Left atrial pump strain predicts long-term survival after transcatheter aortic valve implantation

BACKGROUND

This study aims at investigating left atrial (LA) deformation by left atrial reservoir (LARS) and pump strain (LAPS) and its implications for long-term survival in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Speckle tracking echocardiography was performed in 198 patients with severe AS undergoing TAVI. Association of strain parameters with cardiovascular mortality was determined.

RESULTS

Over a follow-up time of 5 years, 49 patients (24.7%) died. LAPS was more impaired in non-survivors than survivors (P = 0.010), whereas no difference was found for LARS (P = 0.114), LA ejection fraction (P = 0.241), and LA volume index (P = 0.292). Kaplan-Meier analyses yielded a reduced survival probability according to the optimal threshold for LAPS (P = 0.002). A more impaired LAPS was associated with increased mortality risk (HR 1.12 [95% CI 1.02-1.22]; P = 0.014) independent of LVEF, LAVI, age, and sex. Addition of LAPS improved multivariable echocardiographic (LVEF, LAVI) and clinical (age, sex) models with potential incremental value for mortality prediction (P = 0.013 and P = 0.031, respectively). In contrast, LARS and LAVI were not associated with mortality.

CONCLUSIONS

In patients undergoing aortic valve replacement for severe AS, LAPS was impaired in patients dying during long-term follow-up after TAVI, differentiated survivors from non-survivors, was independently associated with long-term mortality, and yielded potential incremental value for survival prediction after TAVI. LAPS seems useful for risk stratification in severe AS and timely valve replacement.

3D atrial strain for prediction of atrial fibrillation recurrence

Introduction

Atrial fibrillation (AF) is one of the most common supraventricular arrhythmias. Treatment options apart from medication include interventional catheter-guided pulmonary vein isolation (PVI). However, there is limited knowledge about factors predicting arrhythmia recurrence after PVI.

Aim

To study the association of 3-dimensional (3D) left atrial (LA) strain (LAS) and 3D electro-anatomical voltage mapping (EAVM) with early recurrence of AF after PVI.

Methods

In this prospective single center study, 93 patients undergoing PVI were enrolled between December 2018 and October 2021. All patients underwent an echocardiographic examination within two weeks before PVI using the Canon Aplio i900 system to analyse LAS from 3D LA volume. A 3D EAVM was obtained using high-density mapping catheters during PVI. The CARTO 3 system (Version V6-V7) was used for determining LA scar area by low voltage mapping (local amplitude <0.5 mV) indicated as percentage (EAVM-%). Follow-up time points were set at 2, 3, 6 and 12 months to investigate recurrence of AF, with exclusion of events occurring during the first two months (blanking phase).

Results

During follow-up, 12 out of 93 patients experienced recurrence of AF (12.9%; AF-Group). Baseline characteristics did not differ between AF-Group and Non-AF-Group. In contrast, LAS was significantly impaired in the AF-Group (median −4.6, IQR [−5.6 to −3.6]) when compared to the Non-AF-Group (−6.2 [−8.3 to −4.5]; p=0.009). The EAVM-% did not differ between the groups (AF-Group: 5.0 [1.5 to 21.5]; Non-AF-Group: 4.4 [1.5 to 15.9]; p=0.710). No significant correlations were found between LAS and EAVM-% (r=0.03, p=0.812). A cut-off value of −5.89% for LAS had a sensitivity of 100% and a specificity of 57% for AF recurrence (AUC=70%; p<0.001). Kaplan Meier curves for event-free survival were generated based on the LAS cut-off demonstrating excellent differentiation of those with and without AF recurrence (p<0.001; see figure). Furthermore, LAS was associated with an increased risk of early AF recurrence (HR 1.40, IQR [1.02–1.92], p=0.040), while EAVM-% was not (HR 0.99 [0.95–1.04], p=0.787).

Conclusion

3D LAS was associated with an increased risk of early AF recurrence after PVI, while EAVM-% was not. 3D LAS might be used for identifying patients who would benefit from PVI.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular versus left ventricular global longitudinal strain for association with all-cause mortality after transcatheter aortic valve implantation

Introduction

Speckle-tracking echocardiography plays an increasingly important role in the assessment of aortic stenosis (AS), the most common valvular heart disease in the Western population. Right ventricular (RV) and left ventricular (LV) global longitudinal strain (GLS) were studied for their association with all-cause mortality in AS patients undergoing transcatheter aortic valve implantation (TAVI).

Purpose

To investigate whether simultaneous assessment of RV and LV GLS provides a better association with all-cause mortality during long-term follow-up after TAVI.

Methods

In our prospective registry we identified 109 patients with severe AS who underwent TAVI and had a pre-procedural echocardiography within three months of the procedure allowing complete assessment of RV and LV GLS using TomTec Image Arena. All-cause mortality was defined as endpoint.

Results

RV GLS was lower among non-survivors (N=36; median [IQR]: −13.94 [−16.31 to −12.62]; p<0.001) than survivors (N=73; −17.04 [−20.16 to −15.22]; p<0.001), while LV GLS did not differ (p=0.249). RV GLS >−16.6% differentiated survivors from non-survivors (sensitivity 78%; specificity 63%; ROC AUC 71%; p<0.001), while LV GLS did not (p=0.243). Kaplan Meier curves showed good differentiation of survivors and non-survivors with the RV GLS (p<0.001; Figure 1), but not the LV GLS cut-off (p=0.058). In univariable Cox regression models, RV GLS was associated with all-cause mortality (HR 1.10 [95% CI 1.02 to 1.18]; χ2=6.64; p=0.01), while LV GLS was not (HR 1.05 [0.96 to 1.16]; χ2=1.08; p=0.299). In bivariable models, association of RV GLS with all-cause mortality was independent of LV GLS or LV ejection fraction (LVEF; Table 1). ANOVA likelihood ratios revealed that inclusion of RV GLS to LV GLS or LVEF improved their model fitness, while that of LV GLS did not (Table).

Conclusion

RV GLS was associated with all-cause mortality after TAVI, while LV GLS and LVEF were not. The association of RV GLS was independent of LV GLS and LVEF and showed potential incremental value for assessment of outcome association, while LV GLS did not.

Funding Acknowledgement

Type of funding sources: None.

Association of left ventricular myocardial work with all-cause mortality after transcatheter aortic valve implantation

Introduction

Echocardiography is an important modality for peri-interventional assessment of patients undergoing transcatheter aortic valve implantation (TAVI). Left ventricular (LV) global longitudinal strain measures ventricular deformation at end-systole, while myocardial work parameters determine LV deformation throughout the cardiac cycle and correct for afterload.

Aims

To evaluate LV deformation by myocardial work efficiency (GWE) and index (GWI) in early post-TAVI echocardiography and explore its association with all-cause mortality.

Methods

We analyzed 144 patients with severe aortic stenosis and an echocardiography study within two weeks after TAVI. All echocardiographic analyses were performed using GE EchoPac v2.6. Follow-up data was obtained from medical records until September 2021. All-cause mortality was the primary endpoint.

Results

During a median follow-up duration of 625 [IQR: 511.0–769.8] days, 25 (17.5%) patients died. No significant differences in the baseline characteristics were found between non-survivors and survivors. GWE (Figure 1A) and GWI (Figure 1B) were significantly lower among non-survivors than survivors. Both myocardial work parameters differentiated non-survivors from survivors with a cut-off value of −85% for GWE and 990 mmHg% for MWI (Figure 2; both p<0.001).

Conclusions

In this study, GWE and GWI were lower among non-survivors than survivors and were associated with an increased risk of all-cause mortality after TAVI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss Heart Foundation

Author Correction: Evaluation of uttroside B, a saponin from Solanum nigrum Linn, as a promising chemotherapeutic agent against hepatocellular carcinoma

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Myocardial work analysis in left ventricular non-compaction, and its association with cardiovascular outcomes

Introduction

Left ventricular (LV) non-compaction (LVNC) is a rare cardiomyopathy characterised by a two-layered LV myocardium with prominent trabeculae separated by deep recesses perfused from the LV cavity. Myocardial work analysis (MWA) is a novel echocardiographic method that calculates pressure-strain loops from longitudinal strain and bedside blood pressure measurement. Our study investigates the MWA features of LVNC patients and their association with outcomes.

Methods

We compared 40 LVNC with preserved LVEF (≥50%) (pEF-LVNC) and 40 LVNC patients with reduced LVEF (<50%) (rEF-LVNC) to 40 healthy matched controls. GE EchoPAC® (Version 203) was used for echocardiographic analysis. A combined endpoint was defined as heart failure progression, sustained ventricular tachycardia, thromboembolic accidents, and atrial fibrillation.

Results

Clinical characteristics, conventional echocardiography, and strain analysis results are detailed in Table 1 and Figure 1. Myocardial work index was significantly reduced in rEF-LVNC (1088 [138–1211 mm.Hg%]) and pEF-LVNC (1394 [1138–1501 mm.Hg%]) in comparison to control (1827 [1758–1981 mm.Hg%]), but there was no difference between the two LVNC groups. Global constructive work (GCW) was significantly lower in rEF-LVNC (1094 [947–1281 mm.Hg%]) than in pEF-LVNC (1730 [1368–1691 mm.Hg%]) (p=0.001), while both LVNC groups were lower than control (2201 [1965–2406 mm.Hg%]) (pEF-LVNC p=0.001, rEF-LVNC p<0.0001). Global wasted work (GWW) was significantly lower in rEF-LVNC (204 [181–231 mm.Hg%]) than in pEF-LVNC (154 [115–171 mm.Hg%], p<0.0001) and control (61 [45–98 mm.Hg%], p<0.0001). Global work efficiency (GWE) was significantly lower in rEF-LVNC (18.3 [15.4–19.6%], p=0.001 than in pEF-LVNC and control. In both pEF-LVNC and rEF-LVNC, impaired GWE and GCS were the parameters most significantly associated with increased risk of cardiovascular events as detailed in Figure 2.

Conclusion

MWA is a promising parameter for risk assessment of LVNC patients especially because it is less load-dependent and, unlike LVEF, incorporates left ventricular haemodynamics.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): 2018 research grant from the Swiss Heart Foundation

Circumferential deformation in diagnosis and risk assessment of patients with left ventricular non-compaction

Introduction

Echocardiography-based deformation analysis is used for studying left ventricular (LV) mechanics and have an emerging role in the diagnosis of cardiomyopathies. Left ventricular non-compaction (LVNC) is a rare cardiomyopathy characterised by a two-layered LV myocardium with prominent trabeculae separated by deep recesses perfused from the LV cavity. Left ventricular hypertrabeculation (LVHT) may be difficult to differentiate from LVNC. In this study, we aim to develop a diagnostic algorithm based on the circumferential deformation (CD) of LVNC, LVHT and controls; and find their associations with LVNC outcomes.

Methods

We compared 45 LVNC patients, 45 LVHT individuals, and 45 matched healthy controls. LVNC was diagnosed according to current echocardiographic criteria. LVHT was defined as presence of three or more trabeculae in the LV apex visualised in both parasternal short axis and apical views. Controls had a normal echocardiographic examination and no evidence of cardiovascular disease. Strain analysis was performed using TomTec Image-Arena (version 4.6).

Results

Receiver observer characteristics curve (ROC) analyses revealed that GCS <22.3% differentiated LVNC from control or LVHT. In individuals with global circumferential strain (GCS) below 22.3%, an apical peak circumferential strain (PCS) cut-off value of 18.4% differentiated LVNC [<18.4%] and LVHT [≥18.4%] (fig. 1). An independent echocardiographer (Table 1) performed blind validation of diagnosis on 32 subjects from each group.

Combined endpoint of cardiovascular events in LVNC (CVE) is described in figure 2. Multi-variate regression analyses have shown that GCS was associated with 11-fold increased risk of CVE independent of LVEF and NC:C ratio, while global longitudinal strain (GLS) displayed only 2-fold increased risk. Regional basal and apical peak circumferential or longitudinal strain, left ventricular twist, basal-apical rotation ratio have shown significant associations (Fig. 3).

Conclusions

A diagnostic algorithm with GCS and aPCS (threshold value 18.4%) differentiates LVNC from LVHT and control with very high sensitivity and specificity independent of additional echocardiographic or clinical information. Circumferential strain derived parameters exhibit a very strong association with outcomes independent of LVEF and NC:C ratio. Absence of CVE in LVHT provides further evidence on the distinct nature of LVNC and LVHT.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): 2018 research grant from the Swiss Heart Foundation

P1842Impact of left ventricular outflow tract sphericity on transcatheter heart valve hemodynamics and outcome after transcatheter aortic valve implantation

Background

Accurate assessment of aortic annulus and left ventricular outflow tract (LVOT) anatomy is mandatory for appropriate device selection in order to achieve optimal deployment of transcatheter heart valves (THV).

Aim

To evaluate the impact of LVOT shape as determined by the sphericity index (ratio of long and short LVOT diameter) on THV hemodynamics.

Methods

1000 consecutive patients diagnosed with severe symptomatic aortic stenosis and undergoing TAVI between May 2008 and July2017 were analyzed. Assessment of aortic root dimensions including the LVOT was performed by contrast-enhanced multidetector computed tomography (MDCT) in all patients. The primary endpoint was 30-day device success as defined by the VARC-2 criteria. Secondary endpoints included all-cause mortality, cardiovascular mortality, permanent pacemaker implantation (PPI), and a 30-day combined early safety endpoint (all-cause mortality, all strokes, life threatening bleeding, acute kidney injury stage 2 or 3, CAD obstruction requiring intervention, major vascular complication, valve related dysfunction requiring repeat intervention).

Results

Patients were divided into 3 groups according to LVOT sphericity index (SI) quartiles. The three groups (low-SI: 0.4–0.63, n=250; mid-SI: 0.64–0.75, n=500; high-SI: 0.76–1.0, n=250) were well balanced in terms of baseline characteristics, except for gender distribution with more female patients in the low-SI group (36.8% vs. 49.0% vs. 60.0%; p=0.ehz748.05941). Assessment of calcification volume and Agatston score demonstrated significantly higher aortic valve and LVOT calcification in the high-SI group. The primary endpoint of device success after 30-days did not differ between the 3 groups (92.4% vs 91.9% vs. 87.9%; p=NS). However, moderate or severe paravalvular regurgitation (PAR) occurred significantly more often in the high-SI as compared to the other groups (4.1% vs. 5.2% vs. 10.6%; p=0.004 for low-SI vs. high-SI). In contrast, PPI rates, the early safety endpoint at 30 days, and all-cause mortality at 1 year did not differ between the groups. In the high-SI group implantation of a BE valve was associated with a significantly higher rate of device success as compared to SE valves (93.8% vs. 82.2%, p=0.007). This difference was driven by a higher rate of moderate or severe PAR (6.9% vs. 15.3%, p=0.007) in patients treated with SE valves. Moreover, patients in the high-SI group receiving a SE valve required more often a PPI than those treated with a BE valve (26.2% vs 13.3%, p=0.012). There was no difference between the THV types in the other SI groups in terms of primary and secondary endpoints.

Conclusion

A more circular LVOT is associated with higher aortic valve and LVOT calcification. Implantation of a SE THV results in higher rates of moderate or severe PAR and persistent conduction disorder requiring PPI in such patients.

P3689Association of echocardiographic progression and genetic profile in arrhythmogenic right ventricular cardiomyopathy

Background

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is frequently associated with mutations in genes coding for desmosomal proteins. In this study, we investigated the association of genetic status with ARVC progression as defined by echocardiographic parameters.

Methods

We tested 62 ARVC patients for their genetic profile. Accordingly, they were grouped in mutation positive (48 (77%) patients; median age 48.5 years; 33 (69%) males), and mutation negative (14 (23%) patients; median age 45 years; 10 (71%) males). Prevalent mutations were Desmoglein-2 (DSG2) in 16 (26%), Desmoplakin (DSP) in 14 (23%), and Plakophilin-2 (PKP2) in 9 (15%) patients.

Results

At baseline, there were no significant differences in clinical characteristics between the two groups. Patients were followed-up for a median time period of 1420 days, and there was no significant difference in the duration of follow-up between the two groups (p=0.05).

In the mutation positive group, there was a significant increase in right ventricular end-diastolic area (p=0.002), right atrial short (p=0.008) and long (p=0.002) diameter, left atrial diameter (p=0.014), and a decrease in left ventricular ejection fraction (p=0.014) during follow up. Right ventricular functial parameters did not change significantly (tricuspid annular plane systolic excursion: p=0.24; fractional area change: p=0.088).

In the mutation negative group, none of the aforementioned echocardiographic findings exhibited any significant difference during follow-up: right ventricular end-diastolic area (p=0.1); right atrial short (p=0.7) and long (p=0.9) diameter, left atrial diameter (p=0.6), and left ventricular ejection fraction (p=0.3). Similarly, right ventricular functional parameters did not change significantly (tricuspid annular plane systolic excursion: p=0.77; fractional area change: p=0.80. Results are summarized in the figure.

Change in echocardiographic findings.

Conclusions

There is a strong association between echocardiographic progression of ARVC phenotype and the presence of a pathogenic mutation. Such mutations should be searched in all patients with an ARVC phenotype, and mutation positive individuals should be followed-up in shorter intervals.

Effect of localised vibration on muscle strength in healthy adults: a systematic review

OBJECTIVE

To investigate the effects of local vibration on muscle strength in healthy adults.

DATA SOURCES

The electronic databases PubMed, CINAHL, Scopus and Web of Science were searched using a combination of the following keywords: vibration, vibration therapy, power, maximal voluntary contraction, performance, rate of force development and vibratory exercise. In addition, the Medical Subject Headings 'vibration', 'strength' and 'exercise' were used. The bibliographical search was limited to articles published in English.

STUDY SELECTION

Trials that evaluated the effect of localised vibration on muscle strength in healthy humans were included.

DATA EXTRACTION

Two independent evaluators verified the quality of the selected studies using the PEDro Scale and the Cochrane Collaboration's tool for assessing the risk of bias. Muscle strength was calculated for each intervention.

RESULTS

In total, 29 full-text studies were assessed for eligibility. Eighteen studies did not match the inclusion criteria, and were excluded. The 11 studies included in this review had an average PEDro score of 5.36/10. Most of the studies reported significant improvements in muscle strength after the application of local vibration. There was considerable variation in the vibration training parameters and target muscle location.

CONCLUSIONS

The use of local vibration on the target muscle can enhance muscle strength in healthy adults. Further well-designed controlled studies are required to confirm the effect of local vibration training on muscle strength.

Effect of quadriceps and hamstrings muscle cooling on standing balance in healthy young men

OBJECTIVE

The present study compared the effect of quadriceps and hamstring muscle cooling on standing balance in healthy young men.

METHODS

Thirty healthy young men (18-30 years) participated in the study. The participants were randomly assigned to three groups (n=10 each): quadriceps cooling (QC), hamstring cooling (HC), or control group (no cooling). Participants in the QC and HC groups received 20 minutes of cooling using a cold pack (gel pack), placed on the anterior thigh (from the apex of the patella to the mid-thigh) and the posterior thigh (from the base of the popliteal fossa to the mid-thigh), respectively. Balance score including unilateral stance was measured at baseline and immediately after the application of the cold pack.

RESULTS

No significant difference in the balance score was noted in any group after the application of the cold pack (p⟩0.05). Similarly, no significant differences in post-test balance score were noted among the three groups (p⟩0.05).

CONCLUSIONS

Cooling of the quadriceps and hamstring muscles has no immediate effect on standing balance in healthy young men. However, longitudinal studies are warranted to investigate the long-term effects of cooling these muscles on standing balance.

Management of choledocholithiasis after previous gastrectomy

Common bile duct stones in patients with a previous gastrectomy can be a technical challenge because of the altered anatomy. This paper presents the successful management of two such patients using non-traditional techniques as conventional endoscopic retrograde cholangiopancreatography was not possible.

Evaluation of uttroside B, a saponin from Solanum nigrum Linn, as a promising chemotherapeutic agent against hepatocellular carcinoma

We report, for the first time, the remarkable efficacy of uttroside B, a potent saponin from Solanum nigrum Linn, against liver cancer. The compound has been isolated and characterized from the leaves of Solanum nigrum Linn, a plant widely used in traditional medicine and is a rich resource of several anticancer molecules. Uttroside B, that comprises of β-D-glucopyranosyl unit at C-26 of the furostanol and β-lycotetraosyl unit at C-3, is ten times more cytotoxic to the liver cancer cell line, HepG2 (IC50: 0.5 μM) than sorafenib (IC50: 5.8 μM), the only FDA-approved drug for liver cancer. Moreover, it induces cytotoxicity in all liver cancer cell lines, irrespective of their HBV status, while being non-toxic to normal immortalized hepatocytes. It induces apoptosis in HepG2 cells by down-regulating mainly the activation of MAPK and mTOR pathways. The drastic reduction in HepG2-xenograft tumor size achieved by uttroside B in NOD-SCID mice and substantiation of its biological safety through both acute and chronic toxicity studies in Swiss albino mice warrants clinical validation of the molecule against hepatic cancer, for which, the chemotherapeutic armamentarium currently has limited weapons.

Two new triterpene lactones from Centaurium pulchellum

Two new triterpene lactones, centauriol (1) and centaurione (2) were isolated from the whole plant of Centaurium pulchellum. Their structures were determined by spectral data.

Prolactin hormone in juvenile systemic lupus erythematosus: a possible relationship to disease activity and CNS manifestations

OBJECTIVE

In this prospective study we aimed to determine serum prolactin (PRL) concentrations among patients with prepubertal juvenile systemic lupus erythematosus (SLE) and their possible relationship to disease activity and/or manifestations.

METHODS

Serum PRL was estimated by immunoradiometric assay in 33 prepubertal children with SLE and 20 healthy controls. Patients had complete clinical and laboratory investigations. Disease activity was evaluated using the Systemic Lupus Activity Measurement Index (SLAM).

RESULTS

The mean serum PRL level was higher in juvenile SLE than healthy controls; however, the difference was not statistically significant. There was no significant correlation between the serum PRL levels and total SLAM score among our patients. Serum PRL levels were significantly correlated with erythrocyte sedimentation rate (r = +0.352, p < 0.05) and inversely with each of total leukocyte count (r = -0.504, p < 0.01) and lymphocyte count (r = -0.408, p < 0.05). Hyperprolactinemia was found in 3 (9%) of the children with SLE but not in controls. All 3 patients with hyperprolactinemia (100%) had central nervous system (CNS) manifestations compared to only 3 (10%) patients (p < 0.003) with normal PRL level.

CONCLUSION

Our results suggest a subset of juvenile SLE characterized by hyperprolactinemia and increased prevalence of CNS manifestations. A possible relationship between serum PRL concentrations and disease activity in juvenile SLE was found. Our data point to the importance of further studies of the role of PRL in immunomodulation of pediatric rheumatic diseases.