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

PURPOSE OF THE REVIEW

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

RECENT FINDINGS

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

Clinical and electrocardiographic correlates of myocardial dysfunction after COVID-19 in nonhospitalised patients in long-term follow-up. Data from the polish long-covid cardiovascular study

Clinical evidence indicates that COVID-19 is a multiorgan disease that significantly impacts the cardiovascular system. However, little is known about the predictors of myocardial dysfunction after SARS-CoV-2 infection. Therefore, this research aimed to evaluate the clinical and electrocardiographic correlates of myocardial dysfunction after SARS-CoV-2 infection in nonhospitalised patients without previously diagnosed cardiovascular disease. This observational study included 448 patients selected from the database of 4142 patients in the Polish Long-Covid Cardiovascular study. All patients underwent a 12-lead electrocardiogram (ECG); 24-h Holter ECG monitoring, 24/7 ambulatory blood pressure monitoring, echocardiography, and cardiac magnetic resonance imaging. According to the results of diagnostic tests, patients were divided into two groups depending on the occurrence of myocardial dysfunction after COVID-19. Group 1-without myocardial dysfunction after COVID-19-consisted of 419 patients, with a mean age of 48.82 (SD ± 11.91), and Group 2 (29 patients)-with myocardial dysfunction after COVID-19, with a mean age of 51.45 (SD ± 12.92). When comparing the analysed groups, there were significantly more men in Group 2 (p = 0.006). QRS (corresponds to the time of ventricular contraction in an electrocardiographic examination) fragmentation (p = 0.031), arrhythmias (atrial fibrillation, supraventricular extrasystole, ventricular extrasystole) (p = 0.008), and male gender (p = 0.007) were independently associated with myocardial dysfunction after COVID-19. The study showed that myocardial damage after COVID-19 affects men more often and is independent of typical clinical factors and the severity of the disease course. The QRS fragmentation and arrhythmias observed in the ECG indicate the possibility of myocardial dysfunction in patients after COVID-19, which may be a valuable marker for physicians.

Flow-mediated skin fluorescence: A novel method for the estimation of sleep apnea risk in healthy persons and cardiac patients

BACKGROUND

A pilot study revealed a relationship between the results of flow mediated skin fluorescence (FMSF) and of ECG-Holter-based estimated apnea/hypopnea index (eAHI) in asymptomatic individuals. The aim of this study was to test whether the results of FMSF show a relationship with the eAHI in patients with coronary artery disease or aortic stenosis.

METHODS

Twenty-one patients (12 coronary disease, 9 aortic stenosis) and 37 healthy volunteers were included. FMSF was assessed before, during and after the pressure occlusion of the brachial artery, using a prototype device allowing the quantification of skin fluorescence. The values of FMSF expressed as baseline (BASE), maximum (MAX), and minimum (MIN) were analyzed. The percentages of ischemic response (IR) and hyperemic response (HR) were calculated. The eAHI was assessed from night ECG-Holter recordings. Differences between the groups and the relationships between the parameters were analyzed statistically.

RESULTS

Mean ± standard deviation of BASE, MAX, MIN and IR were not significantly different in both groups (p > 0.05). HR was significantly lower in cardiac patients (14.7 ± 7.5 vs. 11.8 ± 5.1; p = 0.048), whose eAHI was significantly higher (11.0 ± 7.4 vs. 36.3 ± 16.5; p < 0.01). Negative correlation for MAX and eAHI was found in volunteers and patients: r = -0.38, p = 0.02 and r = -0.47, p = 0.03, respectively. In volunteers, HR had a negative correlation with eAHI: r = -0.34, p = 0.04.

CONCLUSIONS

This pioneer study confirms that FMSF can be used to detect the negative correlation between MAX fluorescence and eAHI not only among healthy volunteers, but also among cardiac patients with coronary artery disease or aortic stenosis.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

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

Introduction

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

Aim

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

Methods

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

Results

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

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Continuous hands-free monitoring of echocardiographic exercise test using probe fixation device

BACKGROUND

Stress echocardiography has been widely used in clinical practice for decades and has recently gained even more importance in diagnostic approaches to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise tests. The aim herein, is to assess the feasibility of probe fixation for use during exercise echocardiography.

METHODS

Forty-eight subjects (47 men, mean age 42 ± 17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). The semi-quantitative quality of acquired apical views were assessed at each stage using a four-point grading system.

RESULTS

The mean time required for probe fixation was 9 ± 2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. Twenty-five patients required probe repositioning during exercise (more often on a treadmill). During peak exercise quality of images in all views declined, but for diagnostic purposes it remained sufficient in 29 patients. Thus, 76% of performed tests (60% study population) had sufficient image quality.

CONCLUSIONS

Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. The device is suitable almost exclusively for male patients and in some patients requires repositioning.

Feasibility and clinical utility of real-time tele-echocardiography using personal mobile device-based pocket echocardiograph

INTRODUCTION

Recently introduced microUSB ultrasound probe, which can be connected to personal mobile device constitutes a new class of diagnostic pocket size imaging devices (PSID).The aim of this study was to assess the feasibility and clinical utility of real-time tele-echocardiography with the use such device.

MATERIAL AND METHODS

The study group comprised 30 patients (18 men and 12 women; mean age: 54 ±14 years; mean body mass index: 27 ±6 kg/m²), admitted to various hospital departments (infectious diseases, internal medicine and cardiology). All patients underwent focused echocardiographic examination performed by an inexperienced operator using PSID and collaborating remotely in real-time with cardiologist by means of tele-consultation. Before commencing the examination, the operators underwent 1 h training in use of the PSID.

RESULTS

In most of patients PSID imaging provided sufficient diagnostic image quality. The dimensions of left ventricle, left atrium and the aorta obtained during the this examination showed good correlation with standard echocardiography (r = 0.89, r = 0.82, r = 0.92 respectively), but the correlation for TAPSE measurements was less pronounced (r = 0.52). The agreement in detection of pathologies (wall motion abnormalities, morphological and functional valvular abnormalities) between the tele-echocardiography and standard echocardiographic examination was good to very good (κ ranged from 0.648 to 0.823).

CONCLUSIONS

Pocket size imaging devices allows an inexperienced operator to perform a focused echocardiographic examination under a remote supervision of an experienced cardiologist. The introduction of new technology in the form of PSID with tele-echocardiography feature can revolutionize access to this imaging technique.

Complexity of changes in right ventricular morphology and function in patients undergoing cardiac surgery - 3D echocardiographic study

BACKGROUND

An impairment of standard echocardiographic parameters of right ventricular (RV) function is a known phenomenon in patients undergoing cardiac surgery, but its significance remains to be clarified.

AIMS

To assess changes in RV function in patients undergoing cardiac surgery using speckle tracking and 3D echocardiography.

METHODS

The study population comprised 122 patients, referred for cardiac surgery. Transthoracic echocardiographic (TTE) examinations were performed: before the surgery (TTE1), 1 week after surgery (TTE2) and 1 year after the surgery (TTE 3). Parameters measured during these examinations included both standard and advanced indices of RV size and function, as well as a new parameter introduced by our team -RV shortening fraction (RVSF).

RESULTS

TTE1 was performed on average (standard deviation [SD]) 24 (15) hours prior to surgery, whereas TTE2 and TTE3 were performed on average 7.2 (3) days and 346 (75) days after the surgery, respectively. A postoperative impairment of parameters of RV longitudinal function was observed (P <0.001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of fractional area change and ejection fraction. Additionally during the postoperative period an increase in the value of a RVSF by 12.9% was observed. After 12 months we observed an improvement in the parameters of the longitudinal RV function.

CONCLUSIONS

Uncomplicated cardiac surgery causes transient impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RVSF. After 12 months, an improvement of the longitudinal function can be observed.

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

Introduction

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

Material and methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None. Figure 1

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Exercise stress echocardiography with probe fixated on patient's chest

Background

Stress echocardiography (SE) has been widely used in clinical practice for decades and recently has gained even more importance in diagnostic approach to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise test. We aimed to assess the feasibility of probe fixation for the use during exercise echocardiography.

Methods

48 subjects (47 men, mean age 42±17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). We assessed semi-quantitatively the quality of acquired apical views at each stage using four-point grading system (0 = poor, 1 = suboptimal, 2 = acceptable, 3 = optimal).

Results

The mean time required for probe fixation was 9±2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. 25 patients probe repositioning during exercise (more often on treadmill). During peak exercise quality of images in all views declined, but it remained sufficient in 29 patients for diagnostic purposes. Thus, 76% of performed tests (60% for all study population) were of sufficient image quality.

Conclusion

Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. However the device is suitable almost exclusively for male patients. Moreover, in some patients it requires repositioning.

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Echocardiography during the coronavirus disease 2019 pandemic - the impact of the vaccination program. A 2021 update of the expert opinion of the Working Group on Echocardiography of the Polish Cardiac Society

The coronavirus disease 2019 (COVID-19) pandemic resulted in an urgent need to reorganize the work of echocardiography laboratories in order to ensure the safety of patients and the protection of physicians, technicians, and other staff members. In the previous Expert Opinion of the Working Group on Echocardiography of Polish Cardiac Society we provided recommendations for the echocardiographic services, in order to ensure maximum possible safety and efficiency of imagers facing epidemic threat. Now, with much better knowledge and larger experience in treating COVID-19 patients and with introduction of vaccination programs, we present updated recommendations for performing transthoracic and transesophageal examinations, including information on the potential impact of personnel and the patient vaccination program, and growing numbers of convalescents on performance of echocardiographic laboratories, with the goal of their ultimate reopening.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

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

Funding Acknowledgements

Type of funding sources: None.

Purpose

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

Methods

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

Results

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

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

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

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

Conclusion

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

Right ventricular morphology and function undergo complex changes after cardiac surgery

Background

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

Methods

The study population comprised 122 patients (92 men, mean age 65±11 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2±2 days prior to surgery (TTE1), and 7±4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12±2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function (such as TAPSE, systolic velocity of tricuspid annulus (S'), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS), as well as a new parameter introduced by our team - RV shortening fraction (RV SF), calculated as the change in mid RV transverse diameter.

Results

Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S' and GLS; p&lt;0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. Additionally during the postoperative period an increase in the value of a RV SF by 12.85% was observed. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function.

Conclusion

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

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Grant Polish Cardiac Society

Early overexpression of miR-499 in non-ST elevation acute coronary syndromes predicts long-term risk of major adverse cardiac events

Background

Some studies reported utility of microRNAs in myocardial infarction diagnostic process, whereas their prognostic remains unclear.

Aim

To evaluate the prognostic value of five circulating miRs (miR-1, miR-21, miR-133a, miR-208, miR-499) levels for predicting major adverse cardiac events (MACE), including death, nonfatal myocardial infarction (MI) or cardiovascular rehospitalization (reh.) in patients with NSTE-ACS.

Material and methods

In our prospective, single-center observational study we recruited patients (pts) with NSTE-ACS with symptoms onset &lt;24 hours before the hospital admission and age, gender-matched patients with stable coronary artery disease (SCAD) as controls. Blood was sampled twice (at admission and 4h after in NSTE-ACS and once in SCAD). Relative expression of miRs were calculated using the ΔΔCt method after normalization to the cel-miR-39 spiked-in control. The mean value of miRs relative expression from two time samples in NSTE-ACS pts were used for further analysis. Subjects were categorized according to mean miRs expression at hospital admission into two group (≤ or &gt; median level of miRs).

Results

103 NSTE-ACS pts (median age 67 years, 68% male) were included in this study. During median 1569 (IQR 935–1842) days of follow-up the primary endpoint (MACE) occurred in 66 (64.1%) pts: 18 pts (18.7%) died, 30 pts (20%) presented with MI and 85 pts (56.7%) were readmitted. In a Cox proportional-hazards regression model miR-499 expression &gt; median level (HR=1.82, 95% CI 1.07–3.09) and high-sensitivity troponin T level (HR=1.24, 95% CI 1.05–1.46) were independent predictors of MACE in long term observation, even after adjustment for other covariates (including other miRNAs). Incidence of MI [34% vs 10%, HR=4.1 (2.0–8.5)], rehospitalization for cardiovascular reasons [67% vs 49%, HR=2.1 (1.3–3.3)] and MACE [76% vs 55%, HR=2.2 (1.5–3.5)] was significantly higher in pts with elevated (&gt; median) miR-499 levels at hospital admission. None of analyzed miRNAs was related to long-term mortality, whereas the left ventricular ejection fraction (EF) has been identified as the only one survival predictor (HR=0.95, 95% CI 0.92–0.98).

Conclusions

Elevated miR-499 levels independently of high sensitivity troponin T levels in early phase of NSTE-ACS are related to increased rate of MACE in 4-year follow-up.

Figure 1. miR499 and MACE

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the Polish Ministry of Science and Higher Education “Diamond Grant” program.

Early change in left atrial and left ventricular strain predicts sinus rhythm maintenance after cardioversion

Background

Atrial fibrillation (AF) impairs mechanical function of the heart, especially atria and restoration of sinus rhythm (SR) leads to improvement of mechanics. The predicting role of changes in strain parameters for AF recurrence is not established yet.

Purpose

To analyse changes in left atrial (LA) and left ventricular (LV) mechanical function after conversion to SR and their prognostic values for AF recurrence during 24 months follow-up.

Methods

Prospective study involved 59 patients after successful electrical cardioversion (EC) because of nonvalvular AF (mean age 65±4 years, 47% female). Speckle tracking analysis (STE) was applied to calculate longitudinal strain of LV and LA before EC and within 24 hours after restoration of SR and additionally total left heart strain (TS) defined as a sum of absolute peak LV and LA strain. We calculated change in strain between AF and SR analyses expressed as delta (Δ). During follow-up we noticed AF recurrence in 42 (71%) patients, most of them (93%) during 1st year after EC. Median time of AF recurrence was 3 months.

Results

We noticed significant immediate post-EC improvement in peak LA longitudinal strain (PALS) and LV global longitudinal strain (LVGLS) (table). Unlike CHA2DS2-VASc score, strain parameters were predictors of AF recurrence. Every 1% increment in ΔLVGLS was related with 13% increase in AF recurrence risk (p=0.02) and every 1% increment in ΔPALS and ΔTS were related with 9% decrease in AF recurrence risk (p=0.007 and p=0.0014, respectively). Multivariate analysis revealed ΔTS as a strongest predictor with 9% decrease in AF risk per every 1% increment. The criterion of ΔTS ≤7.5% allows to predict AF recurrence with 81% sensitivity and 63% specificity.

Conclusions

Speckle tracking measurements are able to detect early mechanical changes in LA even within 24 hours of SR and these absolute changes in LVGLS as well as PALS can predict AF recurrence, with optimal stratification by novel parameter - TS.

Funding Acknowledgement

Type of funding source: None

Lung Ultrasound and Pulmonary Congestion During Stress Echocardiography

OBJECTIVES

The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE).

BACKGROUND

B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE.

METHODS

The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up.

RESULTS

According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction.

CONCLUSIONS

Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020-The International Stress Echo Study [SE2020]; NCT03049995).

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638).

RESULTS

Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4,735 patients (age 63.6 ± 11.3 yrs, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (n=1,992 patients) and adenosine (n=18); ≤2.0 for exercise (n=2,087) or dobutamine (n=638).

RESULTS

Force-based LVCR was obtained in all 4,735 pts. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57 % of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Abstract P1398 Figure. Treadmill and ergometer stress test

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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

P4502Noninvasively assessed mitochondrial function estimated by skin fluorescence is abnormal in coronary artery disease

Methods

Prototype device manufactured by Angionica (Poland) was used to quantify FDSF recorded in forearm before, during and after 100 s of brachial artery occlusion in 63 individuals (26 with coronary artery disease (CAD) and 37 healthy volunteers. The absolute value of baseline FDSF (BASE), maximum FDSF (MAX), minimal FDSF (MIN), percentage ischemic response (IR) and hyperemic response (HR) were measured. Age, lipid profile, fasting glucose, HbA1c, C-reactive protein (CRP), systolic and diastolic blood pressure, pulse wave velocity (PWV), augmentation index, time domain heart rate variability parameters (SDNN, rMSSD) and estimated apnea/hypopnea index -eAHI (Holter ECG based), BMI, intima-media thickness (IMT), left ventricle systolic and diastolic function were determined in all study participants to search for potential correlations with FDSF.

Results

Measurements were feasible in all study subjects and examination duration was 9±1min. Hyperemic response (HR) was significantly lower in patients with CAD vs controls: 10,4 vs. 14,36 vs 14,73 – p=0,025. Other parameters: BASE, MAX, MIN, and IR were not significantly different between groups (p>0,05).

In the entire group, HR was correlated with age (r=−0,23 p=0,037), and with total or LDL cholesterol (r=0,37 p=0,001 and r=0,36 p=0,001). Interestingly, HR was also positively correlated with SDNN (r=0,26 p=0,044) and rMSSD (r=0,29 p=0,026).

Mode of FDSF examination

Conclusion

Abnormal mitochondrial function probably secondary to microcirculatory disorder is detectable by noninvasive skin fluorescence test as decreased hyperemic response in patients with coronary disease. Age and cholesterol concentration as well as autonomic balance Holter indices are correlated with hyperemic response.

Acknowledgement/Funding

POIR.01.01.01.0540/15-00

Bicuspid aortic valve morphology and its impact on aortic diameters-A systematic review with meta-analysis and meta-regression

AIM

To evaluate the impact of the 2 most common bicuspid aortic valve (BAV) morphology patterns [right-left (RL) vs right-noncoronary (RN) cusp fusion] on the aortic diameters and the impact of gender, aortic stenosis (AS), aortic regurgitation (AR), and age on the observed effects.

METHODS

The PubMed databases was searched up to December 31, 2016 to identify studies investigating the morphology of BAV and aortic diameters. Inclusion criteria were as follows: the data on diameter of sinuses of Valsalva (SVD) and/or ascending aorta (AAD) and BAV morphology. The additional characteristics [gender, AS and AR (% of patients with moderate or severe AS/AR) and mean age] were collected to perform a meta-regression analysis.

RESULTS

A total of 12 studies with 2192 patients with indexed AAD, 15 studies with 3104 patients with nonindexed AAD and 8 studies with 1271 patients with indexed SVD, and 16 studies with 3454 patients with nonindexed SVD were included. There was no difference between RL and RN group in indexed/nonindexed AAD-mean difference (MD): 0.06 mm/m² (95% CI: -0.65 to 0.77 mm/m² , P = .87) and -0.06 mm (95% CI: 1.10-0.97 mm, P = .91). Differently, the RL BAV was associated with larger indexed/nonindexed SVD than RN phenotype-MD: 1.66 mm/m² (95% CI: 0.83-2.49 mm/m² , P < .001) and 2.03 mm (95% CI: 0.97-3.09 mm, P < .001). Age, gender, AS, and AR had no influence on observed differences.

CONCLUSIONS

RL BAV phenotype is associated with larger SVD than RN BAV, and the observed differences are independent from aortic valve dysfunction degree, age, and gender.

Conscious sedation during cryoballoon ablation of atrial fibrillation: a feasibility and safety study

BACKGROUND

Cryoballoon ablation for atrial fibrillation (cryoAF) is relatively simple, cost-effective and easy procedure. However, general anesthesia during this procedure may have negative impact on patients' mortality and morbidity, as well as procedure costs. We sought to assess the feasibility and safety of conscious sedation during cryoAF.

METHODS

Patients with paroxysmal or persistent, drug-refractory AF who underwent a first procedure of cryoAF were included in our single-center, retrospective study. The loading dose of midazolam was 2 mg and loading fentanyl dose was 25 µg intravenously. Additional doses of midazolam and fentanyl were administered, if necessary. Midazolam and fentanyl were administered to maintain amnesia and analgesia, and patients' responsiveness in Ramsay Sedation Score was assessed every 10 minutes with sedation kept at the Ramsey Sedation Scale not exceeding Ramsey 3 Grade.

RESULTS

A total of 71 patients with mean age 59.5±11.1 years were enrolled (48 males, 68%). The TEE and the TEE-guided transseptal puncture was feasible in all patients. The mean duration of cryoAF procedure was 136.3±36.0 minutes. The overall mean midazolam and fentanyl used doses were: 5.1±3.1 mg (55.7±35.1 µg/kg) and 98.9±51.1 µg (1.13±0.60 µg/kg). In 3 patients (4.2%), vascular complications occurred (femoral vein bleeding with hematoma formation without communication with femoral artery). In 1 case (1.4%) transient right phrenic palsy was observed; symptoms disappeared completely within 12 hours after procedure. The overall acute procedural success rate of cryoAF (defined as electrical isolation of all pulmonary veins) was 68/71 (95.8%).

CONCLUSIONS

Conscious sedation is a safe, efficacious and feasible during cryoablation of pulmonary veins for AF.

Bedside screening with the use of pocket-size imaging device can be useful for ruling out carotid artery stenosis in patients scheduled for cardiac surgery

BACKGROUND

Patients (pts) scheduled for coronary artery bypass grafting, burdened with high risk of carotid stenosis, are recommended to undergo duplex ultrasonography (DUS) of carotid arteries.

PURPOSE

To validate pocket-size imaging device (PSID) equipped with linear probe as an easily accessible tool enabling bedside screening for carotid artery stenosis (CAS).

METHODS

A total of 100 pts (60 men, mean age 69±11 years) with multivessel coronary artery disease underwent bedside DUS of carotid arteries with the use of PSID performed by a cardiology resident trained in DUS. Subsequently, DUS with the use of stationary high-end ultrasound system was performed in all pts to verify findings of PSID examination.

RESULTS

Initial diagnosis of atherosclerotic plaque presence obtained with PSID in 59 patients was confirmed by high-end ultrasound system examination in all cases. There was a statistically significant correlation of intima-media thickness measurements between PSID and stationary system (r=.58; 95% CI: 0.48-0.66; P<.0001), but the coefficient of agreement (κ) between the two methods in classification of intima-media as normal or thickened (>0.9 mm) was only .38 (95% CI: 0.299-0.459). During PSID examination, turbulent flow was observed in 21 pts-CAS was confirmed in all these pts-5 pts were diagnosed with significant CAS, the rest with CAS ranging from 30% to 70%.

CONCLUSIONS

Pocket-size imaging device equipped with linear probe allows for identification of patients with atherosclerotic plaques and turbulent flow in carotid arteries; however, the degree of CAS cannot be reliably determined. The measurement accuracy of intima-media thickness is insufficient for a diagnostic purpose.

Association between microRNA-21 concentration and lipid profile in patients with acute coronary syndrome without persistent ST-segment elevation

INTRODUCTION

MicroRNA (miRNAs) are noncoding RNAs involved in the regulation of gene expression. Certain miRNAs, especially miRNA-21 (miR-21), may be involved in lipid metabolism.

OBJECTIVES

The aim of the study was to evaluate the association between plasma free circulating miR-21 levels and lipid fractions: total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides (TG), as well as their atherogenic profile expressed as the ratio of individual lipid fractions (TC:LDL-C, TC:non-HDL-C, TG:HDL-C, and HDL-C:LDL-C) in patients with acute coronary syndromes without persistent ST -segment elevation (NSTE ACS).

PATIENTS AND METHODS

The study group consisted of 34 patients diagnosed with NSTE ACS on admission to the emergency department. Plasma miRNA levels were determined by real-time polymerase chain reaction and the ΔΔCt method. Serum lipid fractions were assessed after a minimum of 12-hour fasting during the first day of hospitalization.

RESULTS

MiR-21 levels showed a significant inverse correlation with TC (r = -0.5; P = 0.002), LDLC (r = -0.5; P = 0.001), and non-HDL-C (r = -0.6; P <0.001) levels. Moreover, they were inversely correlated with TC:HDL-Cratio (r = -0.6; P <0.001), LDL-C:HDL-Cratio (r = -0.6; P <0.001), TG:HDL-Cratio (r = -0.4; P = 0.037), and TC:non-HDLratio (r = 0.6; P <0.001). In a multivariate analysis, miR-21 levels (β = -0.41; P = 0.018) and the need for revascularization (β = 0.35; P = 0.027) were independent predictors of non-HDL-C levels.

CONCLUSIONS

Free circulating miR-21 levels inversely correlate with TC, LDL-C, and non-HDL-C and are an independent predictor of non-HDL-C levels in patients with NSTE ACS. Thus, the overexpression of miR-21 is associated with a less atherogenic lipid profile.