New perspectives in diagnosis and risk stratification of non-ischaemic dilated cardiomyopathy

Dilated cardiomyopathy is a primitive heart muscle condition, characterized by structural and functional abnormalities, in the absence of a specific cause sufficient to determine the disease. It is, though, an 'umbrella' term that describes the final common pathway of different pathogenic processes and gene-environment interactions. Performing an accurate diagnostic workup and appropriate characterization of the patient has a direct impact on the patient's outcome. The physician should adapt a multiparametric approach, including a careful anamnesis and physical examination and integrating imaging data and genetic testing. Aetiological characterization should be pursued, and appropriate arrhythmic risk stratification should be performed. Evaluations should be repeated thoroughly at follow-up, as the disease is dynamical over time and individual risk might evolve. The goal is an all-around characterization of the patient, a personalized medicine approach, in order to establish a diagnosis and therapy tailored for the individual patient.

Long-Term Follow-Up of a Nonprogressive Left Main Coronary Artery Fistula to Right Atrium

Coronary artery fistula is a rare cardiac abnormality, occurring more frequently in young patients and treated with cardiac surgery or percutaneous interventions in most cases. We present the case of a 63-year-old man with an incidental diagnosis of coronary artery fistula, treated with conservative strategy. (Level of Difficulty: Intermediate.).

941 SARCOIDOSIS: THE IMPORTANCE OF MULTIMODALITY IMAGING

A 55-years old sporty man, without any cardiovascular risk factors nor previously known cardiological history, presented for a cardiological evaluation due to extra-systolic palpitations and dyspnea. The ECG documented a new onset of right bundle branch block, left anterior fascicular block and first degree of atrio-ventricular block. Echocardiography revealed severe left ventricular (LV) systolic dysfunction (LV ejection fraction -EF- 34%), showing also right ventricular (RV) dilatation and disfunction. A 24-hour Holter monitoring did not show any significant arrhythmias and maximal stress test did not reveal any ECG changes nor arrhythmias. Cardiac magnetic resonance (CMR) confirmed the presence of severe biventricular dysfunction; multiple areas of edema and late gadolinium enhancement (LGE) were observed, with ischemic and nonischemic pattern and extensive involvement of the RV and the interventricular septum. In the suspicion of cardiac sarcoidosis a 18-fluorodeoxyglucose positron emission tomography (PET) was performed, confirming the presence of an inflammatory cardiomyopathy in an active phase. A subsequent endomyocardial biopsy was performed, which demonstrated the presence of non-caseating granulomas, signs of inflammation and fibrosis, consistent with the diagnosis of cardiac sarcoidosis. No signs of extra-cardiac involvement were present.

The patient started anti-inflammatory therapy with Prednisone and Metotrexate, along with anti-neurohormonal therapy. However, due to a significant increase in ventricular arrhythmic burden, an implantable cardioverter defibrillator was placed during early follow-up, and Amiodarone therapy was started.

After 5 months of medical therapy, PET scan showed a marked reduction of cardiac inflammation and echocardiography showed a significant LVEF improvement (from 34% to 43%). After slow tapering of steroid therapy Prednisone was stopped, whereas Metotrexate, Amiodarone and anti-neurohormonal therapy were maintained. Follow-up is still ongoing without clinical events.

Sarcoidosis is a systemic inflammatory disease characterized by the presence of non-caseating granulomas in multiple organs. Cardiac involvement is associated with higher incidence of heart failure, ventricular arrhythmias and all-cause mortality. Isolated cardiac involvement is rare but associated with worse prognosis. Multimodality imaging is of paramount importance for the diagnosis and monitoring therapy.

180 LONG TERM FOLLOW UP OF A NON-PROGRESSIVE LEFT MAIN CORONARY ARTERY FISTULA TO RIGHT ATRIUM

A 63 years old man, with multiple cardiovascular risk factor, presented at the emergency department with a transient ischemic attack during an hypertensive crisis. Electrocardiogram revealed a sinus rhythm and no sign of ischemia. No critical stenosis were detected at ultrasonography of the supra-aortic trunks. Brain CT showed an arachnoid cyst in right posterior cerebellar site. Transthoracic echocardiographic showed normal wall motion with a left ventricular ejection fraction of 66%. The transesophageal echocardiography, performed for searching possible emboligenic heart disease, revealed a fistulous aneurysmal formation arising from the left main coronary artery. Angio-CT confirmed a CAF between distal left main coronary artery and right atrium, with a retro-aortic serpiginous course and an ectasic vascular structure (above 8.35 mm), this pathological vessel also had an aneurismatic formation of maximum diameter of 1 cm. CT scan detected also a 50% soft eccentric plaque in mid circumflex coronary artery and a less than 50% soft eccentric plaque in the right coronary artery.

An elective hospitalization was performed in order to better assess the CAF. Coronary angiography revealed no significant coronary atherosclerotic disease and confirmed the CAF with its convoluted course. No left to right shunt was found either in cardiac magnetic resonance (Qp/Qs close to 1) or in right heart catheterization. Maximal stress test with cycloergometer was negative for clinical and electrocardiographic inducible ischemia (120W).

CAF is a rare vascular abnormality, occurring in only 0.002% of the general population. The majority of CAFs have a congenital origin, but occasionally they may be acquired after cardiac surgery or repeated myocardial biopsies in cardiac transplantation. The CAFs may increase in size over time, although this does not occur invariably, and complications include: myocardial ischemia (due to myocardial ‘steal’), thrombosis and embolism, heart failure, atrial fibrillation, rupture, endocarditis/endarteritis, arrhythmias and also spontaneous rupture of the CAF causing hemopericardium. Current treatment options for CAF include surgery or transcatheter closure.

Considered the age of the patient, the absence of clinical symptoms and the absence of left to right shunt, a conservative strategy was chosen. The patient had strict follow up, with clinical and echocardiographic assessment every 6 months, and with annually CT scan and stress test. During these 9 years of follow up the CAF remained stable, and the patients clinically asymptomatic.

738 A RARE CASE OF UNICUSPID AORTIC VALVE WITH SEVERE STENOSIS AND REGURGITATION: CLINICAL PRESENTATION AND MANAGEMENT

A 19-year-old Pakistani migrant, who arrived in our country on foot, presented at emergency department with angina and worsening dyspnoea on exertion. The patient reported an unclear history of aortic valve disease.

Clinical examination revealed a 6/6L systolic murmur with thrill. The electrocardiogram showed sinus rhythm and signs of left ventricular hypertrophy. Chest X-ray reported cardiomegaly and signs of congestion. Troponin I HS was mildly elevated (39 ng/L, n.v. < 18 ng/L).

The patient was admitted to our Cardiology department. Transthoracic echocardiography revealed a mildly dilated left ventricle (LV), with severe hypertrophy, normal kinetics and systolic function (EF 63%), dilated ascending aorta (diam. 41 mm) and severe aortic steno-insufficiency. Transesophageal echocardiography was then performed, revealing a highly calcified, unicuspid unicommissural aortic valve with severe stenosis and regurgitation. A separate origin of left coronary ostia was also documented.

The patient was referred to urgent cardiac surgery. A modified Bentall procedure (mechanical valve and prosthetic conduit) was performed with reimplantation of the coronary ostia. Due to a post-surgical complete atrioventricular block, a dual-chamber pacemaker (DDD) was implanted.

Follow-up echocardiography showed reduction of LV volumes and wall thickness and normal prosthetic function.

Unicuspid aortic valve is a very rare congenital disease, with a prevalence of about 0.02% in the adult population and is frequently associated with ascending aorta dilatation. The treatment is aortic valve replacement. Complete atrioventricular block can occur after surgery, requiring cardiac pacing.

253 EXCERCISE-INDUCED PULMONARY HYPERTENSION AND CORONARY ARTERY ANOMALY: AN UNUSUAL ASSOCIATION

A healthy 55-year-old competitive sportsman, with familial history of early sudden cardiac death, came to our attention following the finding of asymptomatic exercise-induced myocardial ischemia (ST depression in V3- V6).

Computed tomography (CT) coronary angiogram excluded atherosclerotic disease but showed a dominant right coronary artery (RCA) originating from left Valsalva sinus and with an interarterial course between the ascending aorta and the pulmonary artery. Both the trunk of the pulmonary artery and the right ventricle were reported as mildly dilated

Transthoracic echocardiography showed a normal left ventricle (LV), while confirmed right ventricle (RV) dilatation, moderate tricuspid regurgitation (TR) and interatrial septal aneurysm. Stress echocardiography excluded inducible ischemia, but highlighted exercise-induced pulmonary hypertension (PH) (PAPs 25 → 70 mmHg), while a transesophageal echo confirmed a left-to-right shunt due to a 8-mm Patent Foramen Ovale (PFO).

Rheumatological, thromboembolic and parenchymal lung diseases were excluded as possible causes of exercise-induced PH; a rest right heart catheterization (RHC) showed a Qp/Qs ratio at the upper limits of normal range without PH. Nuclear stress testing identified trivial asymptomatic septal ischemia. The patients started medium dose of beta-blockers and early follow-up was planned.

This clinical case raises some questions: why is RV dilated? What role does PFO play? What is the cause of the inducible ischemia? What is the pathogenesis of exercise-induced PH?

Pulmonary Arterial Hypertension, in early stages, often manifests only under exertion, but it is usually characterized by exercise dyspnea and low oxygen saturation. Moreover, intracardiac shunts may be involved in developing PH.

In this specific case, pulmonary trunk may be expanded by pressure overload, causing the compression of aberrant RCA and consequent ischemic abnormalities. RV dilatation might be explained by exercise-induced PH itself, but it was not severe and has to be demonstrated by exercise right heart catheterization.

The main questions are: which is the primary etiology of right chamber enlargement and myocardial ischemia? Which is the most appropriate therapeutic approach (i.e. conservative vs interventional)?

Evolving trends in epidemiology and natural history of cardiac amyloidosis: 30-year experience from a tertiary referral center for cardiomyopathies

OBJECTIVE

Natural history of cardiac amyloidosis (CA) is poorly understood. We aimed to examine the changing mortality of different types of CA over a 30-year period.

PATIENTS AND METHODS

Consecutive patients included in the "Trieste CA Registry" from January 1, 1990 through December 31, 2021 were divided into a historical cohort (diagnosed before 2016) and a contemporary cohort (diagnosed after 2016). Light chain (AL), transthyretin (ATTR) and other forms of CA were defined according to international recommendations. The primary and secondary outcome measures were all-cause mortality and cardiac death, respectively.

RESULTS

We enrolled 182 patients: 47.3% AL-CA, 44.5% ATTR-CA, 8.2% other etiologies. The number of patients diagnosed with AL and ATTR-CA progressively increased over time, mostly ATTR-CA patients (from 21% before 2016 to 67% after 2016) diagnosed non-invasively. The more consistent increase in event-rate was observed in the long-term (after 50 months) in ATTR-CA compared to the early increase in mortality in AL-CA. In the contemporary cohort, during a median follow up of 16 [4-30] months, ATTR-CA was associated with improved overall and cardiac survival compared to AL-CA. At multivariable analysis, ATTR-CA (HR 0.42, p = 0.03), eGFR (HR 0.98, p = 0.033) and ACE-inhibitor therapy (HR 0.24, p < 0.001) predicted overall survival in the contemporary cohort.

CONCLUSION

Incidence and prevalence rates of ATTR-CA and, to a less extent, of AL-CA have been increasing over time, with significant improvements in 2-year survival of ATTR-CA patients from the contemporary cohort. Reaching an early diagnosis and starting disease-modifying treatments will improve long-term survival in CA.

A 20-year experience in cardiac tumors: a single center surgical experience and a review of literature

INTRODUCTION

Cardiac tumors are rare and heterogeneous entities which still remain a diagnostic and therapeutic challenge. The treatment for most cardiac tumors is prompt surgical resection. We sought to provide an overview of surgical results from a series of consecutive patients treated at our tertiary care center during almost a 20-year experience.

METHODS AND RESULTS

In this single center study, 55 consecutive patients with diagnosis of cardiac tumor underwent surgical treatment from January 2002 to April 2021. Of these, 23 (42%) were male and the mean age was 62 ± 12 years. Fifteen (27%) patients were symptomatic at the time of the diagnosis, mostly for dyspnea and palpitations. The most frequent benign cardiac tumor was myxoma (32; 58%), occurring mainly in the left atrium (31; 97%). Pleomorphic sarcoma was the most frequent primary malignant cardiac tumor (4; 7%), mainly located in the ventricles (1; 25% in the left ventricle; 2; 50% in the right ventricle). In all cases of benign tumors surgery was successful with no relapses. Two (50%) pleomorphic sarcomas showed subsequent relapses. After a median follow-up of 44 months, 15 (27%) patients died. Although malignant tumors presented a limited survival, benign tumors showed a very good prognosis.

CONCLUSION

Cardiac tumors require a multidisciplinary approach to guarantee a prompt diagnosis and appropriate treatment. In our surgical experience, outcome after surgery of benign tumors was excellent, while malignant tumors had poor prognosis despite radical surgery.

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

BACKGROUND

Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.

METHODS

We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.

RESULTS

Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P = 0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001-1.609; P = 0.049) were independently associated with 30-day mortality.

CONCLUSIONS

In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Clinical impact of myocardial fibrosis in severe aortic stenosis

The pressure overload due to the progressive narrowing of the valve area determines the development of the left ventricular hypertrophy which characterizes aortic stenosis (AS). The onset of myocardial fibrosis marks the inexorable decline of an initially compensatory response towards heart failure. However, myocardial fibrosis does not yet represent a key element in the prognostic and therapeutic framework of AS. In this context, cardiac magnetic resonance imaging plays a major role by highlighting both the focal irreversible fibrotic replacement, using the late gadolinium enhancement (LGE) technique, and the earlier diffuse reversible interstitial fibrosis, using the T1 mapping techniques. For this reason, the presence of myocardial fibrosis would be useful to identify a subgroup of patients at greater risk of events among the subjects with severe AS. Actually, more and more evidences seem to identify the presence of LGE as a powerful prognostic factor to be used to optimize the timing of prosthetic valve replacement. Randomized clinical trials, such as the EVoLVeD trial currently underway, will be needed to better define the importance of myocardial fibrosis assessment in the management of patients with AS.

Relationship between aortic valve stenosis and the hemodynamic pattern in the renal circulation, and restoration of the flow wave profile after correction of the valvular defect

OBJECTIVE

The index of maximal systolic acceleration ([AImax]: maximal systolic acceleration of the Doppler waveform divided by peak systolic velocity) shows diagnostic accuracy in screening of renal artery stenosis. This study aimed to determine whether an upstream factor of resistance, such as aortic valve stenosis (AVS), can affect Doppler parameters detected in the peripheral arteries.

METHODS

In this prospective study, we measured the AImax in non-stenotic renal interlobar arteries of 62 patients with AVS. Patients were divided into three groups on the basis of severity of valvulopathy as follows: mild-to-moderate AVS (M-AVS; n = 24), intermediate AVS (I-AVS; n = 15), and severe AVS (S-AVS; n = 23) based on Nishimura's criteria.

RESULTS

The AImax in the renal parenchymal arteries was significantly lower in the S-AVS group (8.9 ± 3.6 s^-1) than in the M-AVS (15.3 ± 3.8 s^-1) and I-AVS groups (16.7 ± 5.2 s^-1). The AImax was positively correlated with the aortic valve area and inversely correlated with the tranvalvular aortic pressure gradient. After aortic valve replacement, the AImax significantly increased from 10.7 ± 4.0 s^-1 at baseline to 19.3 ± 4.4 s^-1.

CONCLUSIONS

Proximal resistance can lead to diagnostic bias of Doppler parameters that are applied in the diagnosis of peripheral vasculopathies, particularly in renal artery stenosis.

Prevalence and predictors of persistent sinus rhythm after elective electrical cardioversion for atrial fibrillation

AIMS

To evaluate the prevalence and predictors of persistent sinus rhythm in a recent cohort of unselected patients undergoing electrical cardioversion for atrial fibrillation.

METHODS

We enrolled all consecutive patients undergoing elective electrical cardioversion for atrial fibrillation between January 2017 and December 2018. We analysed baseline clinical and echocardiographic data as well as pharmacological antiarrhythmic therapy. Primary endpoint was the maintenance of sinus rhythm at 12 months after electrical cardioversion.

RESULTS

Of the 300 patients enrolled, 270 (90%) had successful electrical cardioversion and among them, 201 patients have 12-month follow-up data (mean age 70 ± 10 years; 74% men). At 12 months, only 45.7% were in sinus rhythm. Patients without sinus rhythm compared with persistent sinus rhythm at 12 months had a lower baseline left ventricle ejection fraction (LVEF) (49.1 ± 16 vs. 59.7 ± 9%, P = 0.02) and had more frequently a history of atrial fibrillation more than 12 months (55 vs. 34% P = 0.003). At the multivariate analysis, only the duration of the disease beyond 12 months (OR 0.26, 95% CI: 0.08-0.88, P = 0.032), LVEF (OR 1.06, 95% CI: 1.01-1.12, P = 0.012) and the presence of sinus rhythm at 1-month follow-up (OR 18.28, 95% CI: 3.3-100, P = 0.001) were associated with the probability of maintaining sinus rhythm at 12 months.

CONCLUSION

In unselected patients with atrial fibrillation undergoing elective electrical cardioversion, only 45.7% were in sinus rhythm at 12 months. The presence of sinus rhythm at 1-month follow-up emerged as an independent predictor of maintenance of sinus rhythm. This highlights that early re-evaluation of these patients appears useful for assessing longer term outcomes also from the perspective of a possible selective approach to ablation strategies.

Impact on clinical outcomes of right ventricular response to percutaneous correction of secondary mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular function (RVF) is a strong determinant of prognosis in patients with reduced ejection fraction heart failure (HFrEF) and secondary mitral regurgitation (SMR). Percutaneous mitral valve repair (pMVR) can promote the recovery of RVF.

Purpose. We sought to characterize the RV response to pMVR in HFrEF with SMR and to assess the influence of improved RVF after pMVR in this specific setting of patients.

Methods. We included all the patients with HFrEF and SMR≥3+ successfully treated with pMVR between April 2012 and January 2020 in two tertiary care centers for HF. Improved RVF was defined as DRVFAC≥5% at early follow-up (median time 4 months). The primary endpoint was a composite of death/heart transplant (D/HT).  

Results. In total, 110 patients were included. Mean age was 67 ± 12 years, mean LVEF was 31 ± 8% and mean RVFAC was 31 ± 10%. DRVFAC≥5% occurred in 54 (49%) patients and was independent from the measures of left ventricle recovery. During a median follow-up of 36 months (IQR 19-52), 40 patients (36%) died or were transplanted.  After adjustment for other significant covariates, DRVFAC≥5% was significantly associated with lower risk of D/HT (HR 0.49, 95% CI 0.24 – 0.98 p &lt; 0.042) along with M2+ at follow-up (HR 0.36; 95% CI 0.17-0.74 p 0.005).

Conclusions. In patients with HFrEF and SMR, the improvement of RVF is frequent after pMVR and is associated with better long-term survival free from HT.

Abstract Figure.

Focus on arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy is a myocardial disease generally caused by desmosomal mutations and characterized by progressive replacement of cardiomyocites with fibro-adipose tissue. In the classic form of the disease right ventricle is predominantly affected. However, biventricular and left-dominant variants have been recently recognized, leading to the new nosological definition of arrhythmogenic cardiomyopathy. The condition affects mostly young adults and athletes and is clinically characterized by ventricular arrhythmias, heart failure and sudden cardiac death. The diagnosis is based on clinical-instrumental criteria, including family history, morpho-functional and electrocardiographic abnormalities, ventricular arrhythmias and genetic defects (Task Force Criteria, 2010). The main goal in the management of patients is the prevention of sudden cardiac death, where implantable cardioverter-defibrillator is the only effective therapeutic strategy. Many arrhythmic risk factors have been described. Recently, an on-line calculator has been proposed, but it needs further validation.

High prevalence of subtle systolic and diastolic dysfunction in genotype-positive phenotype-negative relatives of dilated cardiomyopathy patients

BACKGROUND

The early diagnosis of genetically determined dilated cardiomyopathy (DCM) could improve the prognosis in mutation carriers. Left ventricular global longitudinal strain (LV GLS) and peak left atrial longitudinal strain (PALS) are promising techniques for the detection of subtle systolic and diastolic dysfunction. We sought to evaluate the prevalence of subtle systolic and diastolic dysfunction by LV GLS and PALS in a cohort of genotype-positive phenotype-negative (GPFN) DCM relatives.

METHODS AND RESULTS

In this retrospective study, we analyzed echocardiograms of forty-one GPFN relatives of DCM patients. They were compared with age and sex matched healthy individuals (control group). Reduced LV GLS and PALS were defined as >18% and <23.1%, respectively. GPFN relatives (37 ± 14 years, 48.8% male) and controls were similar according to standard echocardiographic measurements. Conversely, LV GLS was -18.8 ± 2.7% in the GPFN group vs. -24.0 ± 1.8% in the control group (p < 0.001). Twenty subjects (48.8%) in the GPFN group and no subjects in the control group had a reduced LV GLS. PALS was 29.2 ± 6.7% in the GPFN group vs. 40.8 ± 8.5% in the control group (p < 0.001). Seven subjects (18.4%) in the GPFN group and one (2%) in the control group had a reduced PALS. A cohort of 17 genotype-negative phenotype-negative relatives showed higher values of LV GLS compared to GPFN.

CONCLUSIONS

Despite standard echocardiographic parameters are within the normal range, LV GLS and PALS are lower in GPFN relatives of DCM patients when compared to healthy individuals, suggesting a consistent proportion of subtle systolic and diastolic dysfunction in this population.

Modifications of medical treatment and outcome after percutaneous correction of secondary mitral regurgitation

Aims

The optimization of guideline‐directed medical therapy (GDMT) in reduced ejection fraction heart failure (HFrEF) is associated with improved survival and can reduce the severity of secondary mitral regurgitation (SMR). Highest tolerated doses should be achieved before percutaneous mitral valve repair (pMVR) and drugs titration further pursued after procedure. The degree of GDMT titration in patients with HFrEF and SMR treated with pMVR remains unexplored. We sought to evaluate the adherence to GDMT in HFrEF in patients undergoing pMVR and to explore the association between changes in GDMT post‐pMVR and prognosis.

Methods and results

We included all the patients with HFrEF and SMR ≥ 3 + treated with pMVR between 2012 and 2019 and with available follow‐up. GDMT, comprehensive of dosages, was systematically recorded. The study endpoint was a composite of death and heart transplantation. Among 133 patients successfully treated, 121 were included (67 ± 12 years old, 77% male patients). Treatment rates of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor neprilysin inhibitor (ACEIs/ARBs/ARNI), beta‐blockers, and mineralcorticoid receptor antagonist at baseline and follow‐up were 73% and 79%, 85% and 84%, 70% and 70%, respectively. At baseline, 33% and 32% of patients were using >50% of the target dose of ACEI/ARB/ARNI and beta‐blockers. At follow‐up (median time 4 months), 33% of patients unchanged, 34% uptitrated, and 33% of patients downtitrated GDMT. Downtitration of GDMT was independently associated with higher risk of death/heart transplantation (hazard ratio: 2.542, 95%confidence interval: 1.377–4.694, P = 0.003).

Conclusions

Guideline‐directed medical therapy is frequently underdosed in HFrEF patients with SMR undergoing pMVR. Downtitration of medications after procedure is associated with poor prognosis.

Left ventricular noncompaction, morphological, and clinical features for an integrated diagnosis

The presence of myocardial noncompaction (NC), regardless of the criterion used, does not identify cardiomyopathy per se. The distinction between a morphological variant and the presence of an NC cardiomyopathy is challenging. However, thanks to larger cohorts of patients and longer periods of follow-up, better clinical characterization and prognostic evaluation are becoming available. Indeed, the physician is required to integrate the evidence of NC with the clinical history of the patient, which is supplemented by necessary advanced instrumental investigations before a definite diagnosis of NC cardiomyopathy can be made. Therefore, we extensively revised the current literature in order to help the clinicians to identify clinical features which are pivotal supporting diagnostic element for the correct recognition of Left ventricular noncompaction cardiomyopathy and thus highlighting the difference between a form of cardiomyopathy and a mere intraventricular hypertrabeculation.

Sacubitril/Valsartan Induces Global Cardiac Reverse Remodeling in Long-Lasting Heart Failure with Reduced Ejection Fraction: Standard and Advanced Echocardiographic Evidences

Sacubitril/valsartan reduces mortality in heart failure with reduced ejection fraction (HFrEF) patients, partially due to cardiac reverse remodeling (RR). Little is known about the RR rate in long-lasting HFrEF and the evolution of advanced echocardiographic parameters, despite their known prognostic impact in this setting. We sought to evaluate the rates of left ventricle (LV) and left atrial (LA) RR through standard and advanced echocardiographic imaging in a cohort of HFrEF patients, after the introduction of sacubitril/valsartan. A multi-parametric standard and advanced echocardiographic evaluation was performed at the moment of introduction of sacubitril/valsartan and at 3 to 18 months subsequent follow-up. LVRR was defined as an increase in the LV ejection fraction ≥10 points associated with a decrease ≥10% in indexed LV end-diastolic diameter; LARR was defined as a decrease >15% in the left atrium end-systolic volume. We analyzed 77 patients (65 ± 11 years old, 78% males, 40% ischemic etiology) with 76 (28–165) months since HFrEF diagnosis. After a median follow-up of 9 (interquartile range 6–14) months from the beginning of sacubitril/valsartan, LVRR occurred in 20 patients (26%) and LARR in 33 patients (43%). Moreover, left ventricular global longitudinal strain (LVGLS) improved from −8.3 ± 4% to −12 ± 4.7% (p < 0.001), total left atrial emptying fraction (TLAEF) from 28.2 ± 14.4% to 32.6 ± 13.7% (p = 0.01) and peak atrial longitudinal strain (PALS) from 10.3 ± 6.9% to 13.7 ± 7.6% (p < 0.001). In HFrEF patients, despite a long history of the disease, the introduction of sacubitril/valsartan provides a rapid global (i.e., LV and LA) RR in >25% of cases, both at standard and advanced echocardiographic evaluations.

1040 Unexpected prevalence of subtle systolic and diastolic dysfunction in genotype-positive phenotype-negative relatives of dilated cardiomyopathy patients

Funding Acknowledgements

None

Background

Left ventricular global longitudinal strain (LV-GLS) and peak left atrial longitudinal strain (PALS) are promising techniques for the detection of a subtle systolic and diastolic dysfunction for an early diagnosis of genetically determined dilated cardiomyopathy (DCM). Purpose. We sought to evaluate the prevalence of subtle systolic and diastolic dysfunction by LV-GLS and PALS in a cohort of genotype-positive phenotype-negative (GPFN) DCM relatives. Methods. We analysed echocardiograms (including LV-GLS and PALS) of 41 GPFN relatives of DCM patients (GPFN group - 37 ± 14 years, 48.8% male). They were compared with a matched group of 52 healthy individuals (control group). Reduced LV-GLS and PALS were defined as &gt;-18% and &lt;23.1%, respectively, according to literature data. Results. GPFN and control groups were grossly similar according to standard echocardiographic measurements. Conversely, mean LV-GLS was -18.8 ± 2.7% in the GPFN group vs. -24.0 ± 1.8% in the control group (p &lt; 0.001). 20 subjects (48.8%) in the GPFN group and no subjects in the control group had a reduced LV-GLS. The mean PALS was 29.2 ± 6.7% in the GPFN group vs. 40.8 ± 8.5% in the control group (p &lt; 0.001). 7 subjects (18.4%) in the GPFN group and one (2%) in the control group had a reduced PALS. During a median follow-up of 27 months, 6 (14.6%) GPFN relatives developed a LV ejection fraction &lt;50%. Among them, 4 (66%) had a reduced LV-GLS at initial evaluation. Conclusions. LV-GLS and PALS are impaired in GPFN relatives of DCM patients compared to healthy individuals, when standard echocardiographic parameters are normal. Further studies are warranted to add prognostic significance to this result, which may lead in the future to an early therapy initiation.

Abstract 1040 Figure. Mean LV-GLS and PALS in GPFN and control

Treatment of Functional Mitral Regurgitation in Heart Failure

PURPOSE OF REVIEW

To analyze the current state of the art of functional mitral regurgitation (FMR) treatment.

RECENT FINDINGS

The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. The COAPT trial provided a "proof of concept" that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.

Prognostic relevance of pericardial effusion in STEMI patients treated by primary percutaneous coronary intervention: a 10-year single-centre experience

BACKGROUND

Pericardial effusion is frequent in the acute phase of ST-segment elevation myocardial infarction. However, its prognostic role in the era of primary percutaneous coronary intervention is not completely understood.

METHODS

We investigated the association between pericardial effusion, assessed by transthoracic echocardiography, and survival in a large cohort of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention, enrolled in the Trieste primary percutaneous coronary intervention registry from January 2007 to March 2017. Multivariable analysis and a propensity score approach were performed.

RESULTS

A total of 1732 ST-segment elevation myocardial infarction patients were included. Median follow-up was 45 (interquartile range 19-79) months. Pericardial effusion was present in 246 patients (14.2%). Thirty-day all-cause mortality was similar between patients with and without pericardial effusion (7.8% vs. 5.4%, P=0.15), whereas crude long-term survival was worse in patients with pericardial effusion (26.2% vs. 17.7%, P≤0.01). However, at multivariable analyses the presence of pericardial effusion was not associated with long-term mortality (hazard ratio 1.26, 95% confidence interval 0.86-1.82, P=0.22). Matching based on propensity scores confirmed the lack of association between pericardial effusion and both 30-day (hazard ratio 1, 95% confidence interval 0.42-2.36, P=1) and long-term (hazard ratio 1.14, 95% confidence interval 0.74-1.78, P=0.53) all-cause mortality. Patients with pericardial effusion experienced a higher incidence of free wall rupture (2.8% vs. 0.5%, P<0.0001) independently of the entity of pericardial effusion.

CONCLUSIONS

In acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, the onset of pericardial effusion after ST-segment elevation myocardial infarction is not independently associated with short and long-term higher mortality. Free wall rupture has to be considered rare compared to the fibrinolytic era and occurs more frequently in patients with pericardial effusion, suggesting a close monitoring of these patients in the early post-primary percutaneous coronary intervention phase.

Prognostic Value of Global Longitudinal Strain-Based Left Ventricular Contractile Reserve in Candidates for Percutaneous Correction of Functional Mitral Regurgitation: Implications for Patient Selection

PURPOSE

Patients with symptomatic heart failure (HF), reduced left ventricular ejection fraction (LVEF), and high-grade functional mitral regurgitation (MR) may benefit from percutaneous edge-to-edge mitral valve repair (PMVR). However, patient selection still remains a central issue. We sought to investigate the potential role of the global longitudinal strain- (GLS-) based left ventricular contractile reserve (LVCR) at dobutamine stress echocardiography (DSE) in this setting.

METHODS

Thirty-three stable HF patients (MR grade ≥ 3+; median LVEF, 29%; median GLS, -8.3%) who were candidates for PMVR were prospectively enrolled. All patients underwent DSE to assess LVCR (LVEF increase ≥ 5%; GLS increase ≥ 2%; stroke volume [SV] increase ≥ 20% of the measured SV value).

RESULTS

After DSE, a positive LVCR_LVEF was detected in 21 patients (64%), positive LVCR_GLS in 12 patients (36%), and positive LVCR_SV in 14 patients (42%). LVCR_GLS was associated with better symptom relief, MR improvement, and LV reverse remodeling in a short-term follow-up. A significant improvement of GLS during DSE (hazard ratio [HR], 0.549; 95% CI, 0.395-0.765; P < .001), along with history of HF hospitalization (HR, 1.48; 95% CI, 1.119-1.967; P = .006) and beta-blocker therapy (HR, 0.146; 95% CI, 0.046-0.462; P = .001), were independently associated with risk of death/heart transplantation/HF-related hospitalizations.

CONCLUSIONS

LVCR, assessed by speckle-tracking DSE, is associated with better results after PMVR in the setting of advanced HF. Improvement of longitudinal function emerged, beyond the ejection fraction, as an independent predictor of outcomes and could improve the selection of best candidates for the percutaneous correction of functional MR.

Prognostic Role of Left Ventricular Dysfunction in Patients With Coronary Artery Disease After an Ambulatory Cardiac Rehabilitation Program

The relationship between left ventricular ejection fraction (LVEF) and outcomes after cardiac rehabilitation (CR) is not well established; therefore we assessed the prognostic role of LVEF at the end of ambulatory CR program in patients (pts) who received coronary revascularization. LVEF was evaluated at hospital discharge and re-assessed at the end of CR in all ST-elevation myocardial infarction and coronary artery bypass graft pts, while in pts with non-ST-elevation MI or elective percutaneous coronary intervention the echocardiography was repeated if they had an impaired LVEF at discharge. New hospitalizations for cardiovascular causes at 1-year, and cardiovascular mortality during long-term follow-up were analyzed. We enrolled in CR 3078 pts, 86% showed LVEF ≥40% and 9% LVEF <40%. Of those with a discharge LVEF <40%, 56% improved LVEF (LVEF ≥40%) after CR. At 1-year, heart failure was the main cause of new hospitalizations in LVEF <40% group compared with LVEF ≥40% group (5% vs 0.4%, p <0.01). During a mean follow up of 48 ± 25 months, cardiovascular death occurred in 9% of pts with LVEF <40% and in 2% with LVEF ≥40% (p = 0.014). At Cox multivariate analysis, LVEF <40% at the end of CR and age were independent predictors of hospitalization and mortality for cardiovascular causes, while coronary artery bypass graft was a protective factor. In conclusion, during CR the improvement of LVEF occurs in a relevant proportion of patients, the re-assessment of LVEF at the end of the CR is helpful for risk stratification because left ventricle dysfunction at the end of CR is associated with worse cardiovascular outcomes.

Left Ventricular Response to Cardiac Resynchronization Therapy: Insights From Hemodynamic Forces Computed by Speckle Tracking

Aims: Despite continuous efforts in improving the selection process, the rate of non-responders to cardiac resynchronization therapy (CRT) remains high. Recent studies on intraventricular blood flow suggested that the alignment of hemodynamic forces (HDFs) may be a reproducible biomarker of mechanical dyssynchrony. We aimed to explore the relationship between pacing-induced realignment of HDFs and positive response to CRT. Methods and results: We retrospectively analyzed 38 patients from the CRT database of our institution fulfilling the inclusion criteria for HDFs-related echocardiographic assessment early pre and post CRT implantation, with available mid-term follow-up (≥ 6 months) evaluation. Standard echocardiographic and deformation parameters early pre and post CRT implantation were integrated with the measurement of HFDs through novel methods based on speckle-tracking analysis. At midterm follow-up 71% of patients were classified as responders (reduction of Left Ventricular Systolic Volume Indexed ≥ 15%). Patients did not display significant changes between close evaluations pre and post-implant in terms of ejection fraction and strain metrics. A significant reduction of the ratio between the amplitudes of transversal and longitudinal force components was found. The variation of this ratio strongly correlates (R² =0.60) with Left Ventricular (LV) end-systolic volume variation at mid-term follow up. Conclusion: Pacing-induced realignment of HDFs is associated with CRT efficacy at follow up. These preliminary results claim for dedicated prospective clinical studies testing the potential impact of HDFs study for patient selection and pacing optimization in CRT.

Rescue extracorporeal membrane oxygenation in a young man with a stab wound in the chest

A 27-year-old man with haemorrhagic shock and acute cardiac tamponade due to a stab in the chest underwent successful resuscitation and surgical repair of the right ventricular perforation thanks to the use of extracorporeal membrane oxygenation (ECMO) in the emergency department. To the best of the authors' knowledge, this is the first report around the use of ECMO to rescue a victim of a penetrating cardiac trauma. The physicians who have portable ECMO device should be aware of this option when a life-threatening internal bleeding in haemodynamically unstable patients could be quickly controlled by surgery, even if performed in ill-suited settings.

The progression of left ventricular systolic and diastolic dysfunctions in hypertrophic cardiomyopathy: clinical and prognostic significance

OBJECTIVES

The significance of the progression of systolic and diastolic dysfunctions in hypertrophic cardiomyopathy (HCM) is still an open issue. We sought to evaluate the clinical and prognostic implications of the progression of left ventricular systolic and diastolic dysfunction in HCM.

METHODS

One hundred one HCM patients were studied by echo-Doppler at baseline and during follow-up.

RESULTS

During a follow-up of 109 + or - 67 months, 28% of patients showed a progression to left ventricular diastolic dysfunction, defined as restrictive filling pattern (RFP), and 16% to left ventricular systolic dysfunction (left ventricular ejection fraction <50%). The 10-year heart transplant-free survival rate was 45% in patients with RFP at follow-up vs. 82% in the patients without RFP (P < 0.001), and 52% in patients with left ventricular systolic dysfunction at follow-up vs. 75% in the patients with left ventricular ejection fraction of at least 50% (P = 0.001). Baseline predictors of death/transplantation were New York Heart Association class III-IV, indexed left atrial diameter, and RFP. When RFP and left ventricular systolic dysfunction were added at follow-up, both emerged as prognostic predictors (RFP: hazard ratio 8.92, 95% confidence interval 2.5-31.86; systolic dysfunction: hazard ratio 25.35, 95% confidence interval 3.57-179.88) with a significant increase of area under the receiver-operating characteristic curves (0.81 vs. 0.70, P = 0.03) with respect to the baseline model.

CONCLUSION

Left ventricular diastolic and/or systolic dysfunction at follow-up are relatively frequent in HCM and are associated with a poor prognosis.

Heart failure in patients with aortic stenosis: Clinical and prognostic significance of carbohydrate antigen 125 and brain natriuretic peptide measurement

BACKGROUND

Brain natriuretic peptide (BNP) is related to symptomatic status and outcome in aortic stenosis (AS) patients. Carbohydrate antigen 125 (CA125) demonstrated recently a BNP-like behaviour in patients with congestive heart failure (CHF) but has never been studied in AS patients. We aimed to assess the role of CA125 and BNP in AS patients.

METHODS

CA125 and BNP blood levels, transthoracic echocardiography and independent evaluation of CHF symptoms were obtained in 64 consecutive patients (76+/-9 years; 35 males) with AS (valve area 0.9+/-0.3 cm(2)). A pre-specified combined end-point consisting of cardiac mortality, urgent aortic valve replacement and hospitalization for CHF was considered. The median follow-up was 8 months (interquartile range 4.5-10 months).

RESULTS

Both CA125 and BNP have accurately identified patients with III-IV NYHA class: area under the ROC curve was 0.85 for CA125 and 0.78 for BNP (best cut-offs of 10.3 U/mL and 254.64 pg/mL respectively) and were independently correlated to left ventricular ejection fraction. Fifty-two percent of patients with CA125>or=10.3 U/mL vs. 13% with CA125<10.3 U/mL (p<0.01) and 65% patients with BNP>or=254 pg/mL vs. 7% with BNP<254 pg/mL (p<0.001) have reached the end-point.

CONCLUSIONS

Both CA125 and BNP levels are significantly correlated with NYHA class and outcome in patients with AS. CA125 blood level assessment (less expensive) may improve the clinical management in this setting.