Univentricular hearts not undergoing Fontan: the type of palliation matters

INTRODUCTION AND OBJECTIVES

There is scarce information on patients with single ventricle physiology (SVP) and restricted pulmonary flow not undergoing Fontan circulation. This study aimed to compare survival and cardiovascular events in these patients according to the type of palliation.

METHODS

SVP patient data were obtained from the databases of the adult congenital heart disease units of 7 centers. Patients completing Fontan circulation or developing Eisenmenger syndrome were excluded. Three groups were created according to the source of pulmonary flow: G1 (restrictive pulmonary forward flow), G2 (cavopulmonary shunt), and G3 (aortopulmonary shunts±cavopulmonary shunt). The primary endpoint was death.

RESULTS

We identified 120 patients. Mean age at the first visit was 32.2 years. Mean follow-up was 7.1 years. Fifty-five patients (45.8%) were assigned to G1, 30 (25%) to G2, and 35 (29.2%) to G3. Patients in G3 had worse renal function, functional class, and ejection fraction at the first visit and a more marked ejection fraction decline during follow-up, especially when compared with G1. Twenty-four patients (20%) died, 38 (31.7%) were admitted for heart failure, and 21 (17.5%) had atrial flutter/fibrillation during follow-up. These events were more frequent in G3 and significant differences were found compared with G1 in terms of death (HR, 2.9; 95%CI, 1.14-7.37; P=.026) and atrial flutter/fibrillation (HR, 2.9; 95%CI, 1.11-7.68; P=.037).

CONCLUSIONS

The type of palliation in patients with SVP and restricted pulmonary flow not undergoing Fontan palliation identifies distinct profiles. Patients palliated with aortopulmonary shunts have an overall worse prognosis with higher morbidity and mortality.

Non-invasive isthmus identification of complex arrhythmias in congenital heart disease

Sustained re-entrant tachyarrhythmias treatment has become pivotal in the grown-up congenital heart patients clinical management. Cardiac LGE-MRI tissue characterization integrated with high definition electroanatomic map could allow fast recognition and effective treatment of substrate of tachyarrhythmias. Cardiac LGE-MRI areas were suggestive of post-surgical changes both in atrium and ventricle. High-density electro-anatomical map localized areas of slow conduction identifying conducting isthmuses of re-entrant arrhythmias.

Automated Pattern Recognition in Whole-Cardiac Cycle Echocardiographic Data: Capturing Functional Phenotypes with Machine Learning

BACKGROUND

Echocardiography provides complex data on cardiac function that can be integrated into patterns of dysfunction related to the severity of cardiac disease. The aim of this study was to demonstrate the feasibility of applying machine learning (ML) to automate the integration of echocardiographic data from the whole cardiac cycle and to automatically recognize patterns in velocity profiles and deformation curves, allowing the identification of functional phenotypes.

METHODS

Echocardiography was performed in 189 clinically managed patients with hypertension and 97 healthy individuals without hypertension. Speckle-tracking analysis of the left ventricle and atrium was performed, and deformation curves were extracted. Aortic and mitral blood pool pulsed-wave Doppler and mitral annular tissue pulsed-wave Doppler velocity profiles were obtained. These whole-cardiac cycle deformation and velocity curves were used as ML input. Unsupervised ML was used to create a representation of patients with hypertension in a virtual space in which patients are positioned on the basis of the similarity of their integrated whole-cardiac cycle echocardiography data. Regression methods were used to explore patterns of echocardiographic traces within this virtual ML-derived space, while clustering was used to define phenogroups.

RESULTS

The algorithm captured different patterns in tissue and blood-pool velocity and deformation profiles and integrated the findings, yielding phenotypes related to normal cardiac function and others to advanced remodeling associated with pressure overload in hypertension. The addition of individuals without hypertension into the ML-derived space confirmed the interpretation of normal and remodeled phenotypes.

CONCLUSIONS

ML-based pattern recognition is feasible from echocardiographic data obtained during the whole cardiac cycle. Automated algorithms can consistently capture patterns in velocity and deformation data and, on the basis of these patterns, group patients into interpretable, clinically comprehensive phenogroups that describe structural and functional remodeling. Automated pattern recognition may potentially aid interpretation of imaging data and diagnostic accuracy.

LONG TERM OUTCOMES OF ADULTS WITH SINGLE VENTRICLE PHYSIOLOGY NOT UNDERGOING FONTAN REPAIR: A MULTICENTRE EXPERIENCE

BACKGROUND

To describe long-term survival and cardiovascular events in adult patients with single ventricle physiology (SVP) without Fontan palliation, focusing on predictors of mortality and comparing groups according to their cardiovascular physiology.

METHODS

Multicentre, observational and retrospective study including adult patients with SVP without Fontan palliation since their first adult clinic visit. The cohort was subdivided into three groups. (Eisenmenger - Restricted Pulmonary flow - Aortopulmonary shunt) Death was considered the main endpoint. Other clinical outcomes occurring during follow-up were considered as secondary endpoints.

RESULTS

146 patients, mean age 32.5±11.1 years were analysed. Over a mean follow-up of 7.3 ± 4.1 years, 33 patients (22.6%) died. Survival was 86% and 74% at 5 and 10 years, respectively. Right ventricular morphology was not associated with higher mortality. Four variables at baseline were related to a higher mortality (at least moderate AV valve regurgitation, platelet count <150 × 10 ³ /mm ³ , GFR <60 ml/min/1.73m ² and QRS >120ms). 34.2% of patients were admitted to the hospital due to heart failure, and 7.5% received a heart transplant. Other cardiovascular outcomes were also frequent (atrial arrhythmias: 19.2%, stroke: 15.1%, pacemaker/ICD: 6.2%/2.7%).

CONCLUSIONS

Adult patients with SVP who had not undergone Fontan exhibit a high mortality rate and frequent major cardiovascular events. At least moderate AV valve regurgitation, thrombocytopenia, renal dysfunction and QRS duration >120 ms at baseline visit allow identification of a cohort of patients at higher risk of mortality.

Interatrial block is related to atrial dysfunction in hypertensive subjects

Funding Acknowledgements

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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

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

Distribution of myocardial work in arterial hypertension: insights from non-invasive left ventricular pressure-strain relations

A index of non-invasive myocardial work (MWI) can account for pressure during the assessment of cardiac function, potentially separating the influence of loading conditions from the influence of the underlying tissue remodelling. The aim is to assess LV function accounted for loading and explore hypertensive MWI distribution by comparing healthy individuals to hypertensive patients without and with localized basal septal hypertrophy (BSH). An echocardiogram was performed in 170 hypertensive patients and 20 healthy individuals. BSH was defined by a basal-to-mid septal wall thickness ratio ≥ 1.4. LV speckle-tracking was performed, and the MWI calculated globally and regionally for the apical, mid and basal regions. An apex-to-base gradient, seen in regional strain values, was preserved in the distribution of myocardial work, with the apical region compensating for the impairment of the basal segments. This functional redistribution was further pronounced in patients with localized BSH. In these patients, segmental MWI analysis revealed underlying impairment of regional work unrelated to acute loading conditions. Non-invasive MWI analysis offers the possibility to compare LV function regardless of blood pressure at the time of observation. Changes in MWI distribution can be seen in hypertension unrelated to the load-dependency of strain. Accentuated functional changes affirm the role of BSH as an echocardiographic marker in hypertension.

Clinical features and outcomes of adult patients with single ventricle physiology not undergoing Fontan repair

Background

Adult patients with single ventricle (SV) physiology who had not undergone Fontan palliation are uncommon. Little is known about their clinical features and outcomes.

Objective

This study aims to describe the clinical features, cardiovascular outcomes and long-term survival of patients with SV physiology without Fontan palliation.

Methods

Data were collected retrospectively from SV physiology patients followed in adult congenital heart disease (ACHD) units of five tertiary referral centers. None of them had Fontan palliation. Baseline data were recorded on the first visit at ACHD unit. Death was considered as main endpoint. Other outcomes such as atrial or ventricular arrhythmias, endocarditis, ICD or pacemaker implantation, admission for heart failure and heart transplant were also collected and analyzed. Association between clinical/analytical baseline variables and death was also evaluated by univariate Cox regression.

Results

128 patients were included. On the first visit, mean age was 32.3±10.9 years, being the most common defect double inlet left ventricle (63p, 49.2%). The single ventricle had left morphology in 106 cases (82.8%). At baseline mean heaemglobin was 19.1±2.8 g/dl, mean O2 Sat 83±6.9% and 46 patients (36%) had a NYHA status III or IV. 4 different groups were found: a) Unrestricted pulmonary flow with Eisenmenger physiology (24p, 18.8%); b) Restricted forward pulmonary flow with or without pulmonary banding (46p, 35.9%); c) Aortopulmonary shunts as a source of pulmonary flow (20p, 15.5%) and d) cavopulmonary shunt (Glenn) as a definitive palliation (38p, 29.7%). After 7.3±4.1 years follow-up, mortality was 22.7% (29 patients), being sudden death (9p, 7%) the most frequent cause. Survival rate at 5 and 10 years of follow-up were 85% and 76% respectively (Figure 1). About of the rest of the outcomes, highlighting a high rate of atrial tachycardia (38.3%), admission for heart failure (23.4%), stroke (17.2%), endocarditis (9.4%), pacemaker/ICD implantation (11.8%). Baseline variables associated with higher mortality were: older age (HR=1.1 [1.004–1–087]); NYHA III or IV (HR=5.5 [2.4–12.4]); thrombocytopenia (HR=1.01 [1.001–1.003]); anticoagulant treatment (HR=2.6 [1.7–3.9]); glomerular filtration rate below 60 ml/min (HR=3.77 [1.5–9.6]); QRS width (HR=1.03 [1.01–1.05]); atrial arrhythmias (HR=3.1 [1.5–6.5]); moderate or severe AV valve regurgitation (HR=1.5 [1.15–1.97]) and ventricular ejection fraction (HR=0.94 [0.91-0.97]).

Conclusions

Adults survivors with SV physiology without Fontan palliation have a high mortality and frequently suffer from serious cardiovascular events. Several clinical (NYHA status, previous atrial arrhythmias, anticoagulant treatment), analytical (renal function, thrombocytopenia), ECG (QRS width) and echocardiography (AV valve regurgitation and EF) factors can identify patients at higher risk of death.

Figure 1. Survival curve

Funding Acknowledgement

Type of funding source: None

Long term outcome of single ventricle physiology with pulmonary restriction not undergoing Fontan repair

Background

Patients with univentricular physiology who do not complete the palliation to Fontan are a heterogeneous group with unknown long term outcome.

Aims

This study aimed at describing the clinical course and long-term survival of patients with SV physiology with restricted pulmonary flow that had not undergone a Fontan type of repair.

Methods

From the prospectively maintained databases of the adult congenital cardiac units of five tertiary referral centers, data from all SV physiology patients were obtained. Patients completing a Fontan type palliation or developing Eisenmenger physiology and segmental pulmonary hypertension were excluded. Baseline data were recorded on the first visit at adult congenital heart disease (ACHD) unit. The primary end point was death.

Results

101 patients (50.5% females) were identified. Mean age at end of follow up was 39.3±11.3 years. Of these, 45 (44.6%) were unoperated (group 1, restricted forward pulmonary flow with or without pulmonary banding), 38 (37.6%) had undergone a cavopulmonary shunt as a definitive palliation (group 2) and 18 (17.8%) had aortopulmonary shunts (group 3). The main diagnosis was double inlet left ventricle (DILV) (N: 52, 51.5%) and most of the ventricle was left (82.2%). The principal reason for not performing a Fontan repair was mean pulmonary artery pressure &gt;18 mmHg. At initial visit at the ACHD unit patients were 32.2±11.1 years of age. 35% of the patients were in NYHA class III-IV, with no differences between groups. However, patients in group 2 had worse oxygen saturation (p=002) and higher haemoglobin (p=0.037). After a mean follow-up of 7.3±4.1 years, mortality was 20.8% (21 patients), being sudden death (7p, 6.9%) the most frequent cause. Patients in group 3 showed worse ventricular function (p=0.0001) and a trend to higher mortality that did not reach statistical significance (HR 2.7, CI 95% 0.91–8.14, P=0.07).

Conclusions

Patients with single ventricle physiology not undergoing Fontan repair are a population of high risk, with sudden death as main driver of mortality. Patients palliated with aortopulmonary shunts are prone to worse ventricular function and a trend to higher mortality.

Funding Acknowledgement

Type of funding source: Public hospital(s)

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

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

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

Funding Acknowledgements

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

Background and aim

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

Methods

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

Results

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

Conclusion

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

Abstract 421 Figure 1

Aortic root remodelling in competitive athletes

Background

Controversy remains about the cut-off limits for detecting aortic dilatation in athletes, particularly in large-sized individuals. The allometric scaling model has been used to obtain size-independent measurements in cardiovascular structures in the general population.

Aim

The purpose of this study was to validate the use of allometric scaling in the measurement of the aortic root for competitive athletes and to offer reference values.

Methods

This was a cross-sectional study that analyses the dimensions of aortic root found in the echocardiogram performed as part of pre-participation sports screening in competitive athletes between 2012–2015. Beta exponents were calculated for height and body surface area in the whole cohort. In order to establish whether a common exponent could be used in both genders the following model was assessed y = a xb*exp(c*sex). If a common exponent could not be applied then sex-specific beta exponents were calculated.

Results

Two thousand and eighty-three athletes (64% men) were included, from a broad spectrum of 44 different sports disciplines, including basketball, volleyball and handball. The mean age was 18.2 ± 5.1 years (range 12–35 years) and all athletes were Caucasian, with a training load of 12.5 ± 5.4 h per week. Indexed aortic root dimension showed a correlation with ratiometric scaling by body surface area (r: −0.419) and generated size independence values with a very light correlation with height (r: −0.084); and with the allometric scaling by body surface area (r: −0.063) and height (r: −0.070). The absolute value of aortic root was higher in men than in women ( p < 0.001). These differences were maintained with allometric scaling.

Conclusion

Size-independent aortic root dimension values are provided using allometric scaling by body surface area and height in a large cohort of competitive athletes. Aortic root values were larger in men than in women, both in absolute values and after allometric scaling. The use of these indexed aortic reference ranges can be useful for the early detection of aortic pathologies.

Female Athlete With a Double-Chambered Right Ventricle

A 35-year-old female athlete presented with recent episodes of pre-syncope on exertion while exercising. An isolated double-chambered right ventricle was diagnosed by transthoracic echocardiography and cardiac magnetic resonance. This defect typically presents during infancy and/or early childhood, is rarely reported in adults, and is usually associated with other congenital defects. (Level of Difficulty: Advanced.)

Abstract GS5-07: International pooled analysis of the prognostic impact of disseminated tumor cells from the bone marrow in early breast cancer: Results from the PADDY study

Introduction

As early breast cancer might relapse even after complete removal of breast and lymphnodes, the disease must persist in secondary sites. The detection of disseminated tumor cells (DTC) in the bone marrow (BM) has been described as a surrogate of residual disease. Various trials showed an impaired prognosis of DTC positive early breast cancer (EBC) patients. The PADDY (Pooled Analysis of DTC Detection in Early Breast Cancer) study is a large international pooled analysis that aimed to assess the prognostic impact of DTC detection in patients with EBC.

Methods

A pre-specified protocol was followed, and centers known to practice BM sampling for DTC detection were contacted for individual patient data. Patients with EBC, with available follow-up data and BM sampling before any anti-cancer treatment were eligible. BM aspirates were collected at the time of primary surgery. DTC were identified by antibody (A45-B/B3, AE1/AE3, 2E11 and E29) staining against cytokeratin. The DTC status was compared to other prognostic factors using the chi-squared test. Univariate log-rank test and multivariate cox regression were used to compare survival of DTC positive versus DTC negative patients.

Results

Individual data from 10,320 patients (11 centers from Europe and USA) were included with a median follow-up of 91 months. Of all patients, 2,823 (27.4 %) were DTC positive. DTC detection was associated with higher tumor grade, higher T stage, nodal positivity, ER and PR negativity, and HER2 positivity (all p&lt;0.001). In univariate analyses, overall, breast cancer specific, disease-free and distant disease-free survival (OS, BCSS, DFS, DDFS) were significantly shorter in DTC positive patients with p-values of &lt;0.001. Multivariate analyses showed the DTC status to be an independent prognostic marker for OS, BCSS, DFS and DDFS with hazard ratios (HR) and 95%-confidence intervals (CI) of 1.23 (95%-CI: 1.06-1.42, p=0.007), 1.38 (95%-CI: 1.11-1.72, p=0.004), 1.29 (95%-CI: 1.10-1.50, p=0.001) and 1.32 (95%-CI: 1.10-1.58, p=0.003), respectively.

Conclusions

Detection of DTC in the bone marrow is an independent prognostic marker in patients with non-metastatic breast cancer. Further studies should investigate the impact of DTC on metastatic cancer progression and their role for clinical decision making.

Citation Format: Hartkopf AD, Brucker SY, Taran F-A, Harbeck N, von Au A, Naume B, Pierga J-Y, Hoffmann O, Beckmann MW, Rydén L, Fehm T, Aft R, Montserrat S, Walter V, Rack B, Schuetz F, Borgen E, Ta M-H, Bittner A-K, Fasching P, Fernö M, Krawczyk N, Weilbaecher K, Margelí M, Hahn M, Jueckstock J, Domschke C, Bidard F-C, Kasimir-Bauer S, Schoenfisch B, Kurt AG, Wallwiener M, Gebauer G, Wallwiener D, Janni W, Pantel K. International pooled analysis of the prognostic impact of disseminated tumor cells from the bone marrow in early breast cancer: Results from the PADDY study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS5-07.

Gender influence on the adaptation of atrial performance to training

BACKGROUND

High-intensity training has been associated with atrial remodelling and arrhythmias in men. Our purpose was to analyse atrial performance in female endurance athletes, compared to male athletes and controls.

METHODS

This was a cross-sectional study. We included four groups: female athletes, females controls, male athletes and male controls. Left (LA) and right atrial (RA) volumes and function were assessed using 2D and speckle-tracking echocardiography to determine peak atrial strain-rate at atrial (SRa) and ventricular contraction (SRs), as surrogates of atrial contractile and reservoir function, respectively. ANOVA and Bonferroni's statistical tests were used to compare variables among groups.

RESULTS

We included 82 subjects, 39 women (19 endurance athletes, 20 controls) and 43 men (22 endurance athletes, 21 controls). Mean age was similar between groups (36.6 ± 5.6 years). Athletes had larger bi-atrial volumes, compared to controls (women, LA 27.1 vs. 15.8 ml/m², p < 0.001; RA 22.31 vs. 14.2 ml/m², p = 0.009; men, LA: 25.0 vs. 18.5 ml/m², p = 0.003; RA 30.8 vs. 21.9 ml/m², p < 0.001) and lower strain-rate (women, LASRa -1.60 vs. -2.18 s^-1, p < 0.001; RASRa -1.89 vs. -2.38 s^-1, p = 0.009; men, LASRa -1.21 vs. -1.44 s^-1, p = 1; RASRa -1.44 vs. -1.60 s^-1, p = 1). However, RA indexed size was lower and bi-atrial deformation greater in female athletes, compared to male athletes.

CONCLUSIONS

The atria of both male and female athletes shows specific remodelling, compared to sedentary subjects, with larger size and less deformation at rest, particularly for the RA. Despite a similar extent of remodelling, the pattern in women had greater bi-atrial myocardial deformation and smaller RA size.

Left Atrial Function Is Impaired in Some Patients With Stroke of Undetermined Etiology: Potential Implications for Evaluation and Therapy

INTRODUCTION AND OBJECTIVES

Stroke etiology remains undetermined in up to 30% of cases. Paroxysmal atrial fibrillation is found in 20% to 28% of patients with stroke initially classified as being of undetermined etiology. The aim of our study was to analyze left atrial function in ischemic stroke patients to identify patterns associated with cardioembolic etiology and to determine whether the patterns identified can be found in individuals initially classified as having a stroke of undetermined etiology.

METHODS

We studied a cohort of in-hospital ischemic stroke patients referred for transthoracic echocardiography. Treating neurologists determined stroke etiology based on the TOAST classification. Left atrial contractile function was assessed using 2-dimensional echocardiography to determine their ejection fraction and speckle tracking to measure left atrial strain rate: a-wave. Left atrial function was compared between stroke etiology subgroups and healthy controls.

RESULTS

Ninety-seven patients (aged 67±15 years) with ischemic stroke (16.5% large-artery atherosclerosis, 15.5% small-vessel occlusion, 11.3% cardioembolic, 5.1% other determined etiology, 51.1% undetermined etiology) and 10 healthy volunteers (aged 63±7 years) were included. Left atrial ejection fraction was significantly decreased only in patients with stroke of cardioembolic and undetermined etiology compared with the control group (31.5±17.2%, 40.2±17.1%, and 59.1±8.4%, respectively; P=.004). The left atrial strain rate was significantly lower in patients with stroke caused by cardioembolic or undetermined etiology, or large-artery atherosclerosis compared with controls (-0.86±0.49, -1.31±0.56, -1.5±0.47, -2.37±1.18, respectively; P<.001).

CONCLUSIONS

Patients with stroke of undetermined etiology with left atrial function (ejection fraction and strain) similar to that of cardioembolic stroke patients may be misclassified and could potentially benefit from prolonged electrocardiography monitoring. Left atrial function analysis (ejection fraction and strain) might help to identify potential cardioembolic sources in patients with stroke of undetermined etiology.

Emerging risk factors and the dose-response relationship between physical activity and lone atrial fibrillation: a prospective case-control study

Aims

The role of high-intensity exercise and other emerging risk factors in lone atrial fibrillation (Ln-AF) epidemiology is still under debate. The aim of this study was to analyse the contribution of each of the emerging risk factors and the impact of physical activity dose in patients with Ln-AF.

Methods and results

Patients with Ln-AF and age- and sex-matched healthy controls were included in a 2:1 prospective case–control study. We obtained clinical and anthropometric data transthoracic echocardiography, lifetime physical activity questionnaire, 24-h ambulatory blood pressure monitoring, Berlin questionnaire score, and, in patients at high risk for obstructive sleep apnoea (OSA) syndrome, a polysomnography. A total of 115 cases and 57 controls were enrolled. Conditional logistic regression analysis associated height [odds ratio (OR) 1.06 [1.01–1.11]], waist circumference (OR 1.06 [1.02–1.11]), OSA (OR 5.04 [1.44–17.45]), and 2000 or more hours of cumulative high-intensity endurance training to a higher AF risk. Our data indicated a U-shaped association between the extent of high-intensity training and AF risk. The risk of AF increased with an accumulated lifetime endurance sport activity ≥2000 h compared with sedentary individuals (OR 3.88 [1.55–9.73]). Nevertheless, a history of <2000 h of high-intensity training protected against AF when compared with sedentary individuals (OR 0.38 [0.12–0.98]).

Conclusion

A history of ≥2000 h of vigorous endurance training, tall stature, abdominal obesity, and OSA are frequently encountered as risk factors in patients with Ln-AF. Fewer than 2000 total hours of high-intensity endurance training associates with reduced Ln-AF risk.

Echocardiography in the evaluation of athletes

Echocardiography is currently a widely available imaging technique that can provide useful data in the field of sports cardiology particularly in two areas: pre-participation screening and analysis of the cardiac adaptation induced by exercise.

The application of pre-participation screening and especially, the type and number of used diagnostic tests remains controversial. Echocardiography has shown though, higher sensitivity and specificity as compared to the ECG, following a protocol adapted to athletes focused on ruling out the causes of sudden death and the most common disorders in this population. It is still a subject of controversy the actual cost of adding it, but depending on the type of sport, echocardiography might be cost-effective if added in the first line of examination.

Regarding the evaluation of cardiac adaptation to training in athletes,  echocardiography has proved to be useful in the differential diagnosis of diseases that can cause sudden death, analysing both the left ventricle (hypertrophy cardiomyopathy, dilated cardiomyopathy, left ventricle non compaction) and the right ventricle (arrhythmogenic right ventricular cardiomyopathy).

The aim of this paper is to review the current knowledge and the clinical practical implications of it on the field of echocardiography when applied in sport cardiology areas.

Usefulness of echocardiography in preparticipation screening of competitive athletes

INTRODUCTION AND OBJECTIVES

Despite the established diagnostic value of the electrocardiogram in preparticipation screening of athletes, some cardiac structural changes can be missed, particularly in early disease stages. The aim of this study was to evaluate the prevalence of cardiac structural changes via the systematic use of echocardiography in preparticipation screening of competitive athletes.

METHODS

Professional athletes or participants in a competitive athletic program underwent a screening that included family and personal medical history, physical examination, electrocardiography, exercise testing, and Doppler echocardiography.

RESULTS

A total of 2688 athletes (67% men; mean age [standard deviation], 21 [10] years) were included. Most of the echocardiographic evaluations (92.5%) were normal and only 203 (7.5%) showed changes; the most frequent change was left ventricular hypertrophy, seen in 50 athletes (1.8%). Cessation of athletic activity was indicated in 4 athletes (0.14%): 2 for hypertrophic cardiomyopathy (electrocardiography had shown changes that did not meet diagnostic criteria), 1 pectus excavatum with compression of the right ventricle, and 1 significant pulmonary valve stenosis; the rest of the changes did not entail cessation of athletic activity and only indicated periodic monitoring.

CONCLUSIONS

Although rare, some cardiac structural changes can be missed on physical examination and electrocardiography; in contrast, they are easily recognized with echocardiography. These findings suggest the use of echocardiography in at least the first preparticipation screening of competitive athletes to improve the effectiveness of programs aimed at preventing sudden death in athletes.

Usefulness of transoesophageal echocardiography before circumferential pulmonary vein ablation in patients with atrial fibrillation: is it really mandatory?

AIMS

Transoesophageal echocardiography (TEE) is recommended prior to circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) to identify left atrial (LA) or left atrial appendage (LAA) wall thrombi. It is not clear whether all patients undergoing CPVA should receive pre-procedural TEE. We wanted to assess the incidence of LA thrombus in these patients and to identify factors associated with its presence.

METHODS AND RESULTS

Consecutive patients referred for CPVA from 2004 to 2009 underwent TEE within 48 h prior to the procedure. Of 408 patients included in the study, 6 patients (1.47%) had LA thrombi, persistent AF, and LA dilation. Compared with patients without thrombus, these six patients had larger LA diameter (P = 0.0001) and more frequently were women (P = 0.002), had persistent AF (P = 0.04), and had underlying structural cardiac disease (P = 0.014). The likelihood of presenting LA thrombus increased with the number of these four risk factors present (P < 0.001). None of the patients with paroxysmal AF and without LA dilation had LA thrombus. A cut-off value of 48.5 mm LA diameter yielded 83% sensitivity, 92% specificity, and a 10.1 likelihood ratio to predict LA thrombus appearance.

CONCLUSION

The incidence of LA thrombus prior to CPVA is low. Persistent AF, female sex, structural cardiopathy, and LA dilation were associated with the presence of LA thrombus. Our data suggest that the use of TEE prior to CPVA to detect LA thrombi might not be needed in patients with paroxysmal AF and no LA dilation or structural cardiopathy.