after conversion to SR. In addition, standard echocardiographic and Doppler parameters were assessed. Using speckle-tracking method we analysed LA longitudinal strain in reservoir and contractile phase. The clinical endpoint was predefined as AF recurrence.

Results

 During a 24-months follow-up we noticed AF recurrence in 48 (68%) patients. The median time-to-event was 2.4 months (IQR 1 to 6.9). Standard echo measurements revealed a median of LV ejection fraction 55% (IQR 45-58) and median of LA volume indexed to body surface area 42 ml/m2 (IQR 34-51). Median mitral A wave was 0.46 m/s (IQR 0.39-0.5) vs 0.35 m/s (IQR 0.28-0.5) in patients without and with AF recurrence, respectively (p = 0.04). Patients without AF recurrence had also higher mitral annular A’ velocity obtained by tissue Doppler imaging (7.4 ± 2.8 cm/s vs 3.5 cm/s, IQR 2.8-4.8; p &lt; 0.0001), LA reservoir strain (19.4 ± 7.3% vs 11%, IQR 9.6-15.3; p = 0.0003) and LA contractile strain (9.4 ± 4.1% vs 2.8%, IQR 1.2-4.4; p &lt; 0.0001). The table presents results derived from univariate Cox regression analysis.

Conclusion

 LA activity assessed early after the restoration of sinus rhythm is the predictor of AF recurrence. The strongest association was proven for LA contractile strain. Abstract Figure. Univariate Cox regression analysis

Percutaneous closure of atrial appendage with thrombus - a strategy shift? Report of a case series

Funding Acknowledgements

Type of funding sources: None.

Background. Percutaneous closure of left atrial appendage (LAAO)  is a recent preventive modality in atrial fibrillation. (AF) However, presence of thrombus which is a strong stroke risk multiplier represented a standard contraindication to purely percutaneous approach. 

Aim. To test the safety and feasibility of LAAO in patients (pts) with appendage blood stasis and distal thrombus.

Methods. Using a novel generation transvascular device allowing "shallow dive" implantation we tested the feasibility of LAAO in pts with appendage blood stasis and distal thrombus. Additionally, hybrid transvascular approach with arch protection device was also tested. Indications included development of heart failure in AF or recurrent cerebral events in pts with LAA thrombi.

Results. We successfully performed 3 procedures in pts (2F, 1M, age 73-76) with distal LAA thrombus confirmed in 3D TEE / CT. After 3D echocardiographic sizing omitting appendage angiogram, occluder was implanted from right femoral venous access via septal puncture. In 2 patients right radial access was additionally used to introduce commercially available arch protection device. In all cases the occluder did not engage distal appendage zone and was appropriately deployed. However in patients with arch protection 1-2 mm debris was captured by protection device. No neurological sequelae were noted.

Conclusion. Our initial experience documents safety and feasibility of percutaneous LAAO in presence of appendage blood stasis and distal thrombus based on 3DE sizing and novel genertaion device with optional percutaneous aortic arch protection. The long term efficacy of such unorthodox has yet to be determined in the setting of severely prothrombotic milieu, abnormal left ventricular function but with potential for risk reduction or even reopening options of cardioversion. Abstract Figure. Occlusion of LAA appendage with thrombus

Early increase of high-sensitivity cardiac troponin predicts mortality in cancer patients undergoing chemotherapy

Introduction

High-sensitivity cardiac troponin test (hs-TnT) reveals subclinical myocardial damage in many cardiac conditions. We hypothesized that elevated hs-TnT may predict a development of cancer therapy-related cardiac dysfunction and clinical outcomes linked with antineoplastic therapies. We aimed to evaluate the predictive value of hs-TnT for all-cause mortality in a group of patients (pts) with recent diagnosis of cancer.

Material and methods

We included 80 pts (mean age 57±13 years; 98% women) with recently diagnosed cancer (78 breast cancer, 1 colon cancer, 1 DLBCL lymphoma). Transthoracic echocardiography and hs-TnT tests were performed at baseline and after 3, 6 and 12-months. Pts with LVEF &lt;50% and significant valvular disease were excluded.

Results

In the study group 44% pts had arterial hypertension, 54% dyslipidemia, 9% diabetes mellitus; 94% pts were treated with anthracyclines, 30% with trastuzumab, 54% with hormone therapy, 71% with radiotherapy. A significant decrease of LVEF were observed during follow-up (LVEF at baseline, 3, 6 and 12 months: 61.7±2.0%; 60.9±2.0%*; 60.8±2.9%*; 59.9±2.9%*; *p&lt;0.05 vs baseline). A significant reduction of global longitudinal strain was found only at 6-month follow-up (−19,2±2,2% vs −18,6±2,0%; p=0,003). In 38 pts at least a twofold (fourfold in37) increase in hs-TnT &gt;99th percentile was observed. A rise of hs-TnT was most often seen at 3 month (n=35; 43,8%). During median 1056 (221–1906) days off follow-up 18 (24%) pts died and ROC curve analysis revealed that early (0–3 months) hs-TnT increase more than 10 pg/ml [AUC=0,693 (0,545–0,806); p=0,017)] represented a predictor of death [OR=3,4 (1,99–11,87)].

Conclusions

Increase in hs-TnT in cancer patients detected at 3rd month of chemotherapy predicts mortality.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Atrial fibrillation as a risk factor of severe course of COVID-19

Background

Coronavirus disease (COVID-19), the pandemic caused by severe acute respiratory syndrome coronavirus, influences on morbidity and mortality and results in changes of human life. It seems that comorbidities play a vital role in severe course of COVID- 19. Nevertheless, how chronic diseases affect respiratory failure is poorly validated.

Purpose

Our aim was to compare the severity of the course of COVID-19 and the prognosis in patient with and without atrial fibrillation (AF).

Methods

We analyzed 199 patients (72 female, mean age 67±13 years) with COVID-19 hospitalized in our Department since November 2020, including, 68 patients with AF (28 female, mean age 74.5±8 years). Although, only 45 patients took anticoagulants before, the treatment was initiated to all patients with AF on admission to the hospital. Patients with AF were characterized by lower left ventricle ejection fraction than those without AF (49% vs. 54%, p=0.0007).

Results

The severe course of COVID, defined as saturation below 90%, lung involvement above 50% in computer tomography, the need for high- flow oxygen therapy, was noticed in 98 patients (36 pts with AF, 32 pts without AF, p=0.27). Moreover, there was no difference between the groups among separately the need for high- flow oxygen therapy, saturation below 90% and lung involvement above 50% in computer tomography. The absence of atrial fibrillation, with a significance of p=0.01, predisposes to a better prognosis based on the patient's discharge. In multivariate analysis, the factors suggesting a poor prognosis, defined as death or transfer to Intensive Care Unit, were severe course of COVID (p=0.01) and the need for high- flow oxygen therapy (p=0.042).

Conclusions

It is noticed that the presence of AF is associated with a poor prognosis in COVID. Further analysis is still needed to prove this statement.

Funding Acknowledgement

Type of funding sources: None.

Atherosclerosis risk factors may be underestimated in patients with pulmonary hypertension associated with congenital heart disease – results of Polish snapshot registry

Introduction

Classic risk factors of atherosclerosis may contribute to cardiovascular (CV) risk in patients (pts) with pulmonary hypertension associated with congenital heart disease (PAH-CHD), but their prevalence is poorly studied.

Purpose

We evaluated a large cohort of Polish PAH-CHD patients (PAHpts) treated with specific therapies with regard to prevalence of classic risk factors for atherosclerosis.

Methods

A multicenter observational snapshot registry was conducted under the auspices of Polish Cardiac Society to study PAH pts, identified in centers treating &gt;5 such pts in years 2008–2018. The analysis included 250 PAH-CHD pts, including non-corrected CHD – predominantly Eisenmenger Syndrome (Gr. 1, 224 pts, mean age 42±2 years, 63% females) and pts after heart disease correction (Gr. 2, 26 pts, mean age 42±6.5 years, 62% females). The incidence of classic CV risk factors was compared in both groups.

Results

The prevalence of risk factors was considerable considering young age of the cohort and statistically similar in both groups (Figure). Hypertension was present in 14% in Gr. 1 and 15% in Gr. 2. The incidence of diabetes was comparable in both groups (3% vs. 4%). Hyperlipidemia was nearly numerically twice as frequent in Gr. 1 (23% vs. 12%, p=0.18). Current smokers (1%) were only present in Gr. 1, while history of smoking was 4% in both groups. Symptomatic atherosclerosis of peripheral arteries was twice as frequent in Gr. 1 (8% vs. 4%, p=0,71). There was no difference regarding prior stroke (3,6% vs 4%, p=0,63). Chronic kidney disease and atrial fibrillation were one and a half more often in Gr. 1 (respectively, 12% vs. 8%, p=0,81; 12% vs. 8%, p=0.75). Mean heart rate was 72±2 bpm in Gr. 1 and 77±7 bpm in Gr. 2. Gastrointestinal bleeding was reported only in Gr. 1 (2.7%). SCORE calculated risks were low due to low age, but high risk was identified in 9.3% of Gr. 1 and 20% of Gr. 2 (p=0.096).

Conclusions

Based on our data from national survey, classic atherosclerosis CV risk factors are not uncommon in the population of relatively young patients with PAH-CHD, parallel to improved longevity. Selected pts from both groups present with elevated risk of death from atherosclerotic complications. This finding may influence the overall mortality risk in PAH-CHD population and reflects new challenges in management despite progress in specific therapies of pulmonary hypertension.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Diagnostic value of coronary flow reserve assessment by dynamic 99mTc-MIBI SPECT-CZT gamma camera for the detection of coronary artery disease

Background

Coronary flow reserve (CFR) obtained by dynamic acquisition of myocardial blood flow using 99mTc-MIBI SPECT-CZT gamma camera may be useful to diagnose myocardial perfusion defects in patients with coronary artery disease (CAD).

Purpose

To assess the feasibility and diagnostic value of SPECT-derived CFR in patients with suspected of confirmed CAD.

Methods

The study group comprised 55 patients (pts) (43.6% females, mean age 64.6±8.4 years) with suspected CAD who were referred for scheduled coronary angiography. All pts underwent myocardial perfusion study with solid-state CZT nuclear camera (dipyridamole stress protocol) to calculate myocardial blood flow reserve. We measured total CFR, as well as CFR in three coronary territories: left anterior descending artery (LAD CFR), right coronary artery (RCA CFR) and left circumflex artery (LCx CFR).

Results

On coronary angiography 27 pts were found to have significant CAD (at least one major coronary artery ≥70% narrowed). Mean total CFR in pts with CAD was lower than in pts without CAD (1.73±0.59 vs 2.09±0.56, respectively, p=0.02). Similar differences were noted in LAD territory (1.47±0.57 vs 2.00±0.57; respectively, p=0.004) and RCA territory (1.55±0.54 vs 2.01±0.62; respectively, p=0.03). However, the differences in LCx CFR between CAD and no-CAD group did not reach statistical significance. Modest, but significant correlations were detected between LAD CFR and the percentage of LAD stenosis (r=−0.3; p=0.02). Total CFR has acceptable diagnostic value for detecting significant CAD (AUC=0.672; p=0.03). The criterion with the highest diagnostic accuracy was CFR &lt;1.8 – its sensitivity was 63%, specificity 71.4%, and overall accuracy 67%. In analysis of coronary territories the highest diagnostic value was achieved for CFR LAD (AUC=0.744; p=0.007).

Conclusions

SPECT-derived CFR provides acceptable diagnostic accuracy for the detection of significant CAD.

Funding Acknowledgement

Type of funding sources: None.

March, September and December months with the greatest influence of atmospheric pressure on blood pressure in patients with hypertension

Objectives

For a long time, science has searched for the relationship between weather and human health. Atmospheric pressure is the most objective weather factor because, regardless of whether the objects are outdoors or indoors, it affects all objects in the same way. In cardiology, we often look for factors that worsen blood pressure control. Could atmospheric pressure be one of them?

The main objective of our research was to assess the relationship between atmospheric pressure and blood pressure in patients with treated hypertension in different months in the moderate climate of Central Poland.

Material and methods

The study group consisted of 4191 patients with arterial hypertension, divided into 2 near equal groups due to a lower or higher average value of atmospheric pressure when blood pressure was recorded. Blood pressure was monitored by a means of 24-h ABPM. Atmospheric pressure was recorded with the frequency of 1 measurement per minute using a meteorological station. The observations were conducted in the years 2009–2019. Comparisons between blood pressure values in the 2 groups were performed using the Mann-Whitney U test.

Results

We observed a significant difference in blood pressure recorded during the periods of lower and higher atmospheric pressure: for systolic blood pressure during the days of September (125.01±14.99 vs 120.14±12.83, p&lt;0.001) and December (124.22±15.45 vs 127.50±14.35, p&lt;0.05), for diastolic pressure during the days of March (72.24±10.92 vs 69.81±9.13, p&lt;0.02) and for diastolic pressure during the nights of March (61.53±8.96 vs 59.58±9.17, p&lt;0.04).

Conclusions

A significant inverse relationship between atmospheric pressure and blood pressure was observed; during March days and nights for diastolic blood pressure and during September and December days for systolic blood pressure.

This finding may be important for the understanding of why during some months the pharmacological control of blood pressure is poor, and of the consequences of this fact.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): own resources

The reinvented old player – an antazoline is effective in pharmacological cardioversion of atrial fibrillation

Introduction

Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of atrial fibrillation (AF) to sinus rhythm (SR) and is widely used in Poland for this purpose in the last years. However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug.

Aim

To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF.

Methods

Our single center, retrospective, observational study included patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation.

Results

A total of 176 pts (mean age 68.4±12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7–432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9±65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &lt;48h vs others: 75.3% vs 12.0%, p&lt;0.001). In multivariable logistic regression model AF duration (for every 24h in AF – OR=0.97; 95% CI 0.96–0.98), the left atrium antero-posterior diameter (OR=0.92; 95% CI 0.86–0.99) and the serum creatinine level (OR=0.15; 95% CI 0.03–0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT's effectiveness was 48h (AUC=0.876; 95% CI 0.815–0.922) – Figure 1. There were only one episode of bradycardia &lt;45 bpm related to ANT administration.

Conclusions

Antazoline is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&lt;48 hours) and in patients without the left atrium enlargement and significant renal disease.

Funding Acknowledgement

Type of funding sources: None. Figure 1. ROC curve analysis

Clinical profile and in hospital mortality of invasively managed patients with suspicion of acute coronary syndrome during the COVID-19 pandemic

Background

The pandemic of COVID-19 significantly changed the treatment of patients with suspicion of ACS and COVID-19 infection. Access to cardiology department and possibility of invasive diagnosis and treatment of ACS are still significantly impaired.

Aim

Our aim was to evaluate the characteristic and prognosis of patients with suspicion of ACS and COVID-19 infection.

Materials and methods

Our department of cardiology was transformed for Covid unit and was dedicated for diagnosis and treatment of patients with suspicion of ACS. COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test. From 14th of October 2020 to 14th of March we performed 39 coronary angiographies. We included 39 patients (27 men) with mean age 69±8.5. In that group 11 patients had NSTEMI, 10 patients had STEMI, 2 patients Tako-Tsubo and 16 unstable angina. All patients underwent coronary angiography, and in 27 patients we performed PCI.

Results

In hospital mortality rate was 35% (14 patients). Cardiac arrest was present in 3 (8%) patients and cardiogenic shock in 4 (10%) patients. The rate of NSTEMI was higher in patients who died 7 vs 4 (p=NS) and STEMI were comparable in both groups 4 vs 6, (p=ns). The IL 6 levels in patients who died were 389±278pg/mL, in compare to 101±93pg/mL (p=0.3) who survived. Independent predictors of death were: sex with the OR=1,1 (95% CI: 0.6–2.4), p=0,03 and IL-6 level on admission OR=1,4 (95% CI: 0.6–2.4), p=0,04. There were no statistically significant differences regarding age, left ventricle ejection fraction, CRP levels and oxygen saturation od admission.

Conclusion

This study confirms the higher risk of death in patients with ACS and SARS-CoV-2. In the multivariable analysis only sex and Il-6 level on admission were the independent risk factors of the in hospital death. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are needed.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking-derived left atrial stiffness predicts adverse events after successful electrical cardioversion

Background

Atrial fibrillation (AF) impairs cardiac mechanics and leads to adverse remodelling. Increased left atrial (LA) stiffness reflecting LA reservoir function and left ventricular (LV) filling pressure is one of the symptoms of LA remodelling.

Purpose

To analyse LA stiffness within 24 hours after successful electrical cardioversion and its prognostic value during 2-years follow-up.

Methods

Prospective study involved 71 patients with nonvalvular AF (mean age 64±13 years, 61% male). All patients underwent echo during 24 hours after conversion to sinus rhythm. We analysed standard echocardiographic and Doppler parameters. Using speckle-tracking method we assessed peak LA longitudinal strain in 4- and 2-chamber view. LA stiffness was calculated as the quotient of peak LA longitudinal strain (LA reservoir function) and mean E/E' ratio. The clinical endpoints were predefined as AF recurrence and cardiovascular hospitalization.

Results

Median time of current AF episode was 2 (IQR 0.4–5) months. Standard echo measurements revealed median of LV ejection fraction 55% (IQR 45–58) and median of LA volume indexed to body surface area 42 ml/m2 (IQR 34–51). During follow-up we noticed AF recurrence in 48 (68%) patients and cardiovascular hospitalization in 43 (61%) patients. Median time-to-event was 2.4 (IQR 1 to 6.9) and 7 (IQR 2.1–11) months, respectively. Receiver operating characteristic curve analysis revealed that LA stiffness &gt;0.53 (AUC=0.821; p&lt;0.0001) and &gt;0.95 (AUC=0.788; p&lt;0.0001) were the optimal cut-off values for predicting AF recurrence and cardiovascular hospitalization. Figure presents Kaplan-Meier survival analysis for AF recurrence (A) and for hospitalization (B). Moreover LA stiffness remain statistically significant in multivariate Cox regression analysis even after adjustment for betablockers, antiarrhythmic drugs, coronary artery disease, heart failure and mitral regurgitation. Relative risk was 1.51 (95% CI 1.09–2.09), p=0.01 for AF recurrence and 1.49 (95% CI 1.05–2.13) for cardiovascular hospitalization.

Conclusions

Speckle tracking-derived LA stiffness assessed early after the restoration of sinus rhythm independently predicts AF recurrence and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Pocket-size ultrasound devices may improve the prompt assessment of Covid-19 patients

Introduction

Clinical usefulness of pocket-size ultrasound device [PSUD] was previously confirmed in numerous clinical scenarios. During the previous year Covid-19 patients have become a focal point of the cardiology and internal medicine wards. However, there is no data on the use of PSUD in this scenario.

Purpose

To asses if PSUD may be useful in providing additional information in Covid-19 patients.

Methods

In 63 patients (41 men, mean age 63±11) with confirmed Covid-19 the scope of physical examination was expanded with bedside assessment performed with PSUD equipped with dual probe. PSUD examination included: right ventricle measurement, automated LVEF assessment, 4-point compression ultrasound test of lower limbs and lung ultrasound (presence of B-lines, lung consolidations or thickening of pleura). Subsequently, within the next 24 hours all patients underwent chest CT scan, CT pulmonary angiogram and full echocardiographic examination performed on a high-end stationary device.

Results

Lung lesions typical for Covid-19 were confirmed in CT in 53 (84%) patients. The sensitivity and specificity of bedside PSUD examination for diagnosing lung involvement was 92% and 90%, respectively, when presence of any pathology on lung ultrasound was considered as a positive criterion. Increased number of B-lines had a sensitivity of 81%, specificity 83% for the ground glass symptom in CT detection, (AUC 0,82; p&lt;0,0001). Pleural thickening was diagnosed by PSUD with a 95% sensitivity and 88% specificity (AUC 0,91, p&lt;0,0001), whereas lung consolidations with a 71% sensitivity and 86% specificity (AUC 0,79, p&lt;0,0001). In 20 patients (32%) pulmonary embolism was confirmed by angioCT – in 10 among them embolism was limited to subsegmental arteries. RV was found to be dilated in PSUD examination in 27 patients (43%), CUS was positive in 1 patient. Thus, RV enlargement treated as a marker of PE had low sensitivity and specificity (60% i 65% respectively), AUC=0,62, p=0,06. Mean LVEF in standard echocardiography was 46±12%, but during PSUD examination automated LV function analysis software failed to calculate LVEF in 29 (46%) cases due to suboptimal image quality.

Conclusion

In Covid-19 patients PSUD is particularly useful for lung ultrasound and the detection of lung pathologies. RV enlargement observed during PSUD examination has relatively low sensitivity and specificity for the detection of pulmonary embolism in Covid-19. Furthermore, due to low quality of images automated LV function assessment failed to provide any result in almost half of patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemics upon pulmonary hypertension patients: insights from BNP-PL national database

Introduction

COVID-19 pandemic has caused not only an increase in overall and cardiovascular mortality, but also hindered access to health care, diagnosis and treatment of diseases other than coronavirus infection.

Aim

Assessment of the impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy of pulmonary hypertension (PH) in Poland, along with an analysis of the incidence and course of COVID-19 among patients (pts) diagnosed with PH, treated under the National Health Fund program, registered in the national BNP-PL database.

Methods

The records of the complete population of Polish pts treated under the National Drug Program of PH (PAH and CTEPH), registered in the national database of BNP-PL, updated on an ongoing basis by all PH centers, were analyzed. The frequency of SARS-CoV-2 infections, the clinical severity of their course and the mortality were reviewed, taking into account the specific therapies used. The basic clinical characteristics of the group of sick and deceased patients were compared to the remaining patients registered in the BNP-PL database. The rate of increase of new diagnoses ended with inclusion in the Drug Program between March and December 2020, compared to the corresponding periods of the previous year, and the change in the treatment profile were compared.

Results

The analysis included 1704 pts (PAH 1134, CTEPH 570). The incidence of SARS-CoV-2 infections was 3.8% (n=65), including PAH 2.7% (n=46) and CTEPH 3,2% (n=18). 32 patients (49%) required hospitalization. Mortality rate was 28% (18/65) – including 7/18 outside of hospital. Those who died due to COVID-19 were older (mean age 68.4±15.8 vs. 50.8±18.8 yrs; p&lt;0,001), had higher WHO class and more cardiovascular comorbidities (4±2,06 vs. 2,66±1,8; p=0,01) (Table 1). During the pandemic the number of new diagnoses of PH markedly decreased compared to the corresponding period in 2019 (total 150 vs. 203, PAH 90 vs. 123, CTEPH 60 vs. 80, respectively). A significant increase in total mortality was also observed in the PH group (9,72 vs. 5,85%). Moreover, escalation of specific PH therapy decreased significantly (14,7% vs. 21,6%). Incidence of COVID-19 study group was lower than estimated for general Polish adult population (3,8% vs. 6,5%).

Conclusions

COVID-19 pandemic deeply influenced the diagnostic and therapeutic process of pulmonary hypertension by reducing the number of new diagnoses, escalation therapy and increased overall mortality in this population. This may be due in part to the conversion of some PAH centers into hospitals treating patients infected with SARS-CoV-2, as well as to patients' fear of admitting to hospital despite clinical deterioration. Pulmonary hypertension is linked to markedly increased mortality in COVID-19, similarly for PAH and CTEPH. Intriguing finding of lower infection rate may be linked to protective lifestyle or specific therapies.

Funding Acknowledgement

Type of funding sources: None.

Pharmacological cardioversion of recent-onset atrial fibrillation in patients with chronic kidney disease: sub-analysis of the CANT study

Purpose

Pharmacological cardioversion (PCV) is commonly a primary option for termination of recent-onset atrial fibrillation (AF) at the emergency departments (ED), and there are reports proving that antazoline is a noteworthy agent to restore sinus rhythm. This is a sub-analysis of the CANT study evaluating the effectiveness and safety of antazoline in patients with AF at different stages of chronic kidney disease (CKD).

Methods

Total n=777 patients admitted to ED for the urgent termination of AF were included into this analysis. We analysed the results concerning effectiveness and safety of PCV with special consideration of antazoline, in patients at 3 stages of CKD defined on the basis of eGFR (CKD-EPI): Group I ≥60 mL/min (n=531), Group II 45–59 mL/min (n=149), and Group III &lt;45 mL/min (n=97). Primary end-point was the termination of AF, a restoration of a sinus rhythm and its persistence until discharge.

Results

Patients of group III were older and with higher prevalence of comorbidities, however, we have not found statistically significant differences in overall effectiveness of PCV in comparison with the other groups. In patients receiving amiodarone, the PCV success rate was similar in all the studied groups, but along with a renal function decline, it decreased in patients receiving antazoline (79.1 vs 35%; p&lt;0.001), and it increased close to a significant manner in patients receiving propafenone (69.9 vs 100%; p=0.067; Figure). In patients of Group I, antazoline restored a sinus rhythm as effectively as propafenone and amiodarone, however in patients of Group III, both antazoline and amiodarone became less effective in restoring a sinus rhythm than propafenone (p=0.002 and p=0.034, respectively). The rate of safety endpoint was highest in patients of Group III (eGFR&lt;45 mL/min), and it was significantly higher than in patients of Group I and II (p=0.008 and p=0.036, respectively). We have not observed antazoline-related adverse events in any of studied groups of patients.

Conclusion

This real-world registry analysis revealed a different influence of CKD on individual drug effectiveness, and while propafenone and amiodarone maintained their AF termination efficacy, antazoline became significantly less effective in restoring sinus rhythm. Its favourable safety profile has not changed.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The study received no external funding

Left ventricular longitudinal strain impairment at rest correlates with reduction of SPECT-derived coronary flow reserve in patients with suspected coronary artery disease

Background

Speckle tracking echocardiography (STE) may be useful for the detection of subclinical systolic function abnormalities. Dynamic acquisition of myocardial blood flow using 99mTc-MIBI SPECT-CZT gamma camera allows the calculation of coronary flow reserve (CFR).

Purpose

The aim of our study is to assess the relationship between left ventricular longitudinal strain (LS) and CFR in patients with suspected coronary artery disease (CAD).

Methods

55 patients (pts) (43.6% females, mean age 64.6±8.4 years) with suspected CAD underwent transthoracic echocardiography with assessment global and local LS by STE. We calculated mean global left ventricular LS (GLS), as well as LS of individual coronary artery territories (LAD LS, LCx LS and RCA LS). All pts underwent myocardial perfusion study with novel solid-state CZT nuclear camera (dipyridamole stress protocol). We measured CFR of the left ventricle and individual coronary territories.

Results

Mean absolute GLS in pts with total CFR &lt;2 was significantly lower than in pts with CFR &gt;2 (median value −13.9 vs −18.3; p&lt;0.001). Similar differences were observed in all three coronary territories (p≤0.01). Modest but significant correlations were detected between total CFR and GLS values (r=−0.56; p&lt;0.001), LAD CFR and LAD LS (r=−0.54; p&lt;0.001), RCA CFR and RCA LS (r=−0.36; p=0.007), LCx CFR and LCx LS (r=−0.53; p&lt;0.001). GLS at rest had good diagnostic value for detecting total CFR &lt;2 (AUC=0.767; p&lt;0.001). The criterion with the highest diagnostic accuracy was GLS &gt; (−15.8) – its sensitivity was 68%, specificity 77.7%, and overall accuracy 73%.

Conclusions

Indices of left ventricular longitudinal function obtained by speckle tracking echocardiography correlate with SPECT-derived CFR in patients with suspected CAD.

Funding Acknowledgement

Type of funding sources: None.

Cinderella drug: an antazoline is effective in pharmacological cardioversion of atrial fibrillation - Single center experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of persistent atrial fibrillation (AF) to sinus rhythm (SR). However, published data on its effectiveness, safety and  clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. 

Aim

To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. 

Methods

We conducted a single center, retrospective, observational study including patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. 

Results

A total of 176 pts (mean age 68.4 ± 12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7 – 432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9 ± 65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &lt;48h vs others:  75.3% vs 12.0%,  p &lt; 0.001). In multivariable logistic regression model AF duration (for every 24h in AF - OR = 0.97; 95% CI 0.96 – 0.98), the left atrium antero-posterior diameter (OR = 0.92; 95% CI 0.86 – 0.99) and the serum creatinine level (OR = 0.15; 95% CI 0.03 – 0.73) were identified as  independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT’s effectiveness was 48h (AUC = 0.876; 95% CI 0.815 – 0.922). There were only one episode of bradycardia &lt;45 bpm related to ANT administration. 

Conclusions

Intravenous antazoline administration is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Abstract Figure.

What can we find in the ECG recording in convalescent from COVID-19 with mild and moderate course

Funding Acknowledgements

Methods

Results

Does automated left ventricular ejection fraction assessment available on handheld ultrasound devices represent improvement in the diagnostic accuracy?

Funding Acknowledgements

Type of funding sources: None.

Purpose

To assess the accuracy of an algorithm for automated measurement of the left ventricular ejection fraction (LVEF) available on handheld ultrasound device (HUD).

Methods

112 patients admitted to the cardiology department, who were referred for the conventional echocardiographic examination, underwent additional assessment performed with HUD (Vscan Extend, GE Vingmed Ultrasound, Horten, Norway). In each case 4 – chamber apical view was obtained and LVEF was calculated by means of the LVivo software. Imaging quality was assessed in a 4-grade scale. Subsequently, during the examination performed with the use of the stationary echocardiograph the three-dimensional (3D) measurement of LVEF was recorded.

Results

Ultimately 96 (53 men, mean age 63 ± 11) patients were enrolled into the study group  In the remaining 16 cases (14%) 3D image quality was not sufficient to allow the calculation of the LVEF. LVivo software was unsuccessful in calculating LVEF in all these 16 patients and in additional 20 patients, who remained in the study group due to satisfactory 3D image quality.

The quality of images acquired with the use of HUD was assessed as optimal in 25 (26%) patients, good in 37 (39%), acceptable in 24 (25%), poor in 10 (10%).

The average LVEF value was 46%±14 with the 3D LVQ measurements and 48%±14 using the LVivo software. The correlation coefficient between  the LVEF values obtained with the two methods was  r = 0,92; (P &lt; 0,0001). Using paired samples t-test we found that the difference between these two techniques was not significant (mean difference 4,5± 3,4%; P = 0,35).

LVivo software EF assessment is based on a single apical view and for this reason we have assumed that the differences in EF can be larger in patients with regional wall motion abnormalities, in whom LVEF values derived from different apical views can significantly vary. For this reason the group of patients with history of myocardial infarction (40pts, 42%) was analysed separately and we found that the difference between LVivo and 3D LVEF was also not statistically significant (mean difference 6,1± 3,3%; P= 0,14). The correlation coefficient equalled  r = 0,78; (P &lt; 0,0001).

Conclusion

The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality. Such expanded capabilities of HUDs can potentially lead to the overall improvements of the diagnostic accuracy of the ultrasonographic examinations, particularly when in hands of the non-expert echocardiographers.

Early assessment of left atrial function after cardioversion predicts recurrence of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

The restoration of sinus rhythm (SR) improves the mechanical function of the heart.

Purpose

To assess left atrial (LA) function before and within 24 hours after successful electrical cardioversion (EC) and its prognostic value for atrial fibrillation (AF) recurrence during 24 months follow-up.

Methods

Prospective study involved 71 patients with non-valvular AF (mean age 64 ± 13 years, 61% male). All patients underwent echocardiography before and after EC. We analysed standard parameters in two-dimensional echo, pulse-wave Doppler and tissue Doppler echocardiography. Using speckle-tracking method we assessed peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS).

Results

During follow-up we noticed AF recurrence in 48 (68%) patients. Median time to AF recurrence was 2.4 (IQR 1 to 6.9) months. Left ventricular ejection fraction as well as E/E’ and PALS assessed during AF were statistically insignificant as potential predictors in univariate regression model. Receiver operating characteristic curve analysis revealed that left atrial volume index &gt;37 ml/m² (AUC = 0.811, p &lt; 0.0001), E/A ratio &gt;2.1 (AUC = 0.828, p &lt; 0.0001), A wave ≤0.4 m/s (AUC = 0.662, p = 0.01), mean E/E’ ratio during sinus rhythm &gt;8.5 (AUC = 0.815, p &lt; 0.0001), mean A’ wave of ≤5.5 cm/s (AUC = 0.848, p &lt; 0.0001), PALS-SR ≤14.1% (AUC = 0.767, p &lt; 0.0001), PACS ≤4.3% (AUC = 0.883, p &lt; 0.0001) were the optimal cut-off values for predicting AF recurrence.

Conclusions

The assessment of LA and diastolic function conducted within 24 hours after successful cardioversion predicts long-term maintenance of sinus rhythm.

Clinical value of stress transaortic flow rate during dobutamine echocardiography in low-gradient aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND/INTRODUCTION

The clinical value of rest transaortic flow rate (FR) has been shown previously in low-gradient aortic stenosis (LGAS) for the prediction of outcome. However limited data exists on the prognostic value of stress FR in LGAS following low-dose dobutamine stress echocardiography (LDDSE).

PURPOSE

We aimed to assess the value of stress FR in patients with LGAS in the diagnosis of AS severity and the prediction of mortality.

METHODS

This is a multi-centre cohort study of patients with low left ventricular ejection fraction (LVEF) and LGAS (aortic valve area –AVA &lt;1cm²) who underwent LDDSE.

RESULTS

Of the 287 patients (mean age:  75.1 ±10 years, males: 71%) over the mean follow-up of 24 ±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Lower stress FR was independently associated with increased risk of mortality (HR= 0.99, 95%CI= 0.99-0.999, p= 0.02) after adjusting for age, chronic kidney disease, presence of symptoms (NYHA II-IV), aortic valve intervention, rest LVEF and guideline-defined severe AS (AV mean gradient- AVMG ≥40mmHg with AVA &lt;1cm² at peak stress).  The minimum cut-off for prediction of mortality was stress FR 210ml/sec. Among the different criteria of AS severity during stress, i.e. guideline-defined criterion, or stress AVMG ≥40mmHg, or stress AVA &lt;1cm² at stress FR ≥210ml/s, only the latter was independently associated with mortality (HR= 1.81, 95%CI= 1.04-3.2, p= 0.04) (Table 1) and was the parameter of AS severity that predicted improved outcome following aortic valve intervention (p &lt;0.005) (Figure 1). Guideline-defined stroke volume flow reserve did not predict mortality.

CONCLUSIONS

Assessment of stress FR during LDDSE is important for the detection of both AS severity and flow reserve.

Table 1 Multivariable analysis for prediction of all-cause mortality (N = 287) for the different criteria of aortic stenosis HR 95%CI p Age 1 0.98-1.03 0.84 Chronic kidney disease 1..84 1.13-2.99 0.01 Aortic valve intervention 0.37 0.22-0.61 &lt;0.005 Presence of symptoms (NYHA II-IV) 1.87 0.66-5.31 0.24 Rest LVEF (by 1%) increase 0.97 0.95-1 0.06 Stress AVA &lt; 1cm&sup2; with stress AVMG≥40mmHg 1.02 0.31-3.34 0.97 Stress AVMG≥40mmHg 0.57 0.2-1.59 0.28 Stress AVA &lt; 1cm&sup2; at stress FR≥210mmHg 1.81 1.04-3.2 0.04 Abstract Figure 1

P944 From systolic pulmonary arterial pressure to pulmonary vascular resistance and reserve: a simplified method for exercise stress echocardiography

OnBehalf

On behalf of Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI).

Background

The potential of exercise stress echocardiography (ESE) seems to be still underused especialy in the assessment of pulmonary hemodynamics.

Aim

To assess the feasibility and compare pulmonary vascular resistance (PVResistance) and reserve (PVReserve) during ESE in patients at risk of pulmonary hypertension (PH) and controls.

Methods

We performed semi-supine ESE, in 97 subjects (age 49 ± 16 yrs, 63 females): 58 patients (Group 1) at risk for PH (systemic sclerosis and other connective tissue diseases) and 39 healthy controls (Group 2). Rest and stress assessment included: tricuspid regurgitant velocity (TRV), pulmonary acceleration time (ACT), cardiac output (CO), SPAP estimation with Bernouilli equation or from ACT with formula: log10 SPAP= - 0.004 (ACT) + 2.1. We estimated PVResistance from Abbas formula, and PVReserve as ΔCO/ ΔSPAP or (when CO was not available) as minutes of exercise/ΔSPAP. When ΔSPAP was &lt;10 mmHg, it was considered equal to 1.

Results

With TRV or ACT to estimate pressures, and cardiac output or its proxy to estimate flow, PVResistance or PVReserve could be measured in all patients. At peak exercise, PVResistance was higher and PVReserve lower in Group 1 : see Table.

Conclusion

Estimation of PVResistance and/or PVReserve can be obtained in all patients during ESE, integrating TRV with ACT, and using exercise-time as a proxy of CO when the latter is not available. These indices may be useful for a better, noninvasive characterization of the heterogeneity of pulmonary hemodynamics.

Pulmonary hemodynamics ESE data Parameter Group 1, PH (n = 58) Group 2, normals (n = 39) P value TRV rest (cm/s) 243 ± 63 204 ± 31 =0.0147 TRV peak (cm/s) 344 ± 68 204 ± 53 &lt;0.0001 ACT rest (ms) 113 ± 33 128 ± 20 =0.0205 ACT peak (ms) 86 ± 19 94 ± 22 ns SPAP rest (mm Hg) 26 ± 10 21 ± 4 =0.0039 SPAP peak (mm Hg) 45 ± 19 28 ± 13 &lt;0.0001 CO rest (mL/min) 4.9 ± 1.7 5.1 ± 1.7 ns CO peak (mL/min) 7.8 ± 2.8 7.6 ± 2.9 ns Exercise time (min) 7 ± 2 13 ± 3 &lt;0.0001 PVResistance (WU) rest 1.63 ± 0.52 1.54 ± 0.34 ns PVResistance (WU) peak 2.01 ± 0.89 1.27 ± 0.42 =0.0219 PVReserve (ΔCO/ΔSPAP) 1.38 ± 1.13 3.55 ± 2.45 =0.001 PVReserve (Extime/ΔSPAP) 4.69 ± 2.67 10.96 ± 4.39 &lt;0.0001 Legends: WU -Wood Unit, Ex time - exercise time

1682 Feasibility of the exercise stress echocardiography for the evaluation of the right heart and pulmonary circulation unit in different clinical conditions: the right heart international network

Funding Acknowledgements

no funding sources exists

OnBehalf

RIGHT Heart International NETwork (RIGHT-NET)

Purpose

Exercise stress echocardiography (ESE) is a well-validated tool in ischemic and valvular heart diseases. The aim of this study is to assess the ESE feasibility for the evaluation of the right heart pulmonary circulation unit (RH-PCU) in a large cohort of subjects, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension. Methods: 954 subjects [mean age 54.2 ± 16.4 years, 430 women] [254 healthy volunteers, 40 elite athletes, 363 patients with cardiovascular risk factors, 25 with pulmonary arterial hypertension, 149 with connective tissue diseases, 81 with left heart and valvular diseases, 42 with lung diseases], underwent standardized semi-recumbent cycle ergometer ESE with an incremental workload of 25 watts every 2 minutes up to symptom-limited maximal tolerated workload. ESE parameters of right heart structure, function and pressures were obtained according current recommendations. Results: The success rate for the evaluation of the RV function at peak exercise was 903/940 (96%) for tricuspid annular plane systolic excursion (TAPSE), 667/751 (89%) for tissue Doppler–derived tricuspid lateral annular systolic velocity (S’) and 425/772 (63%) for right ventricular fractional area change (RVFAC). Right ventricular–right atrial pressure gradient [RV-RA gradient = 4 x tricuspid regurgitation velocity2] was obtained in 894/954 patients (93.7 %) at rest and in 816/954 (85.5%) at peak exercise. At peak exercise, pulmonary acceleration time (AcT) was feasible among 435/545 (82.5%) patients (Table 1). Conclusions: In daily ESE monitoring of TAPSE and S’ resulted to be less challenging than of RV FAC. ESE was a feasible tool for the evaluation of RV-RA gradient and pulmonary AcT.

Table 1 Parameters Rest mean ± SD Peak mean ± SD P value Assessed n (%) Feasibility at rest n (%) Feasibility at peak n (%) RVED area (cm2) 17.4 ± 5.7 17.4 ± 5.8 0.9 672 632 (94.0) 425 (63.2) RVES area (cm2) 9.7 ± 4.3 9.6 ± 4.9 0.7 672 632 (94.0) 425 (63.2) TAPSE (mm) 22.9 ± 3.9 27.4 ± 5.5 &lt;0.001 940 922 (98.1) 903 (96.0) S’(cm/s) 13.1 ± 2.9 18.5 ± 5.0 &lt;0.001 751 746 (99.4) 667 (88.8) RVFAC (%) 45.7 ± 10 46.7 ± 11 0.121 672 632 (94.0) 425 (63.2) RV-RA gradient (mmHg) 24.3 ± 15 42.5 ± 20 &lt;0.001 954 894 (93.7) 816 (85.5) Pulmonary AcT (m/s) 129 ± 31 116 ± 35 &lt;0.001 545 527( 96.7) 435 (82.5) RVED, right ventricle end diastolic area; RVES, right ventricle end systolic area; p values indicate differences at rest and peak exercise. The term “assessed” indicates that an attempt was done in order to measure the parameter. The term “feasibility” indicates that it was possible to measure the parameter that was assessed.

P1413 Complexity of changes in right ventricular function in patients undergoing cardiac surgery

Background

An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique.

Methods

The study population comprised 105 patients (76 men, mean age 65 ± 16 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2 ± 2 days prior to surgery (TTE1) , and 7 ± 4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12 ± 2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function, such as TAPSE, systolic velocity of tricuspid annulus (S"), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS).

Results

Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S’ and GLS; p &lt; 0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function.

Conclusion

Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. After 12 months, an improvement of the longitudinal function can be observed.

P210 The influence of the right ventricle on the right atrium: a speckle tracking echocardiography study

Purpose

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

Methods

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

Results

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

Conclusions

Right atrial deformation parameters weakly correlate with right ventricular function indices and show no correlation with the size of the right ventricle.

P1398 Echocardiographic continuous monitoring of exercise stress test using probe fixation device

Background

Stress echocardiography (SE) plays an important role among methods of noninvasive diagnosis of ischemic disease. Despite the advantages of physical exercise as the most physiologic stressor, it is difficult (bicycle ergometer) or impossible (treadmill) to obtain and maintain the acoustic window during the exercise. Recently, an innovative probe fixation device was introduced and a research plan was developed to assess the feasibility of external probe fixation during exercise echocardiography on a supine bicycle and upright treadmill exercise for the first time.

Methods

37 subjects (36 men, mean age 39 ± 16 years, 21 healthy volunteers, 16 patients with suspected coronary artery disease) were included in this study. This preliminary testing stage included mostly men due to more problematic probe fixation in women. All subjects underwent a submaximal exercise stress test on a treadmill (17/37) or bicycle ergometer (11/37). Both sector and matrix probes were used. We assessed semi-quantitatively the quality of acquired apical views at each stage – the four-point grading system was used (0-no view, 1-suboptimal quality, 2-optimal quality, 3-very good quality), 2-3 sufficient for diagnosis.

Results

The mean time required for careful positioning of the probe and image optimization was 12 ± 3 min and shortened from 13,7 to 11,1 minutes (mean) in first vs second half of the cohort documenting learning curve. At baseline, 9 patients had at least one apical view of quality precluding reliable analysis. Those patients were excluded from further assessment. During stress, 17 patients maintained the optimal or very good quality of all apical views, whereas in 11 patients the quality significantly decreased during the stress test and required probe repositioning. The mean image quality score at baseline was 2,61 ± 0,48 and 2,25 ± 0,6 after exercise. Expectedly, good image quality was easier to obtain and maintain in the supine position (score 2,74 ± 0,44) points as compared with upright position (score 2,25 ± 0,57).

Conclusion

This preliminary, unique experience with external probe fixation device indicates that continuous acquisition and monitoring of echocardiographic images is feasible during physical exercise, and for the first time ever - also on the treadmill. This feasibility data stem from almost exclusively male patients and the estimated rate of sufficient image quality throughout the entire test is currently around 60%. We are hoping, that gaining more experience with the product could increase the success rate on exercise tests.

Abstract P1398 Figure. Treadmill and ergometer stress test

P1791 Outcome prediction with regional wall motion abnormalities during stress echocardiography

OnBehalf

Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging

Background

Over the last 3 decades, we observed a progressive decline in the prognostic value of a negative stress echo (SE) test based on regional wall motion abnormalities (RWMA), likely reflecting both an increase in risk in patients (older and more often diabetics) as well as a potential decrease in test performance due to concomitant anti-ischemic therapy.

Aim

To assess the value of SE in predicting outcome in contemporary populations

Methods

From September 2016 to December 2018, we enrolled 1848 patients (age 63 ± 11 years; 1121 males, 60%) with known or suspected coronary artery disease and/or heart failure evaluated with SE (exercise in 543, dipyridamole in 1184, adenosine in 10, dobutamine in 43) in 9 quality-controlled centers of 6 countries. Wall motion score index (WMSI) was evaluated at rest and peak stress (17-segment model, from 1 = normal-hyperkinetic to 4 = dyskinetic).All patients were followed-up for a median of 16 months.

Results WMSI was 1.09 ± 0.23 at rest and increased during stress (1.17 ± 0.32, p&lt;.001). At individual patient analysis, inducible ischemia with RWMA was present in 352 pts (18.8%). At follow-up, there were 218 events: 22 deaths, 22 non-fatal myocardial infarctions, 62 hospital admissions for acute heart failures, and 112 late (&gt;3 months from SE) myocardial revascularizations. Multivariable analysis identified stress-induced RWMA (Hazard Ratio 2.754, 95% Confidence Intervals: 2.053-3.963, p&lt;.0.001) as an independent predictor of events. Kaplan-Meier curves showed progressively worsening event-free survival for 1247 pts with normal (WMSI = 1.0), 298 pts with mildly (1.05-1.39), 250 pts with moderately (1.4-1.99) or 73 pts with severely (&gt;2.0) abnormal peak WMSI: see figure. In patients with negative SE, event-rate was 1.4% per year considering hard events (death and myocardial infarction) and 0.8 % per year considering only death.

Conclusion RWMA show risk stratification capability in contemporary patients referred to SE testing. The higher the peak WMSI, and the worse the prognosis. Nevertheless, the positivity rate is low (&lt; 20%) and patients with normal baseline and stress function still have a significant event rate. A more comprehensive risk assessment with other parameters is warranted

Abstract P1791 Figure. Survival curves and peak WMSI

P204 Recovery of left atrial function after restoration of sinus rhythm in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is associated with impaired mechanical function of the atria. The restoration of sinus rhythm (SR) leads to improvement of mechanics, however the onset of those changes is not established yet.

Purpose

To analyse changes in left atrial (LA) mechanical function after conversion to SR.

Methods

Forty patients (mean age 65 ± 12 years, 63% male) with nonvalvular AF underwent successful electrical cardioversion. Transthoracic echocardiography with speckle tracking analysis (STE) of LA was performed in AF and within 24 hours after cardioversion, in SR. We analysed standard parameters of left ventricle (LV) and LA. By the use of STE we assessed peak atrial longitudinal strain (PALS), time to PALS indexed to RR interval (TT-PALS/RR) and intra-atrial asynchrony.

Results

Heart rate during echocardiography was higher before cardioversion - median (IQR) 90 beats per minute (80-110) vs 61 (56-72); p &lt; 0.0001. The mean LV ejection fraction in our study group was 48 ± 11%. We noticed significant improvement in LA STE measurements and in early diastolic (E’) mitral annular velocity. There were no significant changes in systolic (S’) mitral annular velocity and in the ratio of transmitral Doppler early filling velocity to E’ (E/E’). Detailed results are present in the table.

Conclusions

Speckle tracking measurements are able to detect early mechanical changes in LA even within 24 hours of SR.

Atrial fibrillation Sinus rhythm p S" (cm/s) 6 (5-6.5) 6 (5-6.6) NS E" (cm/s) 10 (7.5-13) 9.5 (6.8-10.5) 0.0008 E/E" 8.2 (6.3-12.3) 9.3 (7.5-13) NS PALS (%) 9.9 ± 4.6 14.5 ± 6 &lt;0.0001 TTP-PALS/RR (%) 51 (44-58) 42 (38-45) 0.0001 LA asynchrony 15 (11-19) 9 (8-14) 0.0007

P1403 Prognostic value of B-lines during stress lung ultrasound

OnBehalf

Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging

Background

B-lines (also known as comets) by lung ultrasound (LUS) are a marker of pulmonary congestion and interstitial pulmonary edema during stress echocardiography (SE).

Aim

To assess the prognostic value of B-lines during SE.

Methods

We prospectively performed transthoracic echocardiography (TTE) and LUS (4-site simplified scan) evaluation at rest and peak stress in 1437 patients (age 63 ± 11 years; 874 males, 61%) referred for exercise (n = 581), vasodilator (n = 819: dipyridamole, n= 809 and adenosine, n= 10) or dobutamine (n = 37) SE for known or suspected coronary artery disease or heart failure. B-lines were assessed by LUS with a 4-site simplified scan (total score from 0-1, dry lung, to 40, alveolar pulmonary edema). Follow-up (median 16 months) was completed in all.

Results

B-lines were 1.14 [0-35] at rest and increased during stress (2.10 [0-40], p&lt;.001). At individual patient analysis, B-lines appeared de novo/increased (≥2 points) during stress in 306 (21.3%), remained absent or fixed in 1097 (76.3%) and decreased/disappeared in 34 (2.4%). At follow-up, there were 174 events: 17 deaths, 14 non-fatal myocardial infarctions, 51 hospital admissions for acute heart failures, and 92 late (&gt; 3 months from SE) myocardial revascularizations. At multivariable analysis, stress-induced regional wall motion abnormalities (Hazard Ratio, HR, 2.842, 95% Confidence Intervals, CI: 2.016-4.005, p&lt;.0.001) and B-lines change during stress (HR 1.471, 95% CI: 1.054-2.052, p=.022) were independent predictors. Kaplan-Meier curves showed progressively worsening event-free survival for 943 pts with absent (score 0-1), 333 with mild (2-5), 90 with moderate (6-10) and 71 with severe (&gt;10) B-lines at peak stress: see figure.

Conclusion

B-lines by LUS are a useful adjunct to regional wall motion abnormalities for risk stratification during SE. The presence and number of B-lines during stress allow a titration of risk. The outcome is darker with more comets in the SE sky.

Abstract P1403 Figure. Survival curves and peak stress B-lines

P274 Continous echocardiographic monitoring in intensive cardiac care unit with external probe stabilizer - preliminary experience

Background

The role of transthoracic echocardiography (TTE) in the intensive cardiac care unit is crucial. Imaging is currently performed at the bedside for diagnosis but TTE has also potential to noninvasively provide critical views to assist in patient monitoring. Continuous monitoring would be especially helpful when the patient is unstable; however, continuous availability of skilled sonographers to obtain appropriate views represents a limiting factor.

Purpose

Recently, an innovative external fixation device allowing prolonged stabilization of transthoracic ultrasound transducer was introduced. The ring-shaped device fitted for TTE probes is attached to the patient by elastic straps to hold the probe in contact with the skin at a fixed but adjustable angle. We developed a research project to assess for the first time the feasibility of continuous TTE imaging with external probe fixation in the intensive cardiac care unit.

Methods

12 patients (10 men, mean age 66,5 ± 15 years) hospitalized in intensive cardiac care unit due to cardiac arrest, myocardial infarction, pulmonary embolism, end-stage heart failure or respiratory failure were included in the study. The echocardiographic probe be was fixed in the apical window providing a four-chamber view to monitor left ventricular function. We assessed the patient’s tolerance and comfort as well as the quality of images acquired at baseline and at the end of monitoring.

Results

Fixation of the probe was successful in all patients (figure 1). The mean time of fixation was 10 ± 1 minute, with a clear learning curve. The quality of obtained images was sufficient for evaluation and was maintained throughout the entire period of monitoring in all patients. Monitoring was stopped at patients’ request when discomfort caused by the compression of the skin by the probe and the fixation device became significant (figure 2). The mean duration of monitoring was 85 + 64 minutes (range 15 to 240 minutes).

Conclusions

In this preliminary series we have demonstrated for the first time the feasibility of echocardiographic continuous monitoring of patients in the intensive cardiac care unit using TTE probe with the external fixation device. The design of the fixation device opens the evident field for optimization to extend monitoring duration at acceptable levels of discomfort in conscious intensive care patients. We hope the improved version of the fixator will decrease the pressure on the body.

Abstract P274 Figure. Fixation of the device

P805 Clinical and echocardiographic characteristics of Polish patients with Eisenmenger Syndrome - results of a snapshot registry

The first national registry of patients (pts) with PAH-CHD, predominantly with Eisenmenger Syndrome (ES), treated within national program was conducted. We studied clinical and echocardiographic characteristics of a group of adult patients including current therapy profile and mortality.

A multicenter observational study (snapshot registry) was conducted under auspices of Polish Cardiac Society, including pts with PAH-CHD, identified in centers, that treated &gt; 5 pts in the first 10 years of therapeutic program (2008-2018). This analysis included 322 pts (70 deceased), mean age 42 ± 2 years, 65% females. The registry included patients meeting the criteria of the Eisenmenger syndrome in echocardiography (right-left or aligned leak). The living patients were divided into 2 groups: Gr.1 (n = 227) – uncorrected and Gr.2 (n = 25) - after correction of the heart disease.

The average age in Gr.1 was 40 ± 2 years, in Gr.2 40 ± 6 years. The majority were women (68% and 62%). There was no significant differences for mean duration of treatment in groups: 60 ± 12 months vs. 66 ± 6 months (p = 0.42). Both groups didn’t differ in terms of clinical data, i.e. 6MWT 417 ± 50 m vs. 384 ± 15 m;p = 0.15, NT-proBNP level 869 ± 470 pg/ml vs. 901 ± 212 pg/ml;p = 0.57. There was no significant differences for mean LVd in groups: 41,24 mm [12-82] vs. 44,25 mm [30-55]. Mean LVEF was good (60% in gr.1 vs. 57% in gr.2). Mean TAPSE was slightly better in Gr.1: 19,36 mm vs. 17,09 mm. Pericardial effusion were present in almost 15% pts from Gr.1 and less than 1% pts from Gr.2.

Pts after correction were mostly in the II WHO FC, and those uncorrected in the II/III WHO FC. Pts from Gr.2 were more likely to receive polytherapy (60% vs. 47%). ERA were the most commonly used (near 90%).

The most common heart defect was VSD (46% in Gr.1 vs. 32% in Gr.2). Mortality was 22% in entire period, i.e. annual mortality rate of 2.2%. In the group of dead pts women accounted for 74%, the average age was 49 ± 4 years and mean length of treatment was 42 ± 13 months. About 9% of pts from this group had heart defect correction in the past. Monotherapy (66%) predominated among the deceased, mainly using ERA (77%). Pts receiving combination therapy had a longer survival (p = 0.04). It isn’t known whether this result confirms the greater effectiveness of such treatment, as some patients couldn’t wait until the polytherapy became possible within the framework of the Drug Program. Among the deceased, the most common heart disease was ASD (30%), slightly less VSD (29%).

In this first national snapshot registry we documented improving prognosis in PAH-CHD under specific therapies. No differences were present in the length of therapy, clinical data and quality of life depending on whether or not correction surgery was performed. Post-correction pts more often received a polytherapy. The annual mortality in this population is small estimated just over 2%. Targeted combination therapy may contribute to better survival.

P1553 Regional peak systolic longitudinal strain during dipyridamole stress echocardiography in patients with normokinetic response determined by visual assessment

OnBehalf

on behalf of the Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI)

Background

Regional wall motion (RWMA) remains the cornerstone of stress echocardiography (SE) and its evaluation is still based on visual assessment by 2D. Regional longitudinal peak systolic strain (LPSS) provides a quantitative, operator-independent assessment of RWMA.

Aim

To compare 2D (qualitative) versus strain (quantitative) assessment of RWMA during dipyridamole SE.

Methods

In a prospective study we recruited 17 patients (mean age 69 ± 7 years, 11 women) with known or suspected CAD referred for accelerated high dose (0.84 mg/kg in 6") dipyridamole SE. We included patients with normokinesis at rest and with normal SE response. A 17-segment model was used to assess RWMA and strain (LPSS and global longitudinal strain, GLS). Ejection fraction (EF) was measured with Simpson"s biplane method. LPPS and GLS were measured using Automated Function Analysis (AFI).

Results

289 segments could be assessed head-to-head with the 2 methods (2D and Strain). Heart rate was 61 ± 8 bpm at rest and rose to 86 ± 19 at peak stress (p = 0.0001) EF increased from 66 ± 7% (rest) to 73 ± 5% (peak stress, p = 0.0006 vs rest). GLS increased from -17.9 ± 3.4% at rest to -19.8 ± 2.4% at peak stress (p = 0.0074). Stress-rest (Δ) changes in EF did not correlate with Δ-GLS (r = 0.2, p = ns). LPSS was -18.2 ± 5.2% at rest and on average increased to -19.7 ± 5.8 % (p &lt; 0.0001 vs rest), with heterogeneity of regional contractile reserve, highest in apical segments 13-17 (n = 85, LPSS rest= -20.3 ± 4.9 vs stress = - 22.5 ± 4.3, p = 0.0002), intermediate in mid-segments 7-12 (n = 102, LPSS rest= -18.5 ± 5.0 vs stress = -19.8 ± 5.6, p= 0.0166) and lowest in basal segments 1-6 (n = 102, LPSS rest= -16.1 ± 5.0 vs stress = - 17.3 ± 6.1, p= =0.0518= ns), see figure. At individual segment analysis, 50 segments (17.3%) showed an unmatched response, with normal visual response and LPSS reduction (stress ≤ rest at least 15%), observed especially in basal segments, see Table, unmatched 2D strain segments.

Conclusions

DSE allows a simultaneous qualitative and quantitative assessment of regional wall motion and global function by 2D and advanced strain-based indices. Strain-SE is feasible and may corroborate the results of trained naked eye interpretation with quantitative support, but degree of changes in regional strain is related to specific position of segment in basal, mid or apical part of left ventricle, with unmatched results between visual and strain not infrequent, especially in basal segments.

Unmached 2D strain segments Basal (1-6), n = 102 Mid (7-12), n = 102 Apical (13-17), n = 85 P value Basal vs Mid P value Mid vs Apical P value Basal vs Apical 24 (23.5%) 18 (17.6%) 8 (9.4%) ns ns =0.0185 Number and proportion of segments with LPSS worsening ≥15% in basal, mid and apical portion of left ventricle.

Abstract P1553 Figure. Changes of regional LPSS during DSE

P1769 Levels of serum markers of myocardial injury in patients with ST-elevation myocardial infarction correlate with global left ventricular longitudinal deformation

Results

On admission median values (I – III quartile) of CKMB mass and troponin T were 20,0 ng/ml (6,3 – 59,0; range 1,9 – 475,3) and 0,25 ng/ml (0,06 – 1,04; range 0,01 – 11,2), respectively. Maximal values (I – III quartile) of CKMB mass and troponin T were 94,1 (28,0 – 215,7; range 3,2 – 500) and 3,29 (1,6 – 6,3; range 0,42 – 17,2), respectively. Statistically significant correlations were observed for the global values of the longitudinal strain parameters and the concentration of troponin T and CKMB mass (rs from 0.22 to 0.36). The strongest correlations were noted for the maximum serum level of troponin T. Among the best strain parameters was the global systolic longitudinal deflection (SLS). There was no statistically significant correlation between the parameters of transverse deformation and the concentrations of markers for myocardial necrosis.

Conclusions

Troponin T correlates with global left ventricular longitudinal deformation in patients with ST-elevation myocardial infarction.

P1711 Exploring the full spectrum of right ventricular exercise contractile reserve among health and disease: a prospective clinical and echocardiography observational multicenter study

Funding Acknowledgements

None

OnBehalf

RIGHT-NET

Background

Exercise Doppler echocardiography (EDE) has been implemented for applications beyond coronary artery disease detection, but its role in assessing subclinical pulmonary vascular disease and right ventricle (RV) impairment is less clear. The RIGHT heart international NETwork (RIGHT-NET) is a prospective clinical and echocardiography observational multicenter study designed to explore the full spectrum of RV function and non-invasive pulmonary circulation hemodynamics during exercise in a large cohort of subjects, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). Right ventricular (RV) exercise contractile reserve (RVECR) can be assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) and has proved to provide prognostic value in patients with left heart disease (LHD) and pulmonary arterial hypertension (PAH).

Methods

We enrolled 1424 patients (age 55.4 ± 15 years old, 44.4% males): 353 healthy controls, 40 athletes, 369 patients with cardiovascular risk factors (CVRF: arterial hypertension and/or diabetes mellitus), 46 with PAH (confirmed by right heart catheterization), 487 with systemic sclerosis (SSc) without overt PH, and 129 with LHD (including coronary artery disease and heart failure with reduced or preserved ejection fraction).

All enrolled subjects underwent resting and EDE examinations on a semirecumbent cycle ergometer with an incremental workload of 25 Watts every 2 minutes up to the symptom-limited maximal tolerated workload, according to standardised protocols. Key echocardiographic measurements have been acquired at baseline, at 50 Watts, at peak exercise, and after 5-minutes recovery, including but not limited to RV function (TAPSE) and sPAP.

Results

In all six groups the ratio TAPSE/sPAP was significantly different at peak exercise compared to rest values (all p &lt; 0.01). At rest, TAPSE/sPAP values were not significantly different among controls, athletes and CVRF patients, whereas during exercise TAPSE/sPAP values were significantly different, with CVRF showing the lowest values (p &lt; 0.0001 vs controls and athletes). Patients with PAH and LHD had the worst RVECR both at rest and at peak exercise (all p &lt; 0.0001 vs the other groups), while SSc groups reported intermediate values, which were lower than controls (p &lt; 0.0001) and athletes (p &lt; 0.0001), but higher than CVRF subjects (p = 0.003). (Figure)

Conclusions

EDE can non-invasively characterise different dynamic behaviours of the RVECR among healthy subjects, athletes and patients with various pathologic conditions. Whether a thorough EDE assessment of non-invasive hemodynamics, RVECR and coupling may predict later development of manifest PH, clinical deterioration or decreased survival will be further investigated during the ongoing follow-up.

Abstract P1711 Figure

P329 Outcome prediction with force-based left ventricular contractile reserve during stress echocardiography

OnBehalf

Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging

Background

Stress echo (SE) risk stratification is based on regional wall motion abnormalities (RWMA). The assessment of global left ventricular contractile reserve (LVCR) based on load-independent Force may refine prognosis.

Aim

To assess the value of LVCR during SE in predicting outcome

Methods

From September 2016 to December 2018, we prospectively enrolled 1848 patients (age 63 ± 11 years; 1121 males, 60%) with known or suspected coronary artery disease and/or heart failure evaluated with SE (exercise in 543, dipyridamole in 1184, adenosine in 10, dobutamine in 43) in 9 quality-controlled centers of 6 countries. Force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/end-systolic volume by 2D and biplane Simpson method of disks. When Simpson method was not feasible, apical single plane or linear parasternal methods were used to calculate volumes. Abnormal values of LVCR (peak/ rest) based on force were ≤1.10 for dipyridamole and adenosine; ≤1.61 for exercise or dobutamine. All patients were followed-up for a median of 16 months.

Results RWMA and Force-based LVCR were obtained in all pts. Force was 4.24 ± 1.88 mmHg/ml at rest and increased during stress (7.07 ± 4.60 mmHg/ml, p&lt;.001). At individual patient analysis, LVCR was abnormal in 495 (26%) and normal in 1373 (74%) patients. At follow-up, there were 218 events: 22 deaths, 22 non-fatal myocardial infarctions, 62 hospital admissions for acute heart failures, and 112 late (&gt; 3 months from SE) myocardial revascularizations. At multivariable analysis, stress-induced RWMA (Hazard Ratio, HR, 2.899, 95% Confidence Intervals, CI: 2.032-4.137, p&lt;.0.001), force-based LVCR (HR 1.747, 95% CI: 1.245-2.470, p=.002) were independent predictors. Kaplan-Meier curves showed worse event-free survival for pts with abnormal LVCR: see figure.

Conclusion LVCR based on Force is a useful adjunct to RWMA for risk stratification with SE.

Abstract P329 Figure. Survival curves and LVCR

P4357Implementation of interactive mixed reality display of three-dimensional echocardiography during percutaneous structural interventions

Background

Three-dimensional (3D) echocardiographic data acquired from transesophageal (TEE) window are commonly used in planning and during percutaneous structural cardiac interventions (PSCI).

Purpose

We hypothesized that innovative, interactive mixed reality display can be integrated with procedural PSCI workflow to improve perception and interpretation of 3D data representing cardiac anatomy.

Methods

3D TEE datasets were acquired before, during and after the completion of PSCI in 8 patients (occluders: 2 atrial appendage, 2 patent foramen ovale and 3 atrial septal implantations and percutaneous mitral commissurotomy). 30 Carthesian DICOM files were used to test the feasibility of mixed reality with commercially available head-mounted device (overlying hologram of 3D TEE data onto real-world view) as display for the interventional or imaging operator. Dedicated software was used for files conversion and 3D rendering of data to display device (in 1 case real-time Wi-Fi streaming from echocardiograph) and spatial manipulation of hologram during PSCI. Custom viewer was used to perform volume rendering and adjustment (cropping, transparency and shading control).

Results

Pre- and intraprocedural 3D TEE was performed in all 8 patients (5 women, age 40–83). Thirty selected 3DTEE datasets were successfully transferred and displayed in mixed reality head-mounted device as a holographic image overlying the real world view. The analysis was performed both before and during the procedure and compared with flatscreen 2-D display of the echocardiograph. In one case, real-time data transfer was successfully implemented during mitral balloon commissurotomy. The quality of visualization was judged as good without diagnostic content loss in all (100%) datasets. Both target structures and additional anatomical details were clearly presented including fenestrations of atrial septal defect, prominent Eustachian valve and earlier cardiac implants. Volume rendered views were touchlessly manipulated and displayed with a selection of intensity windows, transfer functions, and filters. Detail display was judged comparable to current 2-D volume-rendering on commercial workstations and touchless user interface - comfortable for optimization of views during PSCI.

Conclusions

Mixed reality display using a commercially available head-mounted device can be successfully integrated with preparation and execution of PSCI. The benefits of this solution include touchless image control and unobstructed real world viewing facilitating intraprocedural use, thus showing superiority over virtual or enhanced reality solutions. Expected progress includes integration of color flow data and optimization of real-time streaming option.