Unique cardiac remodeling in young adults born Small for Gestational Age with subsequent central obesity

Background

Being born small-for-gestational age (SGA, 10 percent of all births) is associated with increased risk of cardiovascular mortality (1,2) in adulthood together with lower exercise tolerance (3), but mechanistic pathways are unclear. Central obesity is known to worsen cardiovascular outcomes, but it is uncertain how it affects the heart in adults born SGA.

Purpose

We aimed to assess whether central obesity makes young adults born SGA more susceptible to cardiac remodelling and dysfunction.

Methods

A perinatal cohort study including 80 young adults born SGA (birth weight below 10th centile) and 75 adults with normal birth weight (controls). Current waist-to-hip ratio was used as a surrogate of central obesity. Cardiac structure and function were assessed by cardiac magnetic resonance. Statistical shape analysis was used to study the regional geometric variability of the biventricular surfaces produced by central obesity and SGA, and synthetic surfaces representative of obese and non obese were generated for both SGA and controls.

Results

Figure 1 shows the superimposed representative surfaces of obese and non-obese according to our model, for controls (right column) and SGA (left column). Both SGA and waist-to-hip were highly associated to cardiac shape (F=3.94 p<0.001; F=5.18 p<0.001 respectively) with a statistically significant interaction (F=2.29, p=0.02), indicating a different cardiac remodelling due to obesity in SGA. While controls tend to increase left ventricular end-diastolic volumes, mass and stroke volume with increasing waist-to-hip ratio, young adults born SGA showed unique response with inability to increase cardiac dimensions or mass resulting in reduced stroke volume (both in absolute values and indexed by body surface area) and increased heart rate.

Conclusions

SGA young adults show unique cardiac adaptation to central obesity, which is associated with a decrease in stroke volume. Preventive strategies aiming to reduce cardiometabolic risk in SGA population may be warranted.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union Horizon 2020 Programme

Impact of coaptation gap location on procedural strategy and outcomes following tricuspid transcatheter edge-to-edge repair: insights from the TriClip bRIGHT study

Background

As tricuspid transcatheter edge-to-edge repair (TEER) gains momentum, a better understanding of coaptation gap size and location becomes increasingly important to properly select patients for this therapy. The tricuspid valve is complex and patient phenotypes may be highly variable. It is currently unknown how location of the coaptation gap may impact procedural strategy and clinical outcomes.

Purpose

To characterize the coaptation gap in patients receiving tricuspid TEER and investigate the effect of coaptation gap location on procedural strategy and short-term outcomes.

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe tricuspid regurgitation. Detailed echocardiographic coaptation gap measurements were performed on 135 subjects (from 24 sites) with available echo. Procedural and short-term outcomes were stratified by coaptation gap location.

Results

The biplane RV inflow/outflow and short-axis transgastric (SAX TG) views were available in 90% (122/135) and 56% (76/135) of subjects, respectively. From the SAX TG view, coaptation gap measured 8.2±3.4 and 5.2±2.4 mm in the central and mid regions of the anterior-septal (AS) coaptation line, and 6.5±3.0 and 3.7±2.0 mm in the central and mid regions of the septal-posterior (SP) coaptation line (Figure 1). Coaptation gap measured 4.7±2.4, 5.2±2.4 and 4.6±3.0 mm in the anterior, mid and posterior aspects of the RV inflow/outflow view. The largest coaptation gap presented in the AS region in 79% (95/120) of subjects. A comparison of baseline characteristics, procedural strategy and outcomes stratified by location of the largest coaptation gap is provided in Table 1. Annulus and right ventricle size and presence of pacemakers were similar between groups. Torrential TR at baseline was more common in the SP group. Clipping strategy was similar with the majority of implants placed in the AS region. Implant success and acute procedural success (APS) were achieved in the majority of patients in both groups, with the SP group showing higher APS rates, 96% vs 85%, respectively. At 30-day follow-up, subjects with the largest gap in the SP region experienced more TR reduction at 30-day follow-up, 2.8±1.6 vs 2.1±1.3 grade reduction, respectively. Clinical improvements were observed in both groups: KCCQ increased by more than 15 points on average and the majority of subjects in both groups were NYHA I/II at 30-day follow-up.

Conclusion

Coaptation gap size varies across the tricuspid valve and measurements at the intended clipping location should be taken into account when determining appropriateness of a given anatomy for tricuspid TEER. TriClip TEER offered high rates of implant and procedural success and improved clinical outcomes regardless of coaptation gap location. Subjects with SP coaptation gap localization are infrequent but should not be excluded from TEER therapy.

Funding Acknowledgement

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

Cardiac injury before and after COVID-19. A longitudinal MRI study

Background

Recent MRI-based studies have raised great concern about frequent cardiac involvement even in mild or asymptomatic COVID-19. However, while signs of myocardial injury were found in large proportions of patients after COVID-19, all studies published to date lack baseline imaging and are therefore unable to discriminate between pre-existing and COVID-19-induced injury.

Purpose

In this longitudinal study, we aimed to assess the true cardiac impact of COVID-19 based on pre- and post-COVID-19 late gadolinium enhancement (LGE)-MRI.

Methods

A prospective registry of patients with serial LGE-MRIs was screened for patients with documented SARS-COV-2 infection after cardiac LGE-MRI. Eligible patients then received a post-COVID-19 LGE-MRI using the same scanner and sequence as in the pre-COVID-19 MRI. Inversion recovery prepared T1-weighted gradient echo sequences were acquired in sinus rhythm using ECG gating and a free-breathing 3D navigator, 15–20 minutes after administering an intravenous bolus of 0.2 mmol/kg of gadobutrol. A TI scout sequence was used in order to determine the optimal TI that nullified the left ventricular myocardial signal. The presence of LGE was independently assessed qualitatively by two experienced investigators blinded to patient information. For quantitative analyses a 3D-reconstruction of the left ventricle was performed using ADAS-3D software. LGE was then automatically quantified based on a prespecified signal intensity threshold of ≥3 SD above the mean of a remote non-enhanced myocardial region.

Results

Pre- and post-COVID LGE-MRI from 31 patients with cardiovascular risk factors that had recovered from mild to moderate COVID-19 (23% hospitalised) were analysed. At a median of 5 months post-COVID-19, LGE-lesions indicative of myocardial injury were encountered in 15 out of 31 patients (48%), which is in line with previous reports. However, intraindividual comparison with the pre-COVID-19 MRI reveiled all of these lesions as pre-existing and thus not COVID-19-related. Quantitative analysis detected no increase in the size of individual LGE-lesions, nor in the global left ventricular LGE-extent. There was no difference in any functional or structural parameter between pre- and post-COVID-19 MRI.

Conclusion

This longitudinal study in a cohort of patients considered at high risk of cardiac involvement, did not find any evidence for COVID-19-induced myocardial injury. The complete absence of de novo LGE lesions in this cohort is reassuring and indicates that cardiac sequelae of COVID-19 are rare and certainly not as common as previously suggested.

Funding Acknowledgement

Type of funding sources: None.

Septal flash correction with His-Purkinje pacing predicts echocardiographic response in resynchronization therapy

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Grant of the Catalan Society of Cardiology, 2019; Research Grant Josep Font 2019, Hospital Clínic de Barcelona

His-Purkinje conduction system pacing (HPCSP) has been proposed as an alternative to cardiac resynchronization therapy (CRT); however, no predictors of echocardiographic response have been described. Septal flash (SF) is a marker of intraventricular dyssynchrony.

Methods

The study aimed to analyze whether HPCSP corrects SF in patients with CRT indication, and if correction of SF predicts echocardiographic response. Prospective observational study (n=30). Left ventricular ejection fraction (LVEF) was measured with echocardiography at baseline and at 6-month follow-up. Echocardiographic response was defined as increase in 5 points LVEF. ECG Imaging was performed in 2 patients to validate ventricular activation shortening and to study the basal and HPCSP activation pattern.

Results

HPCSP shortened QRS duration by 48±21ms and SF was significantly decreased (baseline 3.6±2.2mm vs HPCSP 1.5±1.5mm p<0.0001) (Fig.1). At 6-months, mean LVEF improvement was 8.6% ± 8.7% and 64% of patients were responders. There was a significant correlation between SF correction and increased LVEF (r=0.61, p=0.004). A correction of >1.5mm had 81% sensitivity and 80% specificity to predict echocardiographic response (area under curve 0.86, p=0.019).

Conclusion

HPCSP improves intraventricular dyssynchrony and results in 64% echocardiographic responders at 6-month follow-up. Dyssynchrony improvement with SF correction may predict echocardiographic response at 6-month follow-up (Fig.2.).

Cardiac telerrehabilitation: a safe and effective alternative in patients with coronary artery disease

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Ferrer Internaciona Groupl, S.A

Background

Center-based cardiac rehabilitation programs (CRP) have shown to reduce morbidity and mortality after an ischemic cardiac event, but their vastly underutilized. Home-based CRP seems to improve patient’s adherence, but there is still scarce evidence, especially in elderly patients and women.

Purpose

To develop a holistic home-based CRP for ischemic heart disease patients and evaluate its safety and impact on functional capacity, adherence to a heart-healthy lifestyle and quality of life.

Methods

The 8-week home-based CRP will include 60 patients (50% women) with no age limit who have suffered an acute myocardial infarction in the previous 3 months, with LVEF ≥40% and a tablet/mobile device. The CRP (Picture 1) includes 3 weekly exercise sessions combining tailored aerobic and strength training and 1 weekly educational session focused on lifestyle habits, therapeutic adherence, and patient empowerment.

Results

Between January and October 2021, 56 patients were included: 2 were rejected for presenting ventricular arrhythmias in the initial stress test and 4 due to technological barrier; 14 patients are currently performing the CRP. The preliminary results from the 36 patients who have completed the CRP show a significant increase in functional capacity, muscle strength, weekly training volume, adherence to Mediterranean diet, emotional state (anxiety) and quality of life (Picture 2). There have been no complications and patient’s adherence has been excellent for both exercise (85%) and educational (80%) sessions.

Conclusion

A holistic telematic CRP dedicated to patients after an ischemic cardiac event, including patients of both gender and of no age-limit, seems to be a feasible, safe and effective in improving maximal aerobic capacity, weekly training volume, muscle strength, quality of life, compliance with the Mediterranean diet and emotional state.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

The role of segmental speckle tracking echocardiography in characterising right ventricle dilation patterns: a multicentre study on healthy adolescent athletes

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): UK Research and Innovation - Medical Research Council GW4 Studentship

Background

Right ventricle inflow (RV) dilation is a common adaptation to training in professional athletes, but how this impacts myocardial mechanics is yet unclear. Previous studies in athletes have found changes in segmental longitudinal strain (Sl), namely mid segment Sl, compared to normal controls, and have proposed RV dilation as a possible explanation. Whether different patterns of RV dilation are found in athletes, and if these influence regional RV mechanics is not known.

Purpose

To describe the patterns of RV dilation in healthy adolescent athletes and their relationship to segmental myocardial mechanics.

Methods

A total of 346 healthy athletes (<18 years) screened at 3 sports academies between 2014 and 2019 with measurements for RV Sl, RV basal and RV apical diameters were included. Four groups were defined based on the basal and apical RV diameters size relative to the whole group distribution: No RV dilation (both basal and apical RV diameter under the 25th percentile), basal dilation (only basal RV above the 75th percentile), apical dilation (only apical RV above the 75th percentile) and global dilation (both the basal and apical RV above the 75th percentile). The segmental Sl was compared between the groups using a one-way ANOVA test with Bonferroni correction.

Results

The mean (SD) age was 14.5 (1.6) years, with athletes coming from various ethnic (55% arab, 22% white and 22% black) and sports backgrounds (75% mixed, 11% power, 8% endurance and 6% skill). Based on the RV diameters, the following groups were defined: no dilation (n = 35), basal dilation (n = 53), apical dilation (n = 51) and global dilation (n = 33). There were variations in dilation pattern by ethnicity and practised sports (Figure 1).

RV free wall Sl was less negative ("lower") in the apical and global dilation groups compared to the no dilation group (-26.7% and -26.4% vs -28.6%, p = 0.04 and 0.03, respectively). Mid segment Sl was consistently lower in all 3 dilation pattern groups, compared to the no dilation group (Figure 2, *denotes p < 0.05). Basal Sl was lower in the global dilation group compared to those with no dilation (p = 0.05). There were also differences between the basal and apical dilation groups: basal Sl was lower (p = 0.01) and apical Sl higher (p = 0.02) the apical dilation group.

Conclusions

RV dilation in healthy athletes can be global, predominately basal or predominately apical. Apical and global dilation were more prevalent in non-white ethnicity, endurance and power sports. Lower mid segment Sl values were observed in all 3 dilation patterns, but FW Sl was only lower in the apical and global dilation groups. This suggests that there are different patterns of RV remodelling in athletes, which can be further characterised using segmental strain analysis. Abstract Figure. RV dilation by ethnicity and sport  Abstract Figure. RV segmental strain by RV dilation

Automatic measurement of LV wall thickness from 2D cardiac echocardiography

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): PIC from European Union"s Horizon 2020 Marie Skłodowska-Curie Actions ITN

Background

The wall thickness of the left ventricle (LV) is an important parameter in the diagnosis of hypertension and more specifically in hypertrophic cardiomyopathy. A user-dependent manual assessment of distances on 2D echocardiographic images is the current clinical gold-standard.

Purpose

The automation of LV wall thickness measurements in 2D echocardiography in order to improve robustness and reduce time of clinical reports where wall thickness is required, such as hypertrophy and the presence of Basal Septal Hypertrophy (BSH)(1).

Methods

A dataset of 4-chamber (4CH) echocardiograms on 118 patients with a diagnosis of hypertension (2) is used for this study. The images were segmented automatically (3) extracting the blood pool and the myocardium. Based on the curvature of the complete myocardial contour, the valve annular regions are removed leaving the endocardial and the epicardial walls as independent structures. The wall thickness along the myocardium is calculated as the distance from each endocardial border pixel to the closest epicardial point  (see Figure 1). A high pass gaussian filter was applied to remove high frequency noise. Ultimately, the basal-to-mid septal wall thickness ratio that defines BSH (ratio ≥ 1.4) was computed as the maximal of basal-septal segment divided by minimum of mid-septal segment. In order to validate the method for BSH detection, the wall thickness septal ratio was carefully measured by a clinical expert following the guidelines (2). The statistical agreement was accessed via linear correlation and Bland-Altman analysis.

Results

The automatic assessment of LV wall thickness along the myocardium is feasible in 2D echocardiography. The septal ratio showed an excellent agreement with manual measurements (R2 = 0.94, bias=-0.01, see Figure 2), leading to a detection of BSH in n = 19 vs the n = 18 detected manually (1 false-negative and 2 false-positives). In comparison to the intra and inter-observer variabilities of 12% and 42% respectively in the manual measurement (4), the automatic method had no variability for a given image acquisition.

Conclusions

The automatic measurement of myocardial wall thickness from a 2D echocardiographic images is accurate and reproducible. The implementation of the methodology in clinical practise has the potential to improve and automate the assessment of hypertrophic cardiac conditions. Abstract Figure. Pipeline for automatic measurement of WT  Abstract Figure. Agreement of BSH WT ratio

Characterization of coaptation gap in patients receiving tricuspid transcatheter edge-to-edge repair: initial observations from the bRIGHT TriClip study

Funding Acknowledgements

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

Background

As tricuspid transcatheter edge-to-edge repair (TEER) gains momentum, the proper measurement of coaptation gap to determine optimal patients for this therapy becomes increasingly important. Currently, a single septo-lateral measurement from the short-axis transgastric (SAX TG) or RV inflow/outflow biplane view is commonly used as the representative coaptation gap measurement for a patient. However, this measurement is not necessarily performed at the intended location for TEER and may overestimate the coaptation gaps to be treated.

Purpose

To characterize the coaptation gap in patients receiving tricuspid TEER which may provide insights on how to best determine eligibility for edge-to-edge repair.

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe tricuspid regurgitation. Detailed echocardiographic coaptation gap measurements were performed on the first 46 subjects with available echo data by two experienced echocardiographers.  Coaptation gap was measured at four levels in the SAX TG view (Figure 1) and also at the resulting long axis view from a orthogonal view taken from a RV inflow/outflow view obtained at the anterior, mid and posterior aspect of the tricuspid valve (Figure 2).

Results

The biplane RV inflow/outflow and SAX TG views were available in 91% (42/46) and 93% (43/46) of subjects, respectively. From the SAX TG view, coaptation gap measured 9.0 ± 3.9 and 4.9 ± 2.7 mm in the central and mid regions of the anterior-septal coaptation line, and 7.6 ± 3.4 and 4.0 ± 2.1 mm in the central and mid regions of the septal-posterior coaptation line (Figure 1). The largest coaptation gap presented between the anterior and septal leaflets in 78% (33/43) of subjects, with the gap extending across the anterior-septal and septal-posterior coaptation lines in  98% (42/43) of subjects.  Coaptation gap measured 6.2 ± 2.8, 6.6 ± 2.8 and 6.0 ± 3.5 mm in the anterior, mid and posterior aspects of the RV inflow/outflow view (Figure 2). In subjects with both views available, the SAX TG view resulted in larger coaptation gap measurements (+3.4 ± 3.0 mm) in 95% (38/40) of subjects. A significant, positive correlation was observed between the maximum biplane and transgastric measurements (rho = 0.648, p < 0.0001).

Conclusion

A single septo-lateral measurement may overestimate the actual gap size and potentially exclude patients who are viable candidates for TEER. Measurements in both the SAX TG and RV inflow/outflow biplane should be taken into account when determining appropriateness of a given anatomy for tricuspid TEER Future work in larger cohorts is needed to determine which coaptation gap measurements are predictive of procedural outcomes and how these measurements may influence treatment strategy. Abstract Figure 1  Abstract Figure 2

Machine learning-based phenotyping and risk assessment of hypertrophic cardiomyopathy - linking ECGs, morphology and genotypes

Funding Acknowledgements

Type of funding sources: None.

Background

Integrating clinical data to distinguish hypertrophic cardiomyopathy (HCM) phenotypes is relevant in clinical practice. Machine learning (ML) can help - deep learning (DL) networks can automate detection and segmentation of 12-lead electrocardiograms (ECGs), whereas unsupervised learning can group patients to compare ECG, imaging and genetic characteristics. The aim is to automate ECG morphology analysis from all 12 ECG leads and multiple beats, and relate this to HCM genotypes and imaging phenotypes. 

Methods

The single-center cohort included phenotype- and genotype-positive (G+) HCM patients (n = 104) and their phenotype-negative relatives (n = 50, 42% G+). All patients had a digital 12-lead ECG, echocardiography, and a magnetic resonance (CMR) study performed. The workflow is shown in Fig 1. A U-Net DL network was used for ECG delineation (P, QRS, T onsets/offsets) for all cardiac cycles. Three heartbeats were selected for each patient based on their morphology, with the aim of capturing beat-to-beat variability. An unsupervised representation learning algorithm was used to fuse ECG data and assess inter-patient similarities. Patients were clustered based on similarities of ECG biomarkers, and compared with regards to genotypes, family history of sudden cardiac death (SCD), history of ventricular arrhythmias/syncope/aborted SCD, implanted defibrillators (ICD), left ventricular (LV) obstruction, maximal wall thickness, late gadolinium enhancement (LGE), and HCM risk-SCD score.

Results

ML based on ECG biomarkers provided a good separation of HCM patients and relatives (Fig 1A), also showing G- and patients with variants of uncertain significance grouping together (Fig 1B). Clustering resulted in 6 ECG phenogroups (C1-6). C1 and 2 were related to less comorbidities, cardiac remodeling, and HCM risk score, capturing the majority of G- patients. C3 and 4 were related to LV obstruction – where C4 consisted of symptomatic patients with high ICD implantation and event rates, high LGE, and impaired systolic function. C5 captured patients with high comorbidities, extremely remodeled hearts, but no obstruction, whereas C6 patients with positive family history and high arrhythmic events (Fig 1C, Table 1). The average ECG morphology is shown side-by-side for C1 and C5 in Fig 1D – negative T waves, increased R/S wave amplitudes, left axis deviation (LAD) and ST elevation can be recognized as macro-biomarkers in C5 (yellow arrows).

Conclusion

ML can automate the analysis of complex clinical data, simultaneously taking into account the morphology of all ECG components in all 12-leads, throughout multiple beats, compare it with clinical and imaging data, and identify clinically sensible phenogroups as validated by structural and functional findings, as well as with genotypes and clinical information. Automated and comprehensive cardiac data analysis has diagnostic and research potential to help screen populations and phenotype disease etiologies. Abstract Figure 1: analysis pipeline  Abstract Table 1: clinical variables

Exploring phenotypes in hypertrophic cardiomyopathy with machine learning data integration. A multicentric, multimodality pilot study

Background

Interpreting patient phenotypes is a challenge when screening for hypertrophic cardiomyopathy (HCM). Machine learning (ML) can potentially help with advanced data integration - combining information contained in whole-cardiac cycle echo deformation and velocity profiles with standard clinical variables. The aim is to apply an ML approach to integrate whole cardiac cycle echo data with clinical variables to explore HCM phenotypes.

Methods

The cohort consisted of 138 participants from two centres: HCM patients (n=91) and relatives (n=47). Echocardiography was performed, whereas magnetic resonance and genetic testing in 48% and 82%, respectively. Whole cardiac cycle echo data (mitral and aortic velocity profiles, and six regional left ventricular (LV) deformation curves) were combined with clinical variables (age, sex, heart rate, e' medial and e' lateral) and used as the ML input. An unsupervised ML algorithm created a representative space where participants were positioned based on integrated data, blinded to disease status. Clustering was used to determine phenogroups and estimate the average characteristics. Data on family history (FHx), genotype, arrhythmias or syncope, implantable cardioverter-defibrillators (ICD), and late gadolinium enhancement (LGE) were used to interpret the phenogroups. As the LA diameter was not available in the dataset, the HCM risk for sudden cardiac death (SCD) was not calculated, however, the Table shows relevant variables to infer clinical risk.

Results

Clustering divided the participants into 6 phenogroups (P1–6) (Figure). Average echo profiles are shown in the Figure, while the clinical data in the Table. P1/2 was defined by symptomatic patients with a high prevalence of positive genotypes, a positive FHx of SCD, and a burden of comorbidities. Echo findings showed pronounced structural/functional remodeling, and P1 was associated with severe septal hypertrophy and outflow tract obstruction. The high prevalence of ICD devices defined P1/2 as high risk groups. In comparison, patients in P3/4 were younger, with milder LV hypertrophy, but still considerable functional impairment. P3 had a higher burden of FHX and a higher prevalence of pathogenic mutations, whereas P4 a higher incidence of hypertension, high heart rate, mitral inflow fusion and findings of LGE. Finally, P5/6 consisted of younger individuals, predominantly HCM relatives, with a mild phenotype and, thus, low inferred risk. As expected, the majority of patients with the genetic variants of undetermined significance were located in P5.

Conclusion

ML can help derive clinically interpretable phenotypes in HCM based on the automated integration of whole cardiac cycle deformation and velocity data with conventional clinical parameters. The derived phenogroups correspond with established risk profiles in HCM. An expanded dataset is needed to enable further exploration of the phenotype-genotype relations and to define prognostic value.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by the Horizon 2020 European Commission Project H2020-MSCA-ITN

Predictive factors for requiring heart transplantation in patients with hypertrophic cardiomyopathy: data from a referral center

Background

Heart transplant (HT) remains the last treatment option for patients with non-obstructive hypertrophic cardiomyopathy (HCM) who develop end-stage heart failure (HF). Early identification of patients who may require a HT in the future is crucial in order to advise them, establish the appropriate follow-up and determine the appropriate time to include them in the waiting list.

Objectives

Our study sought to find predictive factors related with requiring HT during follow-up in patients with HCM.

Methods

Consecutive patients with HCM referred to a HCM monographic clinic from 2018 to 2020 (HCM controls) and transplanted patients due to HCM in the same tertiary HT hospital since 2003 (cases) were included. Baseline (on the date of HCM diagnosis) and longitudinal data regarding clinical, genetic, ECG and echocardiographic variables were retrospectively evaluated. Follow-up was registered from HCM diagnosis to HT (in cases) or last medical check up (controls).

Results

A total of 157 patients (24 HCM-HT cases and 133 HCM controls) were included (45±19 yo; 57% male). At the time of MCH diagnosis (Table), cases were significantly younger than controls, were more frequently symptomatic and showed significantly higher BNP levels and more advanced diastolic dysfunction (larger left atrium, higher E/A ratio and lower e'); also, HCM-HT reported more family history and had higher proportion of pathogenic mutations (being MYH7 the most frequently involved). Left ventricular (LV) systolic function was slightly reduced in HCM-HT cases. In contrast, HCM controls were more frequently diagnosed by casual findings or family screening and had more LV outflow tract obstruction at first medical evaluation. LV maximal wall thickness (MWT) did not differ between groups. During a median follow-up since HCM diagnosis of 6.2 years (median follow-up of 8.9 and 7.1 years in cases and controls, respectively), HCM-HT cases presented a higher incidence of sustained ventricular tachycardia or ICD therapy (HR=4.0; CI95%:1.6–10.0 p=0.03) and HF admissions (HR=3.9; CI95%:1.8–8.1 p<0.001). There were no cardiovascular deaths during follow-up.

Conclusions

The presence of symptoms in a young non-obstructive HCM patient, along with family history and a pathogenic mutation, should advice clinicians a closer follow-up and early transfer to a HT referral center, especially if associated with diastolic dysfunction and high BNP values.

Funding Acknowledgement

Type of funding sources: None. Table 1

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Assessment of myocardial deformation with CMR: a comparison with ultrasound speckle tracking in a cohort of highly trained endurance athletes

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Plan Nacional I.D., Del Programa Estatal de Fomento De La Investigación Científica y Técnica de Excelencia, Subprograma De Generación Del Conocimiento, Ministerio de Economía y Competitividad 2013.

Background

 Myocardial deformation integrated with cardiac dimensions provides a comprehensive assessment of the ventricular remodelling patterns induced by cumulative effects of intensive exercise. Feature tracking(FT) can measure myocardial deformation from cardiac magnetic resonance(CMR) cine sequences; however, its accuracy is still scarcely validated.

Purpose

 Our aim was to compare FT’s accuracy and reproducibility to speckle tracking echocardiography (STE) in highly trained endurance athletes (EAs).

Methods

 93 EAs (>12 hours training/week during the last 5 years, 52% male, 35 ± 5.1 years) and 72 age-matched controls underwent a resting CMR and a transthoracic echocardiography to assess biventricular exercise-induced remodelling and biventricular global longitudinal strain (GLS) by CMR-FT and STE.

Results

  High endurance training load was associated with larger bi-ventricular and bi-atrial sizes and mildly reduced systolic function of both ventricles (p < 0,05). Strain values (both by CMR-FT and STE) proportionally decreased with increasing ventricular volumes potentially depicting the increased volume and functional biventricular reserve that characterize EAs heart. Strain values were lower when assessed by CMR-FT as compared to STE (p < 0.001), with good reproducibility for the LV (bias = 3.94%, LOA= ± 4.27%) but wider variability for RV strains (Figure 2).

Conclusions

  Biventricular longitudinal strain values were lower when assessed by FT compared to STE. Both methods were comparable when measuring LV strain but not RV strain. These differences might be justified by FT’s lower in-plane spatial and temporal resolution, which is particularly relevant for the complex anatomy of the RV.

Abstract Figure. Fig 1. Bland-Altman plots; FT vs STE.

Cardiac function during COVID-19 intensive care unit hospitalisation - deformation analysis and outcomes

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 European Commission Project H2020-MSCA-ITN-2016

Background

Although the cardiac burden of COVID-19 has been demonstrated, follow-up imaging studies are scarce. The aim was to use speckle-tracking deformation imaging (STE) to prospectively assess cardiac function during intensive care unit (ICU) hospitalisation, comparing ventricular and atrial function of COVID-10 patients that died and those that were discharged.

Methods

In a single-centre, COVID-19 patients (n = 41) (71% male, aged 65 ± 11 years) were prospectively followed with echocardiography as part of ICU treatment. The left and right ventricles (LV, RV, respectively) were studied with STE in the 4-chamber cardiac view. The endpoint was defined as death or ICU discharge. Average values of the strain parameters from the first and final scans in the ICU, respectively, were calculated for the two outcome groups.

Results

Endpoint was not reached in 15% (n = 6) at the time of analysis. The remaining patients (n = 32) were 69% male, aged 66 (interquartile range (IQR) 60-72) years, and with an ICU mortality 26% (n = 9). The median spent in ICU was 24 (IQR 15-43) days. On average, echocardiography was performed three times during ICU hospitalisation, amounting to 103 examinations. The changes in cardiac strain are shown in Table 1. The change in LV longitudinal strain during ICU hospitalisation is shown in Figure 1.

Conclusion

Worsening of LV strain and lack of improvement of RV strain is linked to higher mortality in the ICU. The assessment of cardiac function might contain prognostic information in COVID-19 patients that are admitted to the ICU.

	Patients discharged from thee OCU (n = 23)	Patients that died in the ICU (n = 9)	P value
Initial echo in the ICU
LV strain, % (IQR)	18.00 (15.6-19.95)	14.4 (10.56-20.42)	0.158
RV strain, % (IQR)	16.00 (14.70-20.05)	15.50 (10.38-23.70)	0.712
Final echo before discharge
LV strain, % (IQR)	17.35 (15.13-18.98)	13.20 (10.75-15.40)	0.007
RV strain, % (IQR)	17.65 (16.83-19.60)	15.75 (10.68-20.43)	0.438

ICU - intensive care unit; IQR-inter-quartile range

Validation of a deep learning reconstruction framework for 3D delayed myocardial enhancement imaging

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial delayed enhancement (MDE) MRI plays an important role in the identification of several cardiac conditions, both ischemic and non-ischemic (e.g. myocarditis, IDC, amyloidosis). 3D imaging offers increased resolution, full heart coverage and better depiction of complex pathologies, but its image quality is limited by long acquisition times.

Deep learning (DL) models enable advanced reconstruction algorithms that yield regularized images in practical computation times. In this study we evaluate a novel 3D-DL reconstruction to overcome the trade-off between reconstructed quality and acquisition time on MDE data.

Methods

A group of 14 subjects referred for CMR (5 F / 9 M, 59 ± 11 y.o., 78 ± 13 kg) were scanned with a 3D MDE sequence prototype: SPGR with IR preparation, fat & spatial saturation, respiratory navigator, ARC 2x, FOV 40x40cm, ST 1.4-2.4mm, matrix 280²-320², FA 20deg, BW 62.5 kHz, TE 2.1 ± 0.1ms, TI based on a CINE IR scout. All were retrospectively reconstructed using a 3D DL algorithm, trained on a database of over 700 datasets to reconstruct high-quality images with adjustable noise reduction.

The images were compared with standard 3D Cartesian reconstruction by two experienced cardiologists, to identify alterations in morphology or contrast distribution. Noise was estimated using the intensity standard deviation on a blood pool ROI. Feature preservation was estimated using the structural similarity index (SSI).

Results

The new method improved perceived image quality without loss of structural information or resolution (fig 1). Quantitative analysis (fig 2) confirmed these results: The average coefficient of variation in the blood was 0.08 ± 0.02 in the reference and 0.05 ± 0.02 with the new method; Given a target image noise level, DL reconstruction yielded up to 10% better SSI, compared to anisotropic filtering.

The clinical review didn’t reveal diagnostically significant alterations of structure or uptake pattern. A perceived reduction of sharpness was initially reported but individual examination of landmarks (e.g. pulmonary and coronary arteries) confirmed that no relevant features were being lost with the new reconstruction.

Discussion

The 3D MDE images obtained with DL reconstruction improved the trade-off between image noise -estimated by the blood pool intensity deviation- and feature preservation -estimated by SSI-.

Consistent improvement of image quality without morphological alterations of diagnostic relevance indicates that the new method can be considered for clinical practice. The next step in the validation process will require testing the robustness over a large set of cases with heterogeneous acquisition settings.

Conclusion

We presented the preliminary evaluation of a deep learning reconstruction method with 3D myocardial delayed enhancement data. The results show systematic improvement of overall image quality without loss of relevant diagnostic information.

Abstract Figure.

Improving the robustness of MOLLI T1 maps with a dedicated motion correction algorithm

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial T1 mapping constitutes a reliable indicator of heart diseases related to changes of myocardial extracellular content (e.g. oedema, fibrosis) as well as fat, iron and amyloid content.

T1-mapping techniques rely on fitting a model to a series of MRI measurements. Alignment between these measurements is required for accurate T1 estimation. This is limited by triggering accuracy and patient motion. Image registration is often applied to improve the alignment. In the case of MOLLI series, registration is compromised by contrast variation between the images.

We present the validation of a new registration method, designed to account for the contrast properties of MOLLI data.

Methods

A cohort of 186 patients referred for a CMR was included in this study (115 M / 71 F; weight 75 ± 15 Kg; age 55 ± 16). Scans on a 3.0T MR included a MOLLI sequence with target parameters: 2D bSSFP, 160x148, pFOV 0.8-1.0, 1.4x1.4mm², ST 8mm, TE 1.4ms, TR 3.0ms, FA 35deg, NEX 1, BW 100kHz, 2x ASSET, 5(3)3.

Cartesian 2D reconstruction followed by motion correction was applied retrospectively. A new correction algorithm was implemented, based on a similarity criterion that accounted for T1 relaxation: It consisted of an iterative approach alternating polarity estimation, T1 fitting, relaxation simulation and frame registration. The coefficient of determination (R²) was used as a quality measure. A representative subset of the results was reviewed by two experienced cardiologists.

Results

All reconstructions (totalling 1133 2D MOLLI series) yielded qualitatively correct T1 maps. Results with the new method were compared to conventional motion correction and no correction.

The number of pixels with R²>0.95 was 85%±9% with standard motion correction and 90%±7% with the new dedicated method. In terms of improvement w.r.t. uncorrected data, the standard method yielded +3%±8% and the new one +9%±8%. Motion correction caused noticeable performance degradation in 12% of cases with the standard method, compared to 0.2% with the proposed method.

The relative performance of the different methods can be appreciated in Figure 3.

Discussion

Despite T1 mapping techniques constituting a reliable diagnostic tool in cardiac imaging, they remain sensitive to patient motion and triggering inaccuracies, making them vulnerable to arrhythmia episodes.

Improving the similarity criterion by accounting for T1 relaxation significantly decreased the incidence of misregistration and subsequent T1 inaccuracies. Using the R² of the voxel-wise T1 fit as a surrogate of alignment allowed to confirm the increased robustness of the new, dedicated motion correction method for MOLLI series.

Conclusion

We have demonstrated a new reconstruction pipeline with built-in registration, optimized for MOLLI T1-mapping. Using a large database of clinical data, the new method has been shown to improve the robustness to motion of cardiac T1 mapping.

Abstract Figure.

Evolution of cardiac function in COVID 19 patients in the intensive care unit: insights from machine learning

Funding Acknowledgements

Type of funding sources: None.

Background

Repeated echocardiographic assessment of cardiac function is integral in management of intensive care units (ICU) patients. Machine learning (ML) can assist by integrating whole-cardiac cycle echo data derived from flow assessment and deformation imaging, and grouping patients on the basis of patterns of cardiac dysfunction and its evolution over time. Cardiac involvement has been suggested to be important in COVID-19 outcome and echo evaluation can inform on cardiac status. We use unsupervised ML to investigate and integrate longitudinal data from the COVID-HO study (NCT04371679) to determine the potential of tracking changes in cardiac function during ICU hospitalization. 

Methods

In a single-centre, COVID-19 patients (n = 38) were prospectively followed with echocardiography as part of ICU management. The endpoint was defined as death or ICU discharge. LV myocardial deformation, as well as aortic, mitral and pulmonary artery blood-pool Doppler velocity profiles were used as input for ML. Clinical data was used to validate the ML derived phenotypes. Echo data from the initial and final echo examination were used to create an output space where participants were positioned based on cardiac function blinded to outcome status. Regression was used to estimate the echo and clinical characteristics of different regions in the space. Patient trajectories in the output space were investigated for each patient.

Results

Endpoint was not reached in 24% (n = 9) at the time of analysis. The cohort was 68% male, aged 65 ± 12 years, and with an ICU mortality 21% (n = 8). The median spent in ICU was 10 (IQR 7-18) days. The ML analysis demonstrated a heterogeneous output space (Fig 1A) we could define a gradual change in the shape of the pulmonary outflow velocity profile, from a normal  towards pulmonary hypertension (Fig 1A, x axis). Jointly with differences in diastolic function (mitral inflow fusion and A wave accentuation) defined two regions: with signs of pulmonary hypertension (gray); and with normal pulmonary pressures but LV diastolic dysfunction (yellow). Investigation of patient trajectories (Fig 1B) demonstrated the feasibility of tracking changes during ICU hospitalization, showing a shift of a patient that died in the ICU, from initial diastolic dysfunction towards pulmonary hypertension (red), and a patient shifting from a region with normal diastolic function towards pulmonary hypertension, but with a positive outcome (blue). Echo data concurs with observed dynamics (Fig 1C and 1D).

Conclusion

ML can integrate complex, whole-cardiac cycle echo data to group heterogeneous patients based on similarity of cardiac function. Patient trajectories across the output space demonstrate the feasibility of ML for echo data-based follow-up of patients during ICU hospitalization. Further echo and clinical data integration can improve characterisation of the output space regions and better define changes in cardiac function during hospitalization.

Abstract Figure 1

Collapse

Echocardiographic phenotyping of the continuum of myocardial functional remodelling in left ventricular hypertrophy - machine learning validated with cardiac magnetic resonance

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 European Commission Project H2020-MSCA-ITN-2016 (764738) and the Clinical Research in Cardiology grant from the Spanish Cardiac Society

Background

Exploring phenotypes of left ventricular hypertrophy (LVH) and interpreting the relationship of genotype and phenotype are contemporary clinical challenges. Machine learning (ML) can help by integrating whole-cardiac cycle echo data and separating patients based on subtle differences of cardiac function. The aim is to investigate if an unsupervised ML approach has the potential to explore the LVH spectrum and recognize phenotypes related to distinct disease aetiologies and genotypes.

Methods

The cohort consisted of 342 participants: patients with hypertrophic cardiomyopathy (HCM)(n = 27), HCM relatives (n = 31), hypertensive patients (HTN) (n = 189), and healthy individuals (n = 95). All had echocardiography performed, whereas magnetic resonance (MR) and genetic testing were performed when clinically indicated. Myocardial deformation of the LV and left atrium, aortic and mitral blood-pool Doppler, as well as the septal mitral annular tissue Doppler velocity profiles were used as input for ML. Clinical data, including echo measurements, were not part of the learning, but used to validate the ML-derived phenotypes. An unsupervised ML algorithm was used to create an output space where participants were positioned based on cardiac function. Regression was used to estimate the echo and clinical characteristics of different regions in the space. 

Results

The ML analysis of HCM and relative data shows grouping of HCM patients in the right-most region of the output space (Fig 1B). This region was related to LV outflow tract obstruction, mitral inflow fusion, systolic impairment with septal involvement, as well as LA and LV strain impairment (Fig 1A). Clinical data concurred - showing reduced global longitudinal strain, elevated LV mass, and a pattern of systolic and diastolic impairment - defining a comprehensive phenotype of LV remodelling related to HCM. Exploration of the genotype/phenotype relationship revealed G + P- relatives grouping on the transition from the healthy to the remodelling region. Projection of the HTN and healthy individuals into the HCM space defined the LVH disease spectrum, with healthy individuals projecting in the existing healthy region and HTNs in the transition from health to extreme remodelling (Fig 1C). MR findings of late gadolinium enhancement correlated with the ML-derived functional remodelling phenotype (Fig 1C). Furthermore, 6 patients with a clinical need for septal myectomy were located in the extreme remodelling part of the output space (Fig 1C, red circles).

Conclusion

ML can integrate complex, whole-cardiac cycle echo data to group patients based on similarity of cardiac function. Using an interpretable ML approach, we can explore the spectrum of LV remodelling in different aetiologies and interpret the relationship between genotype and phenotype. The methodology can accommodate new patients by projecting them into the existing space to aid in clinical interpretation, risk assessment and patient management.

Abstract Figure 1

Aetiology-discriminative multimodality imaging of hypertrophic cardiomyopathy: deformation patterns relate to synchrotron-based assessment of microstructural tissue remodelling

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 European Commission Project H2020-MSCA-ITN-2016 (764738) and the Clinical Research in Cardiology grant from the Spanish Cardiac Society.

Background

The aetiology of left ventricular hypertrophy (LVH) is a relevant clinical challenge with consequences for patient management. Phenotypes resulting from hypertensive remodelling and sarcomere mutation often overlap. Synchrotron X-ray phase-contrast imaging (X-PCI) is a technique that can provide 3-dimensional detailed information on myocardial micro-structure non-destructively. The aim is to relate macrostructural/functional, non-invasive, imaging phenotypes of hypertrophic cardiomyopathy (HCM) to the underlying myocardial microstructure assessed with X-PCI.

Methods

Myocardial tissue samples were obtained from three patients (P1-3) with obstructive myocardial hypertrophy undergoing septal myectomy. Medical history and the 5-year HCM risk scores were evaluated. The patients were imaged with magnetic resonance imaging and echocardiography prior to procedure. Myocardial structure was assessed with wall thickness, late gadolinium enhancement (LGE), whereas function with speckle-tracking deformation (STE) and tissue Doppler imaging (TDI). Myectomy tissue was imaged with X-PCI in the TOMCAT beamline, using a multiscale propagation-based protocol combining a low-resolution (LR) and a high-resolution (HR) setup (5.8 and 0.7 um pixel size, respectively).

Results

The clinical and imaging data are shown in Fig 1. On initial assessment, wall thickness, LGE distribution, global longitudinal strain and septal TDI demonstrated a similar macrostructural and functional phenotype of P1 and P2, whereas P3 stood out with more severe hypertrophy, scarring and dysfunction. Additional regional deformation analysis with STE revealed reduced deformation in the basal and mid septum in P1, paired with a hypertensive pattern of post-systolic shortening (PSS) (yellow arrows). In comparison, in P2 and P3, deformation was more heterogeneous regionally, with regions of almost complete absence of deformation (orange arrows). Upon further exploration with TDI, areas with abnormal deformation were identified on the transition from basal to mid septum in both P2 and P3, whereas deformation was normal, but reduced in P1, and paired with PSS. LR X-PCI defined regions of interest to scan with HR (yellow frame), where HR revealed extensive interstitial fibrosis (orange arrow) with normal myocyte size and organisation in P1, compatible with severe hypertensive remodelling. However, in P2 and P3, patches of fibrosis (yellow arrow) paired with enlarged myocytes organized in visible disarray, considerably more prominent in P3, were both compatible with sarcomere-mutation HCM.

Conclusion

The results demonstrate multiscale phenotyping of HCM - relating micro- and macrostructural findings to function, and integrating multimodality data. In-depth regional deformation analysis, validated by synchrotron-based microstructural analysis, showed potential to identify distinct imaging phenotypes in HCM, distinguishing between overlapping presentations in different aetiologies.

Abstract Figure 1

4D flow magnetic resonance imaging to assess left atrial haemodynamics in healthy and hypertrophic subjects

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): - University, research centre and hospital foundation grants for the contracting of new research staff (FI 2020) - Spanish Ministry of Economy and Competitiveness Retos investigacion project

Introduction

The assessment of the left atrium (LA) haemodynamics is key to better understand the development of LA-related pathological processes. In this regard 4D flow magnetic resonance imaging (MRI) can provide complementary information to standard Doppler echocardiographic studies and identify complex blood flow patterns. Yet, until recently, the left atrium (LA) has been largely left aside in 4D flow MRI studies.

Purpose

We aimed at assessing the LA haemodynamics of healthy and hypertrophic cardiomyopathy (HCM) subjects with a qualitative visualization of flow patterns and deriving quantitative indices related to ventricular dysfunction from pulmonary veins (PV)  and mitral valve (MV) velocity profiles.

Methods

Segmentation was performed directly over 4D flow angiograms. A total of 20 cases were processed, 11 healthy and 9 HCM subjects. 4D velocity matrices were masked with the segmented mask to isolate LA haemodynamics. Velocity profiles were then obtained in the PV and MV and integrated over planes perpendicular to the lumen of the vessels to create velocity spectrograms. Fourier spectral analysis was applied to the velocity curves to highlight differences that might go unnoticed in the time domain. In addition, the Q-Criterion was computed for vortex identification, visually inspecting both cohorts across the whole cardiac cycle.

Results

Fourier spectral analysis of the velocity curves suggested that overall, healthy patients have higher dynamic range of the velocity curves. It can be observed in Figure 1, that the usual E/A MV velocity pattern is preserved in 10 of the 11 healthy subjects while 5 of the HCM patients present significant alterations of said curve. In fact, patients 4, 6, 7 and 8 seem to present a 3 peaked MV velocity curve. The vortex analysis identified 3 main types of vortices in healthy subjects: a ‘filling’ systolic vortex (10/11) arising near the most dominant PV (usually the left superior PV) as seen in Figure 2; a conduit phase vortex (7/11), similar in nature to the preceding systolic vortex; and an E-wave vortex (9/11) attached to the LA ostium. Four of the HCM patients (out of the five with altered MV velocity profile) also showed a systolic vortex, but with more complex blood flow patterns and emerging far from the PVs. One of such vortices is shown in Figure 2, composed of two distinct eddies near the MV. The E-wave vortex was also observed but was less predominant than in healthy subjects (3/9).

Conclusions

4D Flow analysis of the LA is feasible and might hold promise in the understanding of the complex haemodynamics in ventricular dysfunction.

Abstract Figure. Velocity Spectrograms and Vortices

Interatrial block is related to atrial dysfunction in hypertensive subjects

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): La Marató TV3

Background

Interatrial block (IAB), a delay of conduction of the sinus stimulus from right to left atria (LA), is defined as surface ECG P-wave duration ≥120 ms. Arterial hypertension (AH) and IAB have been related to development of atrial fibrillation.

Aim

To investigate the IAB prevalence in a cohort of AH patients and relate it to LA function.

Methods

162 patients with well-regulated AT were included. 12-lead ECG were performed and analysed with a digital caliper. 2D and 3D echocardiography were performed, and LA function assessed with speckle-tracking deformation imaging. 

Results

The median age was 56 ± 6 years, 54% were males. Average duration of AH was 10 ± 6 years. IAB was seen in 25% of AH patients.  The comparison between groups is shown in Table 1. There were no differences in demographic characteristics,  QRS complex duration (p = 0.179) or left ventricular (LV) size and function between subgroups. LA was enlarged in IAB patients, which was coupled with impairment of the LA reservoir strain. 

Conclusion

Our results show considerable prevalence of IAB in AH patients. The demonstrated LA enlargement and function impairment is not associated with LV dysfunction, therefore suggesting an independent role of IAB in atrial remodeling.

Table 1 Interatrial block P value Yes (n= 40) No (n= 142) Age 59 (54-62) 57 (53-61) 0.157 Female gender 16 (40%) 58 (48%) 0.467 Duration of Hypertension (years) 10 (6-12) 8 (5-15) 0.421 Systolic blood pressure (mmHg) 136 (125-150) 136 (127-147) 0.799 Diabetes 3 (8%) 16 (13%) 0.410 LVEDV (mL) 73 (63-91) 71 (57-87) 0.424 E/A 0.98 (0.84-1.25) 0.94 (0.79-1.11) 0.230 E/e’ 7.0 (4.9-8.9) 6.6 (5.2-8.4) 0.779 LVEF (%) 63 ± 7 64 ± 6 0.864 LV global longitudinal strain (%) 21.22 ± 2.63 21.19 ± 2.30 0.932 3D LA maximal volume (mL/m2) 36 (30-39) 30 (26-37) 0.028 3D LA minimal volume (mL/m2) 16 (12-18) 14 (11-17) 0.050 LA reservoir strain (%) 27.64 (24.90-31.23) 29.55 (26.17-32.81) 0.032 LA conduit strain (%) 13.91 (10.71-15.47) 14.37 (11.75-16.72) 0.192 LA contractile strain (%) 14.46 (11.86-16.59) 15.52 (13.66-16.96) 0.079 LVEDV Left Ventricular End Dyastolic Volume

Cardiac remodeling in a fetal growth restriction cohort – a follow-up study from preadolescence into adolescence

Background and aim

The persistence of cardiovascular changes in fetal growth restriction (FGR) has been demonstrated from prenatal to preadolescent age, supporting the hypothesis of primary cardiac programming in FGR and the association between low birth weight and cardiovascular risk in adulthood. The aim was to follow-up the FGR cohort and explore the cardiac function and shape in adolescence.

Methods

FGR was defined by estimated fetal weight and birth weight below the 10th centile, while the control group consisted of normally grown fetuses with birth weight above the 10thcentile. The patients were followed from preadolescence (8–12 years of age) to adolescence (12–17 years of age) with 2-D echocardiography and deformation imaging. The adolescent participants underwent a cardiopulmonary exercise test, where echocardiography was performed at peak exercise. Sphericity index was calculated as the ratio of the LV apex-to-base length and LV basal diameter, measured in 4-chambre view.

Results

The cohort included 56 participants: individuals with FGR (n=22) and controls (n=34). The mean follow-up was 4.4±0.5 years. The preadolescent FGR cohort was younger (10 vs. 11 years, p=0.004), of shorter height, and lower body weight. In FGR, the trend in smaller LV end-diastolic volumes (LVEDV) was paired with a shorter apex-to-base length (63 vs. 68 mm, p=0.006), and a significantly more spherical LV (1.9 vs 2.0, p=0.004). While the LV ejection fraction was preserved, the LV global longitudinal strain (GLS) was reduced (21.21 vs 22.45%, p=0.001) and the relaxation time impaired. In the follow-up adolescent cohort, there were no differences in height, weight, LV dimensions, LV sphericity, LV GLS or relaxation time. During the follow-up period, the FGR cohort had a significantly higher increase in weight (40 vs. 31%, p=0.016) and BMI (18 vs. 11%, p=0.008). The same was seen in cardiac dimensions, showing a higher increase in LVEDV (35 vs. 27%, p=0.049) and the LV base-to-apex length (24 vs. 17%, p<0.001) (Figure 1); but equal increase of the LV basal diameter (p=0.770), resulting in a difference in the change of LV sphericity (0 vs. −13%, p=0.007) between subgroups. The rise in LVGLS was also higher in the FGR cohort (6 vs. 1%, p=0.049). During the exercise test there was no difference in maximal workload (112.5 vs. 125 Watts, p=0.981) or oxygen consumption (28.8 vs. 29.1 mL/min/kg, p=0.076). At peak exercise no differences were seen in cardiac dimensions, LV diastolic or systolic function.

Conclusion

The results suggest changes in cardiac shape and function, described in individuals with FGR in prenatal and preadolescent age, seem to be ameliorated in adolescence related to compensatory growth as compared to healthy controls. These findings offer novel information in the research of elevated cardiovascular risk in adults with FGR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Is Isolated tricuspid regurgitation different from functional tricuspid regurgitation?

Introduction

Isolated tricuspid regurgitation (TR) prevalence is increasing in the last decades. Its presence is associated with a worse prognosis when EROA is >40 mm2. Because of high surgery risk and increasing incidence, isolated TR is a challenge in modern cardiology.

Purpose

To evaluate the prevalence and characteristics of isolated TR compared to other TR aetiologies in a large cohort of patients.

Methods

Prospective study where consecutive patients undergoing an echocardiographic study within a three-month period were included. All studies with at least moderate TR were selected. Isolated TR was defined as TR with no likely pulmonary hypertension (>50 mmHg), no overt TR cause (no intrinsic tricuspid disease, LVEF ≥50%, no pacemaker/defibrillator wire across the tricuspid, no other significant valve disease, no disease that may cause TR, no congenital or pericardial heart disease); and no previous valve surgery. Patients with isolated TR and other aetiologies were compared.

Results

2121 patients with at least moderate TR were included. Isolated TR was found in 398 patients (18.8%). Basal characteristics are shown in table 1. Patients with isolated TR did not have a higher prevalence of AF (47.5% vs. 48.6% p=0.362). Isolated TR was less severe (20.5% vs. 32.1% of patients with severe TR; p<0.001) and less symptomatic (NYHA ≥ II in 27.8% of patients vs. 69.3%; p<0.001).

After selecting patients with at least severe TR, patients with isolated TR were also less symptomatic (NYHA≥II in 47.8% of patients vs. 70.7%; p<0.001) and they had better RV function (TAPSE <17 mm in 13.4% vs. 35.6%; p=0.001).

We found that patients with isolated severe TR had a larger tricuspid annulus diameter (25.4±0.8 mm/m2 vs. 24.0±0.3 mm/m2; p=0.047).

Conclusions

In this large prospective study, isolated TR is present in 18.8% of significant TR. Isolated TR was less severe, was associated with less RV dilatation (but with larger tricuspid annulus diameter) and patients had a better functional class compared to other TR aetiologies.

Differeces in NYHA and RV function

Funding Acknowledgement

Type of funding source: None

Long-term follow-up of patients with Chagas cardiomyopathy living in a non-endemic area: moving towards identification of early markers of disease progression

Background

The number of patients with Chagas disease residing in Europe has increased significantly due to migration flows. Globally, Chagas cardiomyopathy has worse prognosis than other types of dilated cardiomyopathies and about 30% of patients develop cardiac involvement after a variable latency period (10–30 years). However, there is lack of data regarding the evolution of patients with Chagas disease living in a non-endemic area and potential early predictors of disease progression.

OBJETIVE

To describe the natural course of Chagas disease, the incidence rate of transformation into cardiac form and to assess if early predictors of myocardial involvement translate into a worse long-term prognosis in our non-endemic cohort.

Methods

Clinical and echocardiographic follow-up was performed in 202 individuals from endemic areas of Chagas disease. At baseline, electrocardiogram, BNP and a comprehensive echocardiography including diastolic function and longitudinal myocardial strain were performed. Four different groups were defined: healthy controls (N=77); Chagas indeterminate form (positive serology, normal ECG and left ventricle (LV) dimensions and LV ejection fraction (>50%) and no segmental abnormalities, N=92); Chagas patients with abnormal ECG but normal LV dimensions and motility (N=15); and Chagas patients with LV diameter>55 mm or LV ejection fraction<50% or segmental abnormalities (N=18). The primary clinical outcome included advanced atrioventricular block, sustained ventricular tachycardia, heart failure, heart transplant, death or progression of cardiac disease defined as LV systolic dysfunction or new segmental abnormalities. Kaplan Meier with Long rank test and Cox regression analysis was used.

Results

Mean age was 37±9 and 34% were male. Median follow-up was 69 months (range 1 to 147). The primary endpoint occurred in a total of 17 (8.4%) individuals: 5 (5.4%) in the Indeterminate group; 3 (20%) in the abnormal ECG group; and 9 (50%) in the group with abnormal LV dimension or motility, with no events among controls (long-rank test<0.01, Figure 2). Six patients evolved from the indeterminate phase to cardiac involvement (2 with isolated ECG changes and 4 with abnormal echocardiography without previous changes in ECG (Figure 1). On echocardiography, there were no differences regarding changes in LV dimensions or LV ejection fraction between Chagas patients with normal baseline echo and controls, but a significantly reduction of Em was observed (−1.6±3.0 vs. 0.2±1.0) in the former. Excluding patients with abnormal echo at baseline, BNP (HR=1.03, p=0.001), Em (HR=0.78, p=0.05) and left atrial diameter (1.23, p=0.01) were predictors of the combined event.

Conclusions

Conversion from the indeterminate to Chagas cardiomyopathy in our cohort was approximately 1.1%/year, but it may happen directly with contractility disturbances. BNP and comprehensive echocardiography may help to early detect disease progression.

Figure 1. Distribution of patients and KM curves

Funding Acknowledgement

Type of funding source: None

Inflammation and fibrosis biomarkers are related to atrial dysfunction in patients at risk of atrial fibrillation

Introduction

Arterial hypertension mitral regurgitation and endurance training are risks factors for incidental atrial fibrillation (AF). Left atrial (LA) remodeling in the context of volume and pressure overload may be the substrate for AF development. Inflammation and subsequent fibrosis may be related to the development of this atrial remodeling. Our aim was to analyze if there is any correlation between inflammation and fibrosis biomarkers and left atrial dysfunction in blood samples of subjects with hypertension or mitral regurgitation and in endurance athletes.

Methods

A population of 478 subjects at risk of atrial fibrillation were enrolled to this study. The cohort was composed by 275 endurance athletes, 185 patients with arterial hypertension and 32 with moderate to severe mitral regurgitation. All patients underwent 2D (two-dimensional) echocardiography with speckle-tracking analysis (LA strain and LA strain-rate) and 3D (three-dimensional) echocardiography to assess LA volume and volume-based function. Furthermore, blood samples were obtained to measure plasma levels of BNP, troponin-I and the following fibrosis and inflammatory biomarkers: MMP-9 (Matrix Metalloproteinase 9), CXCL16 (CXC chemokine), CXCL6, FABP3, PIGF, OSM, endocan-1.

The whole cohort was divided into quartiles according to their reservoir strain value (surrogate of atrial relaxation impairment), and correlation between biomarkers, atrial 2D volumes and 3D volumes was calculated.

Results

Quartile ranges regarding reservoir strain (RS) were: 1st quartile (<28.9%), 2nd quartile (28,9%-32,1%), 3rd quartile (32,95–35,4), 4th quartile (>35,4%).

The first quartile (worse left atrial reservoir function) was mainly composed by hypertensive and mitral regurgitation subjects while the 4th quartile (with larger left atrium but better reservoir function) was mostly integrated by athletes. The 1st quartile (worse atrial function) showed higher levels of fibrotic (MMP-9) and inflammatory biomarkers (CXCL16, FABP3, PIGF, BNP, Troponin-I and PIGF) as compared to the other quartiles.

Conclusions

Inflammation and fibrosis biomarkers (CXCL16, FABP3, PIGF and MMP-9) are higher in subjects with worse LA reservoir function. This suggests a correlation among inflammation (fibrosis) and atrial dysfunction in a population at risk for AF development.

Biomarkers according RS quartiles

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Fundaciό La Maratό de TV3

Electromechanical delay by speckle-tracking echocardiography: a novel tool for distinguishing between Brugada syndrome and isolated right bundle branch block

Background

The electrocardiographic (ECG) definition of Brugada syndrome (BS) can be challenging because benign ECG abnormalities, such as right bundle branch block (RBBB), may mimic pathological ECG characteristics of BrS. However, although myocardial delay and deformation can be quantified by advanced imaging, it has not yet been used to differentiate between BrS and RBBB.

Purpose

The aim of this study was to characterize the electro-mechanical behavior of the heart of patients with type-1 BrS and subjects with isolated complete RBBB in order to differentiate these conditions.

Methods

In this two-center study, 66 subjects were analyzed by standard and speckle-tracking echocardiography (STE): 22 type-1 BrS, 24 isolated complete RBBB, and 20 healthy subjects. The participants were not treated by any drug potentially influencing myocardial conduction.

Results

Standard echocardiographic parameters did not differ among the groups. STE demonstrated that right ventricular (RV) mechanical dispersion (MD) was greater in RBBB as compared to BrS and controls (p<0.05). In patients with isolated RBBB, the greatest delay of RV time-to-peak longitudinal strain (TTP) was found in RV free-wall basal segments. Mean absolute deviations of TTP calculated for each left ventricular (LV) region were greater in patients with RBBB as compared to those with BrS and to controls with a localisation of the delay in LV antero-septal, anterior, lateral, and infero-septal basal segments (figure 1).

Conclusions

Advanced echocardiographic techniques may help to differentiate between BrS and RBBB. Indeed, STE allows to identify an electro-mechanical conduction delay in RBBB patients that is not found in patients affected by type-1 BrS.

Electromechanical delay by STE

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Italian Society of Cardiology

Aortic stiffness and distensibility in elite athletes: impact of discipline and gender

Background

Aortic remodeling in athletes is variable among sports disciplines with more ascending aorta (Asc Ao) dilatation in endurance (EAs) as compared to power athletes (PAs). Nevertheless, the impact of this differential remodeling on the Asc Ao functional properties is not well established. The aim of this study was to assess the distensibility and stiffness of the ascending aorta in endurance and power elite athletes in order to evaluate if this aortic remodeling implies functional changes.

Methods

119 elite athletes (61 EA and 58 PA, 49% female sex, mean age: 18.7±7.1 years) underwent standardized pre-participation screening with 12 lead ECG, transthoracic echocardiography and maximum stress test. Asc Ao diameter was measured from parasternal long axis views in 2D echocardiography. The aortic distensibility index (ADi) was calculated as 2 × (systolic Asc Ao diameter − diastolic Asc Ao diameter) / (diastolic Asc Ao diameter) × (pulse pressure) (cm–2 dyn–1 10–6). Aortic stiffness (AS) index was defined as Ln (systolic blood pressure/diastolic blood pressure) / (systolic Asc Ao diameter − diastolic Asc Ao diameter)/diastolic proximal Asc Ao diameter.

Results

Globally, EA presented larger AscAO, both in absolute and indexed values, than PA (28±3.0 vs 26±3.0cm, p<0.001 and 16.4±1.5 vs 15.7±1.9cm, p<0.05, while were no differences in AS or ADi) (Figure 1A). Nevertheless, ADi in male EAs was higher than in male PAs (ADi: 4.3±1.7 vs 3.2±1.3 cm2/dyn/10–6, p<0.05) and AS was lower (AS: 4.7±1.7 vs 6.3±3.8, P<0.005) (Figure 1B and 1C). Female athletes presented higher ADi (ADi: 4.7±1.9 vs 4.0±1.6 cm, p<0.05) and a trend towards lower AS (4.8±2.9 vs 5.1±2.6, p: 0.4) than male athletes. There were no differences in AS or ADi between female EAs and PAs.

Conclusion

Male EAs showed an increased aortic distensibility with lower stiffness as compared to that observed in male PAs. This difference was not observed in female EAs and PAs, potentially due to better baseline distensibility with less room for improvement with endurance training.

Funding Acknowledgement

Type of funding source: None

Left atrial performance during exercise in endurance athletes: the impact of gender

Background

High-intensity endurance training is associated with an increased risk of atrial fibrillation (AF) in male athletes while it seems to have a protective effect for the development of atrial arrhythmias in female athletes. Mechanisms underlying this fact are unknown but a differential atrial adaptation to exercise may be involved.

Aim

To evaluate left atrial (LA) performance during exercise in endurance athletes (EAs) of both sexes.

Methods

Highly-trained (>10 hours training/week) EAs performed a maximal cardiopulmonary exercise test. LA evaluation was performed at rest and immediately after exercise. LA analysis consisted of standard and speckle-tracking assessment: atrial contractile, reservoir and conduction strain.

Results

80 EAs (55% women, 34.8±5.8 years) were enrolled. Baseline LA size and functional parameters were similar in both sexes (Table 1). Compared to men, women achieved a higher predicted VO2max (Δchange+11.9%, p<0.01) but a similar increase of systolic blood pressure (Δ+63 vs +66%, p=0.58). Exercise induced a mild decrease in LA size but of similar amplitude for both sexes. LA strain parameters of EAs improved with exercise, but a significantly greater improvement in LA reservoir and conduit function was noted in women compared to men. In EAs with marked atrial remodelling (LA ≥35ml/m2), the same trend of greater improvement of LA reservoir and conduit function in women persisted.

Conclusion

In highly-trained EAs, premenopausal women have better LA function profile during exercise compared to men, even when the LA is significantly dilated. This discriminatory LA adaptation in female EAs could at least partly explain the dichotomous relationship between AF and exercise regarding sexes and warrants further studies to clarify the underlying mechanism.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Government of Spain - Plan Nacional I+D, Ministerio de Economia y Competitividad

Left atrial adaptation to different overloads: is atrial enlargement always related to atrial dysfunction?

Introduction

The adaptative response to different loading conditions of the left atrium (LA) has been scarcely studied. This might have clinical implication in terms of risk of emboli and atrial fibrillation development. Our aim is to assess function in enlarged LA with 3-dimensional (3D) echocardiographic volume assessment and speckle-tracking deformation analysis, and compare findings between patients with arterial hypertension (HTN), mitral regurgitation (MR) and endurance athletes (EA).

Methods

A population of 478 subjects were enrolled: 57% (n=273) EA, 37% (n=176) patients with well-controlled HTN and 6% (n=29) with moderate-to-severe MR. From this cohort, we selected the patients with enlarged atriums defining a 2D cut-off value of ≥34 mL/m2. These patients underwent 2D and 3D echocardiography. LA function was assessed with speckle-tracking analysis and phasic volume indices.

Results

LA enlargement was seen in 63% (n=299) of the cohort: 80% (n=219) of EA, 30% (n=53) of HTN and 93% (n=27) of MR patients. Analysis of LA function in these patients is shown in Table 1. As expected, MR was related to the largest LA volumes, followed by athletes - which had significantly larger volumes than HTN patients. LA reservoir strain and LA ejection fraction, as well as LA conduit strain and LA passive Ejection Fraction, were preserved in the athletes group while reduced in HTN and MR, whereas the LA contractile strain and LA active Ejection Fraction were reduced only in the MR subgroup.

Conclusions

These findings suggest that LA adapts differently to pressure and volume overload and also influenced by the amount of overload. Additionally, LA enlargement may not be associated with the same degree of LA dysfunction in different at-risk populations.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Fundaciό La Maratό de TV3

Prevalence and pattern of cardiovascular magnetic resonance late gadolinium enhancement in highly trained endurance athletes

BACKGROUND

Intensive endurance exercise may induce a broad spectrum of right ventricular (RV) adaptation/remodelling patterns. Late gadolinium enhancement (LGE) has also been described in cardiovascular magnetic resonance (CMR) of some endurance athletes and its clinical meaning remains controversial. Our aim was to characterize the features of contrast CMR and the observed patterns of the LGE distribution in a cohort of highly trained endurance athletes.

METHODS

Ninety-three highly trained endurance athletes (> 12 h training/week at least during the last 5 years; 36 ± 6 years old; 53% male) and 72 age and gender-matched controls underwent a resting contrast CMR. In a subgroup of 28 athletes, T1 mapping was also performed.

RESULTS

High endurance training load was associated with larger bi-ventricular and bi-atrial sizes and a slight reduction of biventricular ejection fraction, as compared to controls in both genders (p < 0.05). Focal LGE was significantly more prevalent in athletes than in healthy subjects (37.6% vs 2.8%; p < 0.001), with a typical pattern in the RV insertion points. In T1 mapping, those athletes who had focal LGE had higher extracellular volume (ECV) at the remote myocardium than those without (27 ± 2.2% vs 25.2 ± 2.1%; p < 0.05).

CONCLUSIONS

Highly trained endurance athletes showed a ten-fold increase in the prevalence of focal LGE as compared to control subjects, always confined to the hinge points. Additionally, those athletes with focal LGE demonstrated globally higher myocardial ECV values. This matrix remodelling and potential presence of myocardial fibrosis may be another feature of the athlete's heart, of which the clinical and prognostic significance remains to be determined.

129Magnetic resonance predictors of ventricular tachycardia recurrence after radiofrequency substrate ablation: septal and transmural channels

 

Ventricular tachycardia (VT) substrate-based ablation has become a gold standard in patients with structural heart disease. Success of VT ablation is related with mortality reduction.

Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is a powerful technique to assess substrate of VT. Myocardial fibrosis is electrically inert (Core) but it is surrounded by a ‘‘border-zone (BZ)’’ where normal cardiomyocytes intermingle with dense bundles of fibrosis. Slow impulse conduction in the BZ allows for the re-entry circuits leading to VT. Both the presence and extent of LGE have been associated with VT and SCD risk. LGE-CMR tissue characterization can be depicted as pixel signal intensity (PSI) maps and can guide VT ablation.

The aim of this study was to analyze possible VT recurrence predictors in a long term follow-up of patients that underwent VT ablation (endo and/or epicardial) related with LGE-CMR PSI maps.

We analyzed 234 consecutive patients (age: 63.2 ± 14 years, follow-up: 3.14 years ±1.8) undergoing VT ablation with scar-dechannelling technique at a single center from 2013 to 2018.  110 patients underwent a preprocedural LGE-CMR, and in 94 patients (85,5%) a CMR-aided ablation using the PSI maps was performed.

All LGE-CMR images were semi-automatically processed using a dedicated software. PSI-based algorithm was applied to characterize the hyperenhanced area as core or BZ, using fixed threshold of the maximum intensity. A LV 3D shell was obtained and were imported into the navigation system. In the PSI maps, heterogenous tissue channels were defined as a continuous corridor of BZ surrounded by scar core or an anatomic barrier that connects 2 areas of healthy tissue.

Results

Overall recurrence of VT was 41.8 %. There was ICD shock reduction, from 43,6% to a 28,2% (ICD shocks before ablation 2,23 ± 7,32, after: 1,10 ± 2,92).

Left ventricle mass predicted significantly VT recurrence (Mean 168,3 ± 53,3 vs 152,3 ± 46,4 g, HR 1,02 [1,01-1,02], p &lt; 0.001). LGE distribuition was predictive of VT recurrence when a more than 40% of the interventricular septum was involved (62,5% vs 37,8%; HR 1,6 [1,01-1,02]; p = 0,044). No differences in recurrence were found among the patterns of LGE distribution (transmural/epicardial/subendocardial or peculiar segments localizations). The amount of BZ and the total amont of Core + BZ was related with VT recurrence (BZ 26,6 ± 13,9 vs 19,56 ± 9,69 g, HR 1,03 [1,01-1,06], p = 0,012; total Core + BZ 37,1 ± 18,2 vs 29,0 ± 16,3 g, HR 1,02 [1,00-1,04], p = 0,033). Finally VT recurrence was higher in patients with channels with transmural path (66,7% vs 31,4%, HR 3,25 [1,70-6,23], p &lt; 0,001) or midmural channels (54,3% vs 27,6%, HR 2,49 [1,21–5,13], p = 0,013).

CMR-aided scar dechanneling is a helpful and feasible technique which could identify patients with high risk of VT recurrence. High left ventricular mass, septal LGE distribution, transmural and midmural heterogeneous tissue channels were predictive factors of post ablation VT recurrence.

Abstract Figure. VTchannel & heterogeoneus tissue channel

P1163Correction of septal flash excursion with his bundle pacing

Funding Acknowledgements

Grant from the Catalan Society of Cardiology

Background

His bundle pacing (HBP) directly stimulates the conduction system and could therefore correct asynchrony and evolve as a more physiological pacing approach. Septal flash (SF) is a fast contraction and relaxation of the septum occurring during the isovolumetric contraction period. It is a specific marker of cardiac dyssynchrony.  

Purpose

Evaluate whether HBP corrects SF in patients with an indication for CRT or RV pacing.

Methods

A cohort of 20 consecutive patients undergoing HBP at our center was analyzed. HBP indications were:  Group A (n = 3): left bundle branch block (LBBB) and left ventricular (LV) dysfunction (LV ejection fraction [LVEF] &lt; 35%); Group B (n = 14): LV dysfunction (LVEF &lt; 50%) and atrio-ventricular block requiring permanent pacing; Group C (ablate&pace, n = 3): atrio-ventricular node ablation due to rapid atrial fibrillation.

Patients in groups B and C had a RV backup lead implanted, in line with current recommendations. The presence of SF was analyzed in 2D-echocardiography at 15 days post-implant. SF excursion was quantified using M-mode in parasternal short and long axis views as the highest amplitude of the early inward motion. Baseline SF excursion was determined during intrinsic rhythm (group A) or RV pacing (groups B and C). For each patient, the pair of measurements (baseline, HBP) in the axis with the highest baseline SF was selected.

Results

Mean LVEFs were 21 ± 8%, 32 ± 6%, and 41 ± 18% for groups A, B and C, respectively. HBP shortened QRS duration by 42 ± 15 ms and 45 ± 23 ms in groups A (Baseline QRS - HBP QRS) and B + C (RV pacing QRS - HBP QRS), respectively. At baseline, all patients except 1 had SF (Fig. 1A). The mean SF excursion was 4.3 ± 1.9 mm, with SF excursion being larger in group A than in the RV-paced groups (6.3 ± 1.5 mm vs. 3.9 ± 1.8 mm for groups A and B + C, respectively, p = 0.04). HBP abolished SF in 3 patients (15%) and, on average, decreased SF excursion by 2.3 mm (95% CI 1.3-3.2), irrespective of pacing indication (Fig. 1B). The degree of SF excursion reduction after HBP significantly correlated with QRS shortening (r = 0.53, p = 0.024) (Fig 1C).

Conclusions

In conclusion, we show that HBP results in acute correction or decrease of SF, thereby improving LBBB- or RV-induced mechanical dyssynchrony.

Abstract Figure. Septal Flash and His pacing

P1129Bipolar voltage cut-off validation in electroanatomical voltage mapping to identify scar and conduction channels in ventricular tachycardia ablation: need for new cut-off in NICM

Background/Introduction

Substrate-guided techniques have changed the approach and results of ventricular tachycardia (VT) ablation and electroanatomical voltage mapping (EAVM) constitutes a diagnostic and therapeutic cornerstone in this field. In current practice normal myocardium is typically characterized by bipolar voltage &gt; 1.5 mV, dense scar &lt; 0.5 mV, and border zone (BZ) tissue by the range between 0.5 to 1.5 mV. Of note, evidence for these cut-off values has been derived in humans from small observational studies and in animals. Furthermore, some studies suggest that only the 60% of not transmural endocardial scars and the 35% of not endocardial scars are detected without any adjustment of these values. New voltage cut-off values are needed.

Purpose

The purpose of this study is to adjust voltage cut off in order to establish the threshold that more accurately define the pathological substrate in VT ablation. Additionally, predictors of usefulness of current thresholds are analyzed.

Methods

EAVM were created with CARTO3 System and Sensor-Force catheter (Navistar Smart-Touch and Pentaray). We delineated the conducting channels by analyzing the late potentials activation. Based on these channels we looked for the best cut-off values to detect these channels. We describe the baseline characteristics, the best cut-off values for border zone and scar core in our series and we analyzed the accuracy of the current established values to detect the arrhythmogenic VT substrate

Results

We investigated 51 patients (74,5% males; 41,2% ischemic cardiomyopathy, mean LVEF 38,6% +/-13,6) with sustained monomorphic VT submitted to ablation during 2016 and 2017. The range of the voltage adjustment was from 0,01-1 mV for core area and 0,2-6mV as maximum, with an average of 0,31-1,42mV. Using currently accepted bipolar voltage cut-off &lt;0.5 mV the core scar was correctly identified in 80,4% of patients: 90,4% in ischemic and 73,3% in NICM. Regarding BZ, using classical cut off (0.5-1.5mV) only 56,9 % of the cases were well identified: interestingly, accuracy was worse in NICM (46,6%) than in ischemic patients (71,4%) (p = 0,07).

Conclusions EAVM is very important to detect scar and channels in VT ablation, but several elements can affect it and recently the traditional voltage values have been questioned. Our study suggests how the threshold as currently applied in daily practice could be acceptable to detect the core scar area, but it has to be reconsidered in NICM, especially regarding the border zone. An evident trend (p = 0,07) suggests a better accuracy of current values to define VT substrate in ischemic patients than in NICM.

Abstract Figure. Channel Identification

Three-dimensional regional bi-ventricular shape remodeling is associated with exercise capacity in endurance athletes

AIMS

Endurance athletes develop cardiac remodeling to cope with increased cardiac output during exercise. This remodeling is both anatomical and functional and shows large interindividual variability. In this study, we quantify local geometric ventricular remodeling related to long-standing endurance training and assess its relationship with cardiovascular performance during exercise.

METHODS

We extracted 3D models of the biventricular shape from end-diastolic cine magnetic resonance images acquired from a cohort of 89 triathlon athletes and 77 healthy sedentary subjects. Additionally, the athletes underwent cardio-pulmonary exercise testing, together with an echocardiographic study at baseline and few minutes after maximal exercise. We used statistical shape analysis to identify regional bi-ventricular shape differences between athletes and non-athletes.

RESULTS

The ventricular shape was significantly different between athletes and controls (p < 1e-6). The observed regional remodeling in the right heart was mainly a shift of the right ventricle (RV) volume distribution towards the right ventricular infundibulum, increasing the overall right ventricular volume. In the left heart, there was an increment of left ventricular mass and a dilation of the left ventricle. Within athletes, the amount of such remodeling was independently associated to higher peak oxygen pulse (p < 0.001) and weakly with greater post-exercise RV free wall longitudinal strain (p = 0.03).

CONCLUSIONS

We were able to identify specific bi-ventricular regional remodeling induced by long-lasting endurance training. The amount of remodeling was associated with better cardiopulmonary performance during an exercise test.

P1427 Mechanical dispersion assessed with echocardiography versus scar characterization with cardiac magnetic resonance to predict malignant arrhythmia in cardiac resynchronization therapy patients

Background

Recent data have shown that scar characterization with late gadolinium enhancement magnetic resonance (LGE-CMR) is useful to predict malignant arrhythmic events in a cardiac resynchronization therapy (CRT) population. On the other hand, echocardiography 2D strain parameters (such as mechanical dispersion – MD) have been recently suggested as a predictor of ventricular arrhythmia (VA).

Purpose

To compare the usefulness of strain echocardiography and MR scar parameters to predict VA and sudden cardiac death (SCD) in CRT patients (pa).

Methods

110 pa undergoing CRT implant were included. A 2D strain echo and a 3D LGE-CMR were performed before the implant. In the echocardiographic exam, left ventricle ejection fraction (LVEF), global longitudinal strain (GLS), mechanical dispersion (MD) and delta contraction time were quantified. Regarding LGE-CMR, scar mass, border zone (BZ) mass and the presence of BZ channels were assessed with specific software. The primary endpoint was the presence of SCD or appropriate implantable cardioverter-defibrillator therapy at long-term follow-up (FU).

Results

The primary outcome occurred in 23 pa (20.9%) during a mean FU of 53.5 ± 10.4 months. In these pa, MD was significantly increased (130.3 ± 55.5ms vs. 102.0 ± 45.1ms, p &lt; 0.05) whereas LVEF, GLS and delta contraction time were not significantly different. All LGE-CMR parameters were significantly increased in PA with events. At multivariate analysis, both MD and LGE-CMR parameters were independent predictors of malignant arrhythmia (table). The MD cut-off value for prediction of VA was 80.88 ms, with 91.3% sensitivity and 36.8% specificity. The figure shows the Kaplan-Meier curves. Regarding LGE-CMR parameters, the cut-off value, sensitivity, and specificity were 13.8g/82.6%/81.6% for scar mass, 5.54g/85.7%/81.8% for BZ mass, and 90.9%/82.1% for presence of BZ channels.

Conclusions

MD and LGE-CMR scar parameters are independent predictors of VA and SCD in CRT. Due to its high sensitivity, MD could be used to identify pa at high arrhythmic risk that could benefit from a more complex and specific LGE-CMR study.

Multivariate analysis Model 1 Model 2 Model 3 HR (95% CI) p HR (95% CI) p HR (95% CI) p Basal LVEF 1.01 (0.94-1.09) 0.731 1 (0.93-1.07) 0.974 1.04 (0.97-1.11) 0.273 MD (ms) 1.01 (1.00-1.02) 0.043 1.01 (1.00-1.02) 0.017 1.01 (1.00-1.02) 0.003 BZ mass (g) 1.08 (1.05-1.11) &lt;0.001 Presence of BZ channels 18.39 (4.26-79.51) &lt;0.001 Scar mass (g) 1.06 (1.04-1.08) &lt;0.001 LVEF: left ventricle ejection fraction; MD:mechanical dispersion; BZ:border zone

Abstract P1427 Figure. Kaplan-Meier curves

P735 Septal curvature - a novel, semi-automated parameter to aid in recognition of basal septal hypertrophy in arterial hypertension

Funding Acknowledgements

Horizon 2020 European Commission Project MSCA-ITN-2016 (764738), Grant from Fundacio La Marató de TV3 (040310).

Background and aim

Localized basal septal hypertrophy (BSH) is a known marker of increased afterload and localized deformation impairment, and can be seen in one-fifth of patients with arterial hypertension. Although there is variability in the classification, BSH is mainly defined from ratios between several wall thickness measurements. We hypothesize that the curvature of the septum is reflective of localized hypertrophy and will be significantly increased in patients with BSH. Speckle tracking endocardial delineations of the left ventricle (LV) can be used to quantify curvature, with the potential to create a novel, semi-automatized parameter for recognition of patients with an increased impact of afterload on cardiac structure and function.

Methods

An echocardiogram was performed on a total of 149 patients with a diagnosis of long-standing hypertension, treated with at least one antihypertensive drug and on 19 healthy age and sex-matched controls. The interventricular septum thickness was measured at basal and mid-level in the parasternal long axis (PLAX) and 4-chamber (4C) views. BSH was identified from a two-part criterion: both a positive visual assessment of an abrupt change in septal thickness seen in the 4C or PLAX views and a basal to mid-septal ratio ≥ 1.4. A dedicated software for speckle tracking was used to trace the endocardial border of the LV in 4C and 3C view. In post-analysis, we quantified the maximal curvature of the antero- and inferoseptal segments from the exported myocardial contour. Curvature, measured in m-1, was defined as the reciprocal value of the radius of the circle fitted into the curve defined by three subsequent neighboring points in the myocardial contour. Curvature was considered negative if the curve was convex with respect to the LV long-axis.

Results

Using septal wall thickness measurements, 19% (n = 28) of hypertensive patients were classified as having BSH, whereas all healthy controls had normal geometry. Basal antero- and inferoseptal wall thickness was significantly increased in the BSH group, which was coupled with regional deformation impairment (basal inferoseptum, controls vs. non-BSH vs. BSH: 16.1 ± 2.33 vs. 15.14 ± 2.8 vs. 13.02 ± 2.98 %, p &lt; 0.001). The curvature of the basal inferoseptum was significantly higher in the BSH group (controls vs. non-BSH vs BSH: -23.4 (-27.2, -10.9) vs. -28.3 (-40.2, -19.3) vs. -50.5 (-66.8, -33.9) m-1, p &lt; 0.001) (Figure 1), with the same trend seen in the basal anteroseptum. The inferoseptal curvature showed a moderately strong correlation with the inferoseptal basal-to-mid wall thickness ratio (R = 0.527, p &lt;0.001).

Conclusion

Increased septal curvature is an easily quantifiable, single-value, semi-automated parameter reflective of localized thickening that could easily be incorporated into the output of the LV speckle tracking workflow, possibly aiding in the recognition of hypertensive patients in need of a closer clinical follow-up.

Abstract P735 Figure 1

155 Myocardial work in hypertension and mitral regurgitation- insights from non-invasive assessment of left ventricular pressure-strain relations

Funding Acknowledgements

Horizon 2020 European Commission Project H2020-MSCA-ITN-2016 (764738), Grant from Fundacio La Marató de TV3 (040310)

Background and aim

Non-invasive left ventricular (LV) pressure estimates and speckle-tracking deformation curves can be used to quantify an index of myocardial work (MWI) which may offer insight into the early changes and work distribution in hypertension (HTN) and mitral regurgitation (MR) – cardiac diseases related to pressure and volume overload. The aim is to assess segmental strain and MW indices in patients with HTN, MR, and in healthy controls.

Methods

An echocardiogram was performed in 73 participants: 31 patients with a diagnosis of long-standing HTN with signs of LV hypertrophy, 22 patients with MR without hypertension, and 20 healthy age- and sex-matched controls. LV speckle-tracking was performed in 4C, 2C, and 3C apical views. MWI was calculated between mitral valve closing and opening. Average regional values of strain and MW indices were calculated by averaging the 4C, 3C, and 2C basal, mid, and apical segments, as based on the 18-segment model of the LV. Total MW per minute (MWI/min) was calculated by multiplying global MWI by the heart rate.

Results

LV ejection fraction and global longitudinal strain (GLS) were preserved and similar in all groups (GLS, controls vs. mild/moderate MR vs. severe MR vs. HTN: -21.28 ± 2.36 vs. -21.30 ± 1.49 vs. -20.93 ± 2.46 vs. -20.93 ± 2.46, p = 0.602). MR was classified as mild or moderate in 45% (n = 10) and severe in 55% (n = 12). A strong trend of higher global MWI (controls vs. mild/moderate MR vs. severe MR vs. HTN: 2098 ± 373 vs. 2036 ± 341 vs. 2237 ± 351 vs. 2297 ± 427 mmHg%, p = 0.171), as well as MWI/min could be noted in patients with hypertension and severe MR. Averaged regional deformation values showed a gradient increasing from base to apex in all groups, significantly more pronounced in the HTN patients. This deformation pattern was reflected in myocardial work distribution. In HTN, the basal region performed a lower percentage of total work, with the apex performing an increased workload. In the MR subgroups, the work was distributed similarly to the healthy controls Results are shown in Figure 1.

Conclusion

Non-invasive pressure strain relations offer additional information on cardiac function in HTN and MR with preserved LVEF and GLS. In HTN, MW is elevated and redistributed in the LV with an apex-to-base gradient signaling an apical compensation of basal impairment in the setting of increased afterload. Mild and moderate MR is associated with a compensated state of normal global MWI and work distribution, however, MWI/min in severe MR reveals an overall increase in workload - potentially predicting further LV remodeling in these patients over time.

Abstract 155 Figure 1

39 Overview of tricuspid regurgitation (tr). new classification of tr. when severe tr is too severe?

Introduction

Tricuspid regurgitation (TR) importance is growing in the last years. Its presence is associated with a worse prognosis. A new severity classification has been published, adding massive and torrential to the classical TR classification. However, it is not know how many of the patients classified as severe TR, corresponds to the new Torrential or massive classification that for sure will lead to different treatment strategies. Also few published studies have addressed the aetiologies, mechanisms and severity in large cohorts.

Purpose

To evaluate the burden of TR in a large cohort of patients referred for an echocardiography.

Methods

Prospective study where consecutive patients undergoing an echocardiographic study in 10 Spanish hospitals within a three-month period were included. All studies with at least moderate TR were selected for analysis. The evaluation was conduced according to the usual practice of the laboratory. TR assessment was performed as recommended by the European Association of Cardiovascular Imaging. TR was quantified according to Hanh & Zamorano new published classification.

Results

A total of 35088 consecutive echocardiographic studies were performed in the participant hospitals during the recruitment period. TR of at least moderate degree was detected in 2124 studies (6,05%). Mean age was 77,1 years and 62.8% were women.

Mitral or aortic valvulopthy was the most common cause, present in almost half of cases (48.4%). The second cause of TR was idiopathic with 22.2% of cases. Primary TR was found in 7.2% of patients, the most frequent aetiology in these group was cardiac implantable devices with 4.2% of total of TR. Aetiology and severity according to the new classification can be seen in the figures

Atrial fibrillation was present in 47.6% of cases. 56.4% of patients had symptoms at the time of the study (NYHA≥2 at the time of study).

Right ventricle (RV) was dilated (telediastolic basal diameter &gt;42mm) in 39.4% of patients). RV function was impared (TAPSE &lt;17mm) in 30.6% of patients.

Conclusions

In these larger multicentre study, significant TR may is present in up to 6% of the echocardiographic studies and is often symptomatic[m1] . 4,91% of patients had a massive or torrential grade. Most TR are secondary to mitral or aortic valvulopathy. Idiopathic TR has taken the second place.

Abstract 39 Figure. Severity and aetiology of TR

421 Exploring hypertensive patient profiles based on full myocardial deformation and Doppler traces - insights from a machine-learning approach

Funding Acknowledgements

Horizon 2020 European Commission Project H2020-MSCA-ITN-2016 (764738), Grant from Fundacio La Marató de TV3 (040310)

Background and aim

Contemporary echocardiography provides complex data on cardiac function contained in both blood-pool and tissue deformation traces. Their current interpretation relies on clinical experience and selected peak or averaged velocity values, which might not capture the complexity throughout the cardiac cycle. The aim is to investigate if machine learning could recognize relevant patient profiles in arterial hypertension by integrating all echocardiographic data to better define potential pathophysiological changes in left ventricle (LV) remodeling.

Methods

An echocardiogram was performed in 100 patients with established arterial hypertension (&gt; 3 years). Myocardial deformation traces of the LV and the left atrium (LA), assessed by 2D speckle tracking, the aortic outflow Doppler trace, the lateral and septal mitral annular Doppler velocity traces, and the mitral inflow Doppler trace were assessed as measures of cardiac function. An unsupervised machine learning algorithm (multiple kernel learning) was used to reduce the dimensionality of these data, and to position the patients based on the similarities of echocardiographic data. The main patterns of variability present in the data were interpreted through non-linear regression analysis. Classic echocardiographic parameters, measured by a clinician, were then compared between the intermediate and extreme patient profiles across the variability spectrum.

Results

Figure 1 shows differences in velocity and deformation traces between the three representative patient profiles. While at one end of the spectrum, all echocardiographic traces were normal (red and green), the data of the other extreme patient profile (blue) describes a characteristic and consistent LV pressure overload remodeling pattern, with slightly reduced and delayed aortic outflow velocities, fused E and A waves with the ratio &lt; 1, lower e’ mitral annulus velocities, decreased basal septal strain with post-systolic motion, prolonged relaxation in early diastole as seen by the deformation traces, and a change in atrial deformation dynamic with augmentation of LA contractile strain. The clinical measurements concurred with the remodeling profile describing smaller end-diastolic LV diameter and end-systolic and end-diastolic LV volumes, a reduced E/A ratio and e’ medial annular velocity, reduced TAPSE and increased LA contractile strain.

Conclusion

Machine learning based assessment of complex echocardiographic data has the potential to recognize an integrated and comprehensive patient profile related to LV remodeling within the hypertensive cohort without relying on classical clinical measurements and parameters, but by learning from subtle differences globally present in velocity and deformation echocardiographic data.

Abstract 421 Figure 1

P4421Increased circulating levels of VCAM-1 correlate with left atrial remodeling in highly trained athletes

Introduction

Reports have shown increased risk of atrial fibrillation (AF) in athletes. Vascular cell adhesion molecule-1 (VCAM1) is associated with new onset AF in general population. VCAM1 and its relation with left atrial (LA) remodeling have not been investigated in athletes.

Purpose

To study VCAM1 and LA remodeling in marathon runners.

Methods

Study of 36 male marathon runners in the training period previous to race (42 km) and 18 sedentary controls with no risk factors. Athletes were divided in two groups according to highest training intensity reached (group 1, >100 km/week; group 2, 50–100 km/week). Previous to race in all subjects, VCAM1 serum levels were measured by ELISA and an echocardiogram was performed. In athletes, VCAM1 was measured immediately post-race. Wilcoxon and Spearman were used.

Results

See table. Group 1 showed a significant increment in VCAM1 post-race (651±350 to 905±373 ng/mL; p=0.002) as compared to group 2 with no increment (533±133 to 651±138 ng/mL; p=0.117). In athletes, a moderate correlation between LA volume and VCAM1 was found (rho: 0.483; p=0.007).

Baseline characteristics Group 1 (n=18) Group 2 (n=18) Controls (n=18) p value Age (years) 37±6 38±5 36±4 0.373 Heart rate (bpm) 53±8 57±7 69±6 * 0.001 Body surface area (m2) 1.8±0.1 1.8±0.1 1.9±0.1 0.075 LV diastolic diameter (mm) 49±5 48±5 46±4 0.404 LV systolic diameter (mm) 29±5 30±5 30±4 0.879 Septal wall (mm) 9.1±1.2† 8.2±1.1 8.1±0.8 0.005 Posterior wall (mm) 9.3±2.1† 8.5±1.2 7.6±0.8 0.001 Ejection fraction (%) 55±3 55±6 57±4 0.110 LV mass index (g/m2) 106±27† 78±18 58±11 0.001 LA volume (mL/m2) 42±8† 30±11 25±9 0.001 E wave (cm/sec) 78±13 84±12 77±15 0.217 A wave (cm/sec) 50±12 53±10 48±16 0.438 DT (msec) 233±65 229±65 221±66 0.184 VCAM1 (ng/mL) 651±350† 533±133 440±98 0.022 Mean ± SD. *p<0.05 vs group 1 and 2 post Kruskall-Wallis; †p<0.05 vs other groups post Kruskall-Wallis. LV, left ventricle; LA, left atrium; DT, deceleration time.

Conclusions

Most trained athletes had increased levels of VCAM1 as compared to controls and less trained athletes. They also showed an increment post-effort. VCAM1 is related to LA remodeling in athletes. VCAM1 could be a potential biomarker of AF in athletes which should be confirmed.

Acknowledgement/Funding

FONDECYT 1170963 (LG); FONDAP 15130011 (LG,SL)

P3695Predicting adverse outcomes after TAVI procedure - a comparison of two CoreValve generations using real-life outcomes and patient-specific computer simulations

Background and aim

Post-procedure conduction abnormalities (CA) and paravalvular aortic regurgitation (PAR) continue to strain TAVI outcomes. Computer simulations, based on patient-specific anatomy, valve properties, and implantation position, have been validated for prediction of these complications. The new-generation CoreValve Evolut PRO has been shown to have lower levels of PAR and CA than previous generations. The aim was to compare clinical outcomes after Evolut Pro implantation in real-life with outcomes of virtual deployment of the same size, implantation depth adjusted CoreValve Evolut R.

Methods

Patients undergoing Evolut Pro implantation at a single centre were included into the study. Postoperative Doppler echocardiography was assessed to define PAR, the pre- and postoperative 12-lead ECGs for CA, and the postoperative angiograms to measure implantation depth based on annular plane distance from the non-coronary and left coronary aortic valve cusps. Preoperative multislice computed tomography was used to generate patient-specific models of the native aortic root. Implantation of the Evolut R valve and corresponding aortic root deformation was simulated using computational mechanics, whereas blood flow and level of PAR were predicted using computational fluid dynamics. Prediction of CA – new onset left bundle branch block or atrioventricular block type II or III -was based on calculations of contact pressure in a patient-specific region of the aortic root containing the AV conduction system (ROI). Outcomes were predicted in three implantation depth positions - high, medium, low – where the position closest to the real-life implantation depth was chosen for outcome comparisons.

Results

Study diagram is shown in Figure 1. Thirty-three patients (57% female, mean age 82±6 years old) underwent a TAVI intervention with an Evolut PRO valve. Evolut PRO implantation depths were, in general, closest to the lowest modeled Evolut R depth. Comparison demonstrated similar overall incidence of moderate-to-severe PAR. The Evolut R simulation predicted 18 patients without PAR and 2 with PAR. With the Evolute PRO, 1 of the 18 not predicted developed significant PAR, and 1 of the 2 predicted did not develop PAR. CA were notably higher with the Evolut R simulation, where CA were present in 9 out of 12 patients, as compared to the observed 5 out of 12 with the Evolut PRO.

Figure 1

Conclusion

Single-centre outcomes after Evolut Pro implantation in real-life showed a similar overall incidence of moderate-to-severe PAR and a lower incidence of conduction abnormalities as compared to the same size, implantation depth adjusted, patient-specific Evolut R modeled outcomes. As inferred from the results, computer simulations may have high clinical utility in supporting clinical decisions regarding valve choice in TAVI procedures.

Acknowledgement/Funding

Horizon 2020 European Commission Project H2020-MSCA-ITN-2016 (764738)

P3836Myocardial work distribution in hypertensive patients with basal septal hypertrophy - a non-invasive assessment with left ventricular pressure-strain relations

Background and aim

Localized basal septal hypertrophy (BSH) is a known marker of hypertension. However, the underlying functional significance of this morphologic finding is not clear. Non-invasive LV pressure estimates and speckle-tracking deformation curves can be used to quantify myocardial work (MW), which may offer insights into work distribution in increased afterload leading to better understanding of the early changes in hypertensive heart disease. The aim is to assess segmental strain and MW indices in hypertensive patients with and without BSH, as well as in healthy controls.

Methods

An echocardiogram was performed on a total of 149 patients with a diagnosis of long-standing hypertension and on 19 healthy age and sex-matched controls. The septum was measured at basal and mid-level in parasternal long-axis and four-chamber views. A two-part criterion - a positive visual assessment of an abrupt change in septal thickness seen in the 4C or PLAX view and a basal to mid-septal ratio ≥1.4 - was used to identify BSH. LV speckle-tracking was performed in 4C, 2C, and 3C views. Myocardial work index was calculated between mitral valve closing and opening. Average regional values of strain and MW indices were calculated by averaging the 4C, 3C, and 2C basal, mid, and apical segments.

Results

BSH was present in 19.2% (n=28) of the hypertensive cohort. There were no differences in LV ejection fraction or global longitudinal strain between the subgroups. The basal inferoseptum and anteroseptum were thicker in the hypertensive patients, significantly more so in the BSH subgroup, which was coupled with a proportional decrease in local deformation. Averaged regional deformation values showed a gradient increasing from base to apex in all subgroups, more pronounced in the BSH patients due to significantly impaired average basal deformation (controls vs. non-BSH vs. BSH: −18.33±1.92 vs. −17.24±2.14 vs. −15.56±2.08%, p<0.001). This deformation pattern was reflected in myocardial work distribution in hypertension, showing the basal region performing a lower percentage of global work, especially so in the BSH patients, while the apical region performed a significantly higher percentage, with a trend of further increase in the BSH subgroup (Figure 1).

Figure 1

Conclusion

Localised BSH, a structural finding in one-fifth of the hypertensive population, is related to functional impairment in regional systolic deformation and a pronounced redistribution of myocardial work during the cardiac cycle. An apex-to-base gradient in myocardial work signals an apical compensation of basal impairment in the setting of increased afterload. Clinical follow-up of patients is needed in order to assess the prognostic relevance of these findings.

Acknowledgement/Funding

Spanish Ministry of Economy and Competitiveness (TIN2014-52923-R), Fundacio La Maratό de TV3 (040310), H2020-MSCA-ITN-2016 (764738)

P1810May early myocardial involvement detection in chagas disease have a prognosis impact?

Background

Brain natriuretic peptide (BNP) and novel echocardiographic techniques such as speckle-tracking and a comprehensive evaluation of diastolic function can detect early myocardial involvement in patients with Chagas disease. However, there is lack of longitudinal studies that can confirm whether this early myocardial involvement translates into a worse prognosis.

Purpose

To assess if early myocardial involvement detected by BNP or a comprehensive echocardiographic evaluation was associated with future events in Chagas disease.

Methods

182 consecutive individuals from endemic areas who underwent T. cruzi screening where prospectively included from 2007 to 2014. ECG, BNP and a comprehensive echocardiography including diastolic function and longitudinal myocardial strain were performed. Four different groups were defined: healthy controls (N=77); Chagas indeterminate form (positive serology, normal ECG and left ventricle (LV) diameter (<55 mm), LV ejection fraction (>50%) and no segmental abnormalities, N=88); Chagas patients with abnormal ECG but normal LV dimensions and motility (N=7); and Chagas patients with LV diameter>55 mm or LV ejection fraction<50% or segmental abnormalities (N=13). The primary outcome included advanced atrioventricular block, sustained ventricular tachycardia, heart failure, heart transplant or death. Kaplan Meier with Long rank test and Cox regression analysis was used.

Results

Mean age was 37±9 and 34% were male. Median follow-up was 63 months (range 1 to 137). The primary endpoint occurred in a total of 11 (10%) individuals: 2 (2.4%) in the Indeterminate group; 3 (43%) in the abnormal ECG group; and 6 (46%) in the group with abnormal LV dimension or motility, with no events among controls (long-rank test<0.01, Figure). In the global population, age, BNP, diastolic dysfunction parameters and longitudinal strain at the inferior and lateral walls were significant predictors. In the cohort of Chagas patients with normal standard echocardiography (N=92), ECG abnormalities (HR=49, p=0.001), Em (HR=0.68, p=0.03), deceleration time (HR=0.01, p=0.01), left atrial diameter (HR=1.24, p<0.01) and longitudinal strain at the midventricular lateral wall (HR=0.75, p=0.028) remained significantly associated with outcome.

Cumulative survival without events

Conclusions

Outcome was significantly more frequent in Chagas patients with abnormalities in ECG or standard echocardiography. In early forms of the disease, myocardial involvement detected by BNP or a comprehensive echocardiography was associated with prognosis, and may help to individualize treatment and follow-up.

P3770Interatrial block: a prognostic factor for atrial fibrillation in cryptogenic stroke patients

Background

Atrial fibrillation (AF) is a well-known risk factor for ischemic stroke. Interatrial block (IAB), resulting from a conduction delay in Bachmann's bundle, is an electrical abnormality that, especially in its advanced (A-IAB) form, has been associated with atrial fibrotic cardiopathy and remodeling, sharing a common pathologic substrate with AF. Therefore, IAB has been proposed as a marker of atrial electromechanical dysfunction that may predispose to the development of AF. We hypothesized that IAB could be a marker of AF in patients with cryptogenic stroke (CS).

Methods

We retrospectively screened a cohort of CS patients with no prior history of AF, and collected their demographic, cardiovascular risk factors and other co-morbidities, stroke severity and resultant functional disability (NIHSS and mRS scales), CHA2DS2-VASc score, baseline 12-lead ECG, transthoracic echocardiogram, and neuroimaging studies on admission. All patients underwent continuous ECG monitoring for at least 48h. Forty-eight (64%) patients underwent additional out-patient 24h Holter monitoring following hospital discharge. P-wave (PW) analysis of baseline ECG classified patients into three groups: normal p-wave duration (N, PW <120 ms), partial IAB (P-IAB, PW ≥120 ms) and advanced IAB (A-IAB, PW ≥120 ms and biphasic morphology in leads DII, DIII and aVF). AF episodes (defined as irregular supraventricular arrhythmias without detectable PWs lasting >30 s), frequent premature atrial contractions (PACs) (>1%) and atrial tachyarrhythmia episodes (runs of >3 consecutive PACs) were detected on 24h Holter readings. Ischemic brain lesions were classified as cortical, subcortical or lacunar in relation to their localization and maximal diameter.

Results

Out of the 80 consecutive CS patients identified, 5 were excluded due to poor quality ECG readings. A high prevalence of both P-IAB (n=30, 40%) and A-IAB (n=23, 30.7%) was found in the final analysis with 75 CS patients. No differences were found between demographics, cardiovascular risk factors and co-morbidities, NIHSS, mRS and CHA2DS2-VASc scores, left atrial size and left ventricular ejection fraction among the 3 ECG categories. Cortical ischemic brain lesions were more frequent in patients in the IAB groups than in the N ECG group. After a mean follow-up of 522 days, AF was clinically diagnosed in 13 patients (17%), with an increasing risk in accordance to the severity of the IAB (p<0.05) (Figure 1A). 24h Holter readings showed greater frequency of PACs and atrial tachyarrhythmia episodes in patients with IAB (p<0.05) (Figure 1B).

Figure 1

Conclusions

In CS, IAB is associated with a greater risk to develop AF and its presence identifies a subgroup of patients with probable atrial fibrotic cardiopathy that could potentially benefit from early oral anticoagulation in secondary prevention.