Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Assessment of left atrial function and diastolic dysfunction in patients with Becker muscular dystrophy

Background

Becker muscular dystrophy (BMD) is frequently characterized by myocardial involvement1 but little is known about the prevalence of left ventricular (LV) diastolic dysfunction (DD) in these patients, particularly when using more recently proposed measure of left atrial (LA) function.

Purpose

Purpose of our study was to assess LVDD in patients with BMD using the currently recommended echocardiographic multiparametric approach and adding LA reservoir strain as advanced measure of LVDD.

Methods

A total of 33 BMD patients (38±13 years) were analyzed including standard and advanced echocardiography at the time of their first visit and at 24 months follow-up. A control group consisted of 20 age- and gender-matched healthy subjects.

Results

18% of BMD patients showed an e'lateral <10, 0% an E/e' >14, 22% a LAVI >34ml/m2 and 11% a tricuspid velocity >2.8m/s. When applying the currently recommended multiparametric approach, 83% of BMD patients showed normal DD and 17% showed indeterminate LV diastolic dysfunction (50% positive parameters); no BMD patient had >50% positive DD parameters for confirmed DD. LA reservoir strain was significantly lower in BMD patients as compared to controls (28±10% vs. 42±11%; p<0.001) (Figure), while LA indexed volume (LAVI) was not (26±19 ml/m2 vs. 21±6 ml/m2; p=0.142). When using the reported median value of LA reservoir strain (47%) for normal subjects with comparable age2, 31 (94%) BMD patients had impaired LA strain, but when using the cut-off value of <19% for increased LV filling pressure, 6 (18%) patients showed affected LA reservoir strain. Patients with more impaired six minute walk test (6MWT), defined as in the 1st tertile (1st tertile 0–309m; 2nd tertile 310–523m; 3rd tertile >523m) had significantly lower LA reservoir strain (1st tertile, 22±6% vs. 2nd tertile, 29±14% vs. 3rd tertile, 33±5%; p=0.022). LA reservoir strain tended to deteriorate at 1 year follow-up but not significantly (from 29±10% to 26±12%; p=0.200).

Conclusions

LVDD is not highly prevalent in BMD patients but LA dysfunction as assessed by LA reservoir strain is reduced and may improve detection of myocardial involvement in these patients, also over time.

Funding Acknowledgement

Type of funding sources: None.

Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging

Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.

POS0916 A 10-YEAR JOURNEY OF CARING FOR PATIENTS WITH SYSTEMIC SCLEROSIS: FOLLOW-UP DATA ON DISEASE DURATION OF THE LEIDEN CCISS COHORT

Background

Combined Care in Systemic Sclerosis (CCISS) is a prospective cohort of patients referred to Leiden University Medical Center for Raynaud’s Phenomenon (RP), a suspicion of systemic sclerosis (SSc) or a connective tissue disease. This cohort is characterized by its standardized and extensive annual follow-up. Since initiation of the cohort in 2009, diagnostic criteria for SSc have been updated leading to a higher sensitivity for early SSc (ACR 2013 criteria). A recent Dutch study showed that there is a gap to time of diagnosis between men and women, despite of overall increase of SSc awareness (PMID: 31539063).

Objectives

To determine whether 1. time between first disease symptoms and diagnosis has changed over time, and 2. disease characteristics of SSc at first presentation in an expert clinic have changed over time for the total cohort, and between male and female patients.

Methods

Patients included in the CCISS cohort undergo annual evaluation and clinical, laboratory, and imaging variables are systematically recorded. For this study, patients fulfilling the ACR/EULAR 2013 SSc criteria were included, and categorized into three groups based on the cohort entrance year: 1) 2010 – 2013, 2) 2014 – 2017, and 3) 2018 – 2021. SSc patients with a baseline visit in 2009 (n=65) were excluded as these patients were often not newly referred. Disease duration was defined by months since first RP, since first non-RP symptom and months between first date of diagnosis by a physician and first non-RP symptom. Disease characteristics included presence of interstitial lung disease (ILD), pulmonary arterial hypertension, digital ulcers (DU), diffuse cutaneous SSc, anti-topoisomerase and anticentromere antibodies. At baseline, disease duration and disease characteristics were compared between the three groups using appropriate tests. In addition, disease duration was compared between males and females in the three groups.

Results

In total, 643 SSc patients were included of whom 229 (36%) had their baseline visit from 2010 until 2013, 207 (32%) from 2014 until 2017, and 207 (32%) from 2018 until 2021.

The proportion of female patients was significantly higher in the 2010 – 2013 group compared to the 2014 – 2017 and 2018 – 2021 group (Table 1). Over time, disease duration defined by RP duration and non-RP duration decreased as well as time between diagnosis and first non-RP symptom (Table 1). The proportion of patients presenting with ILD and DU was highest in the first group (Table 1).

Table 1.2010 - 2013 N=2292014- 2017 N=2072018 – 2021 N=207P-valueBASELINEAge, mean (SD)53 (15)57 (14)55 (14)0.003Female, %8676750.010RP duration, months (IQR)122 (46 – 240)93 (20 – 202)67 (20 – 210)0.003Non RP duration, months (IQR)43 (16 – 227)20 (5 – 112)17 (6 – 54)<0.001Diagnosis duration, months (IQR)116 (80 - 177)65 (45 – 105)25 (5 – 45)<0.001ΔRP and Non-RP, months (IQR)24 (0 – 99)18 (0 – 118)22 (0 – 120)0.337Anti-centromere antibodies, %3843490.092Anti-topoisomerase antibodies, %2424180.259Diffuse cutaneous SSc, %1923160.073Interstitial lung disease, %433131<0.001Pulmonary arterial hypertension, %3240.746Digital ulcers, %2013110.041

In both male and female SSc patients, disease duration and time between diagnosis and first non-RP decreased over time with a longer time in females for all durations which was significantly different for time between first RP and non-RP in 2014-2017 and 2018-2021 (Figure 1). For the 2018 – 2021 group, duration since diagnosis for female was 26 (4 - 46) and male 17 months (7 – 39; p=0.355), and time between RP and non-RP for female 24 (0 - 168) and male 12 months (0 – 48; p=0.029).

Figure 1.

Conclusion

Over time, we observe a decrease in disease duration and in SSc patients presenting with ILD or DU at cohort entrance. Our results indicate increased awareness of early SSc and identification of SSc patients before severe complications have occurred. At the same time our results show the urge for specific attention to improve timely diagnosis in female SSc patients.

Disclosure of Interests

None declared

OUP accepted manuscript

This article reviews the most relevant literature published in 2021 on the role of cardiovascular imaging in cardiovascular medicine. Coronavirus disease 2019 (COVID-19) continued to impact the healthcare landscape, resulting in reduced access to hospital-based cardiovascular care including reduced routine diagnostic cardiovascular testing. However, imaging has also facilitated the understanding of the presence and extent of myocardial damage caused by the coronavirus infection. What has dominated the imaging literature beyond the pandemic are novel data on valvular heart disease, the increasing use of artificial intelligence (AI) applied to imaging, and the use of advanced imaging modalities in both ischaemic heart disease and cardiac amyloidosis.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

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

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

POS0843 A NEW RISK MODEL IS ABLE TO IDENTIFY SYSTEMIC SCLEROSIS PATIENTS WITH A LOW RISK OF DISEASE PROGRESSION

Background:

Disease course in Systemic Sclerosis (SSc) ranges from mild, to severe with progressive organ involvement within months. Guidelines for follow-up are mainly based on expert consensus, and advocate annual assessment. So far, no data driven guidelines exist that describe tailormade systematic assessments for individual patients in line with individual disease course.

Objectives:

To develop a prediction model to guide annual assessment of SSc patients tailored in accordance to disease activity.

Methods:

A machine learning approach was used to develop a model that can identify patients without disease progression. SSc patients included in the prospective Leiden SSc cohort and fulfilling the ACR/EULAR 2013 criteria were included. The primary endpoint in the prediction model was disease progression which was defined as progression in ≥1 organ system, and/or start of immunosuppression or death between the two most recent visits. Using elastic-net-regularization, and including 90 independent clinical variables (100% complete), we trained the model on 75% and validated it on 25% of the patients in order to perform internal validation of the final model. We optimized the model on negative predictive value (NPV) to minimize the likelihood of missing progression. By expert assessment of the test characteristics, including swarm plots of the probability scores, cut-offs were identified for low, intermediate and high risk for disease progression.

Results:

Of the 492 SSc patients (range of follow-up: 2-10yrs), disease progression during follow-up was observed in 52% (median time 4.9yrs), including myocardial progression in 29%, lung progression in 23%, skin progression in 16%, and death in 12%. Performance of the model in the test set showed an AUC-ROC of 0.66. Probability score cutoffs were defined: low risk for disease progression (<0.197, NPV:1.0; 29% of patients), intermediate risk (0.197-0.223, NPV:0.82; 27%) and high risk (>0.223, NPV:0.78; 44%). The predictive variables included in the model were: previous use of cyclophosphamide or corticosteroids, start with immunosuppressive drugs, previous gastrointestinal progression, previous cardiovascular event, pulmonary arterial hypertension, modified Rodnan Skin Score, creatinine kinase, and diffusing capacity for carbon monoxide.

Conclusion:

Our machine-learning-assisted model for disease progression enabled us to classify 29% of SSc patients as ‘low risk’. In this group annual assessment programs could be less extensive than indicated by international guidelines.

Baseline characteristicsTotaln=492Non-ProgressorsN=235ProgressorsN=257DemographicsFemale, n (%)389 (79)193 (82)196 (76)Age, mean (SD)55 (14)55 (15)55 (13)Disease duration nonRP, median (IQR)3.2 (0.9-10.3)3.5 (0.8-10.5)3.6 (1.1-9.3)Organ involvementDcSSc, n (%)118 (24)34 (15)84 (33)DLCO% of pred, mean (SD)66 (18)69 (18)64 (17)FVC% of pred, mean (SD)98 (23)96 (24)97 (21)ILD on HRCT, n (%)183 (37)66 (28)117 (46)PAH, n (%)26 (5)10 (4)16 (6)GAVE, n (%)9 (2)4 (2)5 (2)Cardiac involvement, n (%)28 (6)14 (6)14 (5)Myositis, n (%)8 (2)6 (3)2 (1)Renal crisis, n (%)14 (3)6 (3)8 (3)AutoantibodiesAnti-centromere, n (%)194 (39)118 (50)76 (30)Anti-topoisomerase, n (%)116 (24)42 (18)74 (29)

RP=raynaud phenomenon, dcSSc= diffuse cutaneous systemic sclerosis, mRSS=modified rodnan skin score, DU=digital ulcera, DLCO= single-breath diffusing capacity for carbon monoxide, FVC= forced vital capacity, ILD=interstitial lung disease, HRCT= high resolution computed tomography, PAH= pulmonary arterial hypertension, GAVE= gastric antral vascular extasia.

Disclosure of Interests:

None declared

Impact of baseline feature tracking multi-detector row computed tomography-derived left ventricular global longitudinal strain on left ventricular functional recovery in TAVI patients

Background

Advances in left ventricular (LV) analysis with dynamic multi-detector row computed tomography (MDCT) permit measurement of LV global longitudinal strain (GLS) and have shown their impact on risk stratification of patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

Purpose

To evaluate the influence of baseline feature tracking (FT) MDCT- derived LV GLS on LV functional recovery in severe AS patients undergoing TAVI.

Methods

A total of 194 patients with severe AS (50% male, 80±7 years) with dynamic MDCT data allowing LV GLS measurement with a novel FT algorithm and having complete echocardiography evaluation at baseline, at 3–6 months and at 1 year follow-up were evaluated. FT MDCT-derived LV GLS was measured at baseline and the study population was divided according to a cut-off value of MDCT LV GLS −14% (≤−14% [more preserved LV systolic function] vs. &gt;−14% [more impaired LV systolic function]).

Results

Transthoracic echocardiography (TTE)-derived Left ventricular ejection fraction (LVEF) increased over time in both groups: in patients with preserved and reduced MDCT LV GLS, and reached a higher value in patients with preserved MDCT LV GLS (52±7% at baseline, 55±7% at 3–6 months, 58±7% at 1 year follow-up vs. 43±10% at baseline, 49±10% at 3–6 months, 53±11% at 1 year follow-up; p=0.016) (Figure 1). TTE-derived LV GLS also showed greater improvement for patients with preserved MDCT LV GLS (−17±3% at baseline, −18±3% at 3–6 months, −20±3% at 1 year follow-up vs. −12±3% at baseline, −15±3% at 3–6 months, −16±3% at 1 year follow-up; p=0.027) (Figure 1).

Conclusions

In severe AS patients treated with TAVI, LV function improves significantly at 3–6 and at 12 months' follow-up and shows superior recovery in patients with more preserved baseline MDCT LV GLS, suggesting that MDCT-derived LV GLS has an important impact on LV functional recovery after TAVI.

Funding Acknowledgement

Type of funding source: None

Sex difference in left ventricular global longitudinal strain in patients with systemic sclerosis: association with outcomes

Background

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

Purpose

To compare standard and advanced (GLS) echocardiographic parameters between male and female patients with SSc and evaluate their association with cardiovascular outcomes.

Methods

A total of 408 patients (345 females, 54±14 years old and 63 males 51±13 years old) were included in the study. The study endpoint was all-cause mortality combined with hospitalisations for heart failure, myocardial infarction, coronary interventions, device implantations, arrhythmias, cerebral infarction and peripheral ischemic disease.

Results

Males and females were comparable in terms of cardiovascular risk-factors and comorbidities but showed differences in terms of disease characteristics: greater modified rodnan skin score and higher creatine phosphokinase was observed in males as compared to females, although high NT-proBNP and deteriorated glomerular filtration rate was more prevalent in females. By standard echocardiography, male SSc patients were characterised by greater left ventricular (LV) volumes, but no difference was observed in LV ejection fraction. By advanced echocardiographic analysis, LV GLS was more preserved in female patients (−21% (IQR: −22% to −20%) as compared to males (−20% (IQR −21% to −19%), p&lt;0.001. After median follow-up of 39 months (IQR: 22–66), the combined endpoint occurred in 84 patients, males were affected significantly more frequently as compared to females (20 (32%) vs. 64 (19%), p=0.017). Kaplan-Meier survival analysis showed that impaired LV GLS (based on median value −20%) was associated with higher cumulative rates of all-cause mortality both in males and females with SSc (females: Chi-Square = 80.307 Log Rank &lt;0.001; males: Chi-Square = 4.493 Log Rank = 0.034) (Fig. 1). In univariate cox regression analyses, LV GLS was also significantly associated with the endpoint both in males and females (in males HR: 1.291, 95% CI: 1.033–1.612, p=0.025, in females HR: 1.386, 95% CI: 1.290–1.491, p&lt;0.001).

Conclusions

Our study shows that among patients with SSc, LV GLS is more impaired in males as compared to females but in both groups is associated with higher prevalence of death and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding source: None

P3377MDCT-derived left ventricular global longitudinal strain and left ventricular ejection fraction in patients with aortic stenosis: a comparative analysis with echocardiographic measurements

Introduction

Known predictors of poor outcome in aortic valve stenosis patients include older age, significant valvular calcification, rapid hemodynamic progression and impaired left ventricular (LV) systolic function. LV global longitudinal strain (GLS) quantifies myocardial deformation and LV function and is associated with prognosis in patients with severe aortic stenosis (AS). Multi-detector row computed tomography (MDCT) data are key in the evaluation of patients undergoing transcatheter aortic valve implantation (TAVI) and when acquired throughout the entire cardiac cycle, LV systolic function can be assessed. Novel software can assess LV GLS from MDCT-data.

Purpose

The present study aimed at assessing the feasibility of determining novel MDCT-derived LV GLS as well as MDCT-derived LV ejection fraction (EF) and their agreement with echocardiographic LV GLS and LVEF in patients treated with TAVI.

Methods

LVEF and LV GLS were measured on echocardiography and dynamic MDCT using novel CT-software. Agreement between the measurements of two different modalities was assessed using Bland-Altman analysis.

Results

A total 214 patients (51% male, mean age: 80±7 years) were analysed retrospectively. Mean value of LV GLS on echocardiography was −14±4% whereas mean MDCT-derived GLS was −12.5±4%. Mean value of LVEF on echocardiography was 47±10% and mean MDCT-derived LVEF was 39±11%. On Bland-Altman analysis, MDCT-derived strain analysis underestimated LV GLS compared to echocardiography with a mean difference of 1.44% (95% limits of agreement −3.8 to 6.7%). LVEF was also underestimated on CT with a mean difference of 7.68% (95% limits of agreement −11.5% to −26%). Correlation of measurements between MDCT-derived LV GLS and echocardiographic LV GLS was significant (r=0.791, p<0.001), as well as the correlation between MDCT-derived LVEF and echocardiographic LVEF (r=0.590, p<0.001) (Figure).

Conclusions

Assessment of LV GLS and LVEF on dynamic MDCT data provides similar values to those obtained with echocardiography and could be used in the risk-stratification of severe AS patients undergoing TAVI.

P4440Assessment of left atrial function in patients with systemic lupus erythematosus with and without neuropsychiatric manifestations: association with cardiovascular events

Introduction

Cardiac involvement in Systemic Lupus Erythematosus (SLE) may lead to left ventricular (LV) hypertrophy with possible impairment of LV diastolic function and left atrial (LA) function, particularly in patients with severe forms of SLE with neuropsychiatric manifestations (NPSLE) and can also be associated with cardiovascular outcome.

Purpose

We evaluated the prevalence of LV diastolic dysfunction and LA dysfunction in a large cohort of SLE patients including also NPSLE patients, and their association with the occurrence of cardiovascular events (cerebrovascular accidents, lung-embolism, coronary revascularisation, heart failure hospitalisations and development of supraventricular arrhythmias).

Methods

A total of 102 SLE patients (87% female, 42±15 years) were included, of which 43 (42%) with NPSLE according to a multidisciplinary team assessment. All patients fulfilled the American College of Rheumatology (ACR 1997) and Systemic Lupus Erythematosus International Collaborating Clinics (SLICC 2012) classification criteria for SLE. Echocardiography was performed at the first visit: LV diastolic function was assessed according to current recommendations and including Tissue Doppler Imaging measures; LA volume (LAVI) was also measured and LA function was assessed by LA reservoir strain using 2D speckle tracking imaging.

Results

In the SLE patients, mean LV mass index was 82±32 g/m2, 29% of patients showed an e'septal <10, 7% an E/e'>14, 16% a LAVI>34 ml/m2 and 5% a tricuspid velocity >2.8m/s. When applying the currently recommended multiparametric approach, only 4% of SLE patients showed LV diastolic dysfunction. In NPSLE patients, the prevalence of LV diastolic dysfunction was not significantly higher (5%). However, an impaired LA reservoir strain (based on the median value of 25%) was observed in 54% of the total SLE population and in 77% of NPSLE patients suggesting higher sensitivity of this parameter to detect impaired LA function and LV diastolic function. During a median follow up of 11 years (Interquartile range: 4–19 years), 43 (42%) patients developed a cardiovascular event. Kaplan-Meier curve analysis showed that SLE patients with impaired LA strain <25% experienced higher cumulative rates of cardiovascular events, as compared to SLE patients with LA strain≥25% (Chi-square 4.350; Log rank p=0.037). At the uni- and multivariate Cox-regression models, LA strain showed significant association with cardiovascular events (hazard ratio [HR]:0.944; 95% confidence interval [CI]: 0.893–0.997; p=0.039) together with age (HR: 1.030; 95% CI: 1.002–1.059; p=0.039) after correcting for LV mass index and LV diastolic dysfunction.

LA reservoir strain

Conclusions

LA dysfunction as assessed by LA reservoir strain is significantly impaired in SLE and particularly in NPSLE patients and improve detection of myocardial involvement in these patients. Furthermore, LA reservoir strain is independently associated with the development of cardiovascular events.

4312Left ventricular systolic function in patients with systemic lupus erythematosus and its association with cardiovascular events

Introduction

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that may involve the cardiovascular system. Diagnosis of cardiac involvement, particularly at an early stage, represents challenge since symptoms in SLE patients are often atypical and current diagnostic tools are characterized by a low sensitivity to detect myocardial dysfunction. Purpose of this study was to assess left ventricular (LV) systolic function in a large cohort of SLE patients in comparison with a control group of healthy subjects and using standard echocardiographic measures and global longitudinal strain (GLS) by 2D speckle tracking analysis. Furthermore, the association between echocardiographic parameters and the occurrence of cardiovascular events was tested.

Methods

A total of 102 patients (87% female, 42±15 years) were analysed including echocardiography at the time of their first visit. All patients fulfilled the American College of Rheumatology (ACR 1997) and The Systemic Lupus Erythematosus International Collaborating Clinics (SLICC 2012) classification criteria for SLE. During follow-up, cardiovascular events included cerebrovascular accident or transient ischemic attack, pulmonary embolism, coronary artery interventions, hospitalisations for heart failure and development of supraventricular arrhythmias. The control group consisted of 50 age- and gender-matched healthy subjects.

Results

Prevalence of comorbidities, such as hypertension (8%), hypercholesterolemia (4%) and diabetes mellitus (2%) was relatively low in SLE patients. In comparison with the control group, SLE patients were characterized by worse LV systolic function as measured by LV ejection fraction (51±6% vs 62±6%, p<0.001) and by LV GLS (−15±3% vs −19±2%, p<0.001), as well as worse LV diastolic function (e' septal: SLE 9±2 cm/s vs 10±2 cm/s healthy controls, p=0.020; E/e': SLE 8±3 vs 7±2 healthy controls, p<0.001; TR velocity: SLE 2±0.6 m/s vs 1.6±0.5 m/s healthy controls, p=0.020). During a median follow up of 11 years (Interquartile range: 4–19 years), 43 (42%) patients developed cardiovascular events. Kaplan-Meier curves show that SLE patients with more impaired GLS (based on the median value of −15%) experienced higher cumulative rates of cardiovascular events as compared to patients with GLS ≤−15% (Chi-square 7.197; Log rank p=0.007). On uni- and multivariate Cox-regression models, LV GLS demonstrated significant association with cardiovascular events (HR: 2.229; 95% CI: 1.024–4.853; p=0.043), together with age (HR: 1.043; 95% CI: 1.017–1.069; p=0.014) after correcting for LV mass index and e'; in turn, LV ejection fraction was not significantly associated with cardiovascular events.

LV GLS in SLE patients

Conclusions

In SLE patients, LV systolic function as measured by GLS is significantly impaired and independently associated with cardiovascular events. Incorporation of LV GLS in the early assessment of these patients may significantly improve risk-stratification for cardiovascular events.

4935Prognostic influence of MDCT-derived global left ventricular longitudinal strain in patients with aortic stenosis treated with transcatheter aortic valve implantation

Introduction

Transcatheter aortic valve implantation (TAVI) is an effective treatment for patients with severe aortic stenosis (AS), It can lead to an improvement in symptoms and quality of life but there is also an increasing recognition that some patients simply fail to derive a functional, morbidity, or mortality benefit post-TAVI. Left ventricular (LV) ejection fraction is the LV systolic function parameter to risk stratify patients with severe AS. However, LV global longitudinal strain (GLS) provides incremental prognostic value to LVEF. Computed tomography plays an essential role in the evaluation of TAVI candidates. Novel software permits analysis of LV GLS from dynamic Multi-detector row computed tomography (MDCT) data.

Purpose

The present study aimed at investigating the prognostic value of MDCT-derived LV GLS in patients undergoing TAVI.

Methods

LV GLS was measured on dynamic MDCT using novel CT-software (Figure, panel A) at baseline. Patients were followed up for all-cause mortality and cumulative event rates were analyzed with Kaplan-Meier method.

Results

A total 214 patients (51% male, 80±7 years) were analysed retrospectively. Mean value of MDCT-derived LV GLS was −12.5±4%. During a median follow-up of 1378 days (interquartile range: 881–1895 days), 67 (31%) patients died. The Kaplan-Meier curve shows, that TAVI recipients with MDCT-derived LV GL S>−14% experienced higher cumulative rates of all-cause mortality, compared to patients with MDCT-derived LV GLS ≤−14% (Chi-square 10.549; Log rank p=0.001) (Figure, panel B). On uni- and multivariate Cox-regression models, MDCT-derived LV GLS demonstrated significant association with all-cause mortality (hazard ratio [HR]: 0.851; 95% confidence interval [CI]: 0.772–0.937; p=0.001).

MDCT LV GLS and survival

Conclusions

MDCT-derived LV GLS is independently associated with all-cause mortality in patients treated with TAVI.

Ventricular dyssynchrony assessed by gated myocardial perfusion SPECT using a geometrical approach: a feasibility study

PURPOSE

Left ventricular dyssynchrony may predict response to cardiac resynchronization therapy and may well predict adverse cardiac events. Recently, a geometrical approach for dyssynchrony analysis of myocardial perfusion scintigraphy (MPS) was introduced. In this study the feasibility of this geometrical method to detect dyssynchrony was assessed in a population with a normal MPS and in patients with documented ventricular dyssynchrony.

METHODS

For the normal population 80 patients (40 men and 40 women) with normal perfusion (summed stress score ≤2 and summed rest score ≤2) and function (left ventricular ejection fraction 55-80%) on MPS were selected; 24 heart failure patients with proven dyssynchrony on MRI were selected for comparison. All patients underwent a 2-day stress/rest MPS protocol. Perfusion, function and dyssynchrony parameters were obtained by the Corridor4DM software package (Version 6.1).

RESULTS

For the normal population time to peak motion was 42.8 ± 5.1% RR cycle, SD of time to peak motion was 3.5 ± 1.4% RR cycle and bandwidth was 18.2 ± 6.0% RR cycle. No significant gender-related differences or differences between rest and post-stress acquisition were found for the dyssynchrony parameters. Discrepancies between the normal and abnormal populations were most profound for the mean wall motion (p value <0.001), SD of time to peak motion (p value <0.001) and bandwidth (p value <0.001).

CONCLUSION

It is feasible to quantify ventricular dyssynchrony in MPS using the geometrical approach as implemented by Corridor4DM.

Long term vagal stimulation in patients with advanced heart failure: first experience in man

BACKGROUND

Experimentally, vagal stimulation (VS) is protective in chronic heart failure (HF). In man, VS is used in refractory epilepsy but has never been used in cardiovascular diseases. Increased sympathetic and reduced vagal activity predict increased mortality in HF.

AIMS

This pilot study assessed feasibility and safety and tested possible efficacy of chronic VS in HF patients.

METHODS

We studied 8 patients (mean age 54 years). CardioFit (BioControl Medical), a VS implantable system delivering pulses synchronous with heart beats through a multiple contact bipolar cuff electrode, was used. VS was started 2-4 weeks after implant, slowly raising intensity; patients were followed 1, 3 and 6 months thereafter.

RESULTS

All procedures were successful: as sole surgical side effect, one patient had transient hoarseness. VS was well tolerated, with only mild side effects (cough and sensation of electrical stimulation). There was a significant improvement in NYHA class, Minnesota quality of life (from 52+/-14 to 31+/-18, p < 0.001), left ventricular end-systolic volume (from 208+/-71 to 190+/-83 ml, p = 0.03), and a favourable trend toward reduction in end-diastolic volume.

CONCLUSIONS

This novel approach to the treatment of patients with HF is feasible, and appears safe and tolerable. The preliminary efficacy results appear promising. These findings suggest the opportunity to proceed with a larger multicentre study.