Cardiovascular Risk Factors, Angiographical Features and Short-Term Prognosis of Acute Coronary Syndrome in People Living with Human Immunodeficiency Virus: Results of a Retrospective Observational Multicentric Romanian Study

People living with human immunodeficiency virus have increased cardiovascular risk due to a higher prevalence of traditional and particular risk factors such as chronic inflammation, immune dysregulation, endothelial dysfunction, coagulation abnormalities and antiretroviral therapy. In developed countries, coronary artery disease has become the most frequent cardiovascular disease and an important cause of mortality in these patients. The symptomatology of an acute coronary syndrome can be atypical, and the prevalence of each type of acute coronary syndrome is reported differently. Regarding coronary artery disease severity in people living with HIV, the literature data indicates that the presence of single-vessel disease is akin to that of HIV-negative patients, and their short-term prognosis is unclear. This study aims to assess the clinical characteristics, biological parameters, angiographical features and short-term prognosis of acute coronary syndrome in a cohort of Romanian people living with human immunodeficiency virus.

Myocardial work and left atrial function, by speckle tracking echocardiography, are the only independent predictors of mid-term mortality in HFpEF

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by 2 National grants of Romanian Ministry of Research and Innovation - UEFISCDI (PN-III-P1-1-TE-2016-0669, acronym Heart-Preserved and PN-III-P1-1.2-PCCDI2017-0527, acronym BIOVEA).

OnBehalf

HEART-PRESERVED

Background. Heart failure with preserved ejection fraction (HFpEF), defined by the 2021 ESC guidelines and the new universal definition, is one of the most challenging diagnosis in cardiology. Parameters for predicting mortality in HFpEF are still debatable. Left atrial (LA) function and myocardial work (MW) by speckle-tracking echocardiography (STE) might be promising tools for predicting mortality in HFpEF.

Methods. We assessed 88 patients (67 ± 9 years, 33 men) with HFpEF (mean NTproBNP of 357 ± 350 pg/ml) by 2D echo, STE, and CMR. By echo we measured LV ejection fraction (LVEF), E/E’, sPAP, left atrial volume indexed (LAVi), and global longitudinal strain (GLS). We assessed LA function by 2DSTE: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), and LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure 1); and MW by 2DSTE: global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), as GCW/(GCW + GWW) in %. By CMR we evaluated LVEFcmr, LV mass, T1 mapping with mean extracellular volume (ECVm), and pre-gadolinium times quantification (preGDT1m) as markers of myocardial fibrosis. A follow-up visit for cardiovascular mortality was performed by phone at 18 months from the baseline visit.

Results. 12 patients died during follow-up (14%). Comparing non-survivors vs. survivors (see tables from Figure 2), NTproBNP level and LV mass were significantly higher in non-survivors (P < 0.001); meanwhile, GWE was lower, whereas GWW was higher in non-survivors vs. survivors. Moreover, LASRct was lower in non-survivors vs. survivors. All the other echo or CMR parameters, including markers of myocardial fibrosis were not different between non-survivors and survivors (Figure 2). By multiple regression analysis, GWE < 92% (AUC = 0.72, p = 0.018) and LASRct <-1 (AUC = 0.70, p = 0.014) were the only independent predictors of mortality, from all conventional echo, STE, and CMR parameters.

Conclusions

LV assessment by myocardial work and LA assessment by STE are the only independent predictors of mid-term mortality in HFpEF. Abstract Figure. LA deformation analysis  Abstract Figure. Survivors vs non-survivors

Left ventricular noncompaction in patients with heart failure with preserved ejection fraction characterized by multimodality imaging

Background

Left ventricular non-compaction (LVNC) is associated with increased risk of heart failure (HF). If LVNC or hyper-trabeculation in HF with preserved ejection fraction (HFpEF) is an adaptive or stand-alone condition that contribute to generation of HF is not clearly understood yet.

Aim

To describe LV functional and structural parameters in HFpEF with LVNC by comparison with HFpEF without LVNC.

Methods

We assessed 42 patients with HFpEF, 21 with LVNC (61±9 yrs) and 21 without LVNC, age and risk factors matched (LVC), by NTproBNP, 2D echocardiography (2DE), speckle-tracking (STE), and cardiac magnetic resonance (CMR) (Figure 1). LVNC diagnosis was based on Petersen and Jacquier criteria, by the NC/C ratio and the percentage of NC myocardium. Two gradients were calculated: a base to apex gradient (LVbase-apex) and an endo-epicardial gradient (LVendo-epi). LV mass, LV end-diastolic volume (LVEDV), and T1 mapping with extracellular volume (ECV) were measured, while mean value of native T1 for apical segments (apicalT1), mean value of ECV for apical (apical ECV), and basal segments (basal ECV), and gradient between them (ECV base-apex) were calculated.

Results

In the LVNC, mean NC/C ratio was 2.9±0.5mm and the percentage of NC myocardium 24.4±8.8%. NTproBNP was higher in LVNC group (294±282 vs. 163±71 pg/ml, p=0.047). Functional findings were consistent with the structural changes from CMR. LVNC patients have higher native T1 in the apical segments (Table). ECV was globally expanded in LVNC compared to LVC (p=0.002) suggesting diffuse fibrosis, but the difference between groups was more relevant for apical ECV (29.6±3.9% vs 25.1±2.8%, p<0.001), with a higher ECV base-apex gradient in LVNC group. ECV base-apex gradient was negatively correlated with the percentage of NC myocardium (p=0.003, R=0.64).

Conclusion

Patients with HFpEF with LVNC have more fibrosis, with more severe changes in the apical segments on CMR than HFpEF without NC. They have also significantly decreased apical deformation, lower base to apex deformation gradient and lower transmural deformation gradient, due to non-compaction itself, which involves the endocardial layer. These findings suggests that NC in HFpEF is an independent condition rather than an adaptive one.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of Research and Innovation, CNCS-UEFISCDI.

P1334 Multimodal imaging assessment of a very rare cause of heart failure in adults

Introduction

Congenitally Corrected Transposition of the Great Arteries (CCTGA) is a rare defect consisting in the abnormal twisting of the heart during fetal development. As a result, the two ventricles and their valves are reversed. CCTGA is frequently associated with other cardiac abnormalities. 25% of patients are developing heart failure, related to perfusion mismatch (the morphological left ventricle is supplied by a single coronary artery), and to the progressive deterioration of the structural right ventricle situated on the systemic side of the circulation.

Case report

A 45-year-old male was referred to our hospital for fatigue and dyspnea, occuring in the last five months. Physical examination revealed tachypnea, a slightly intense systolic murmur at the apex, and pulmonary congestion, in the absence of cyanosis, peripheral edema or jugular venous distension. Heart rate and blood pressure were normal. Usual laboratory work-up indicated increased levels of NT-proBNP, without any other abnormalities. ECG presented signs of pressure overload of the systemic ventricle (Figure Ia). Transthoracic echocardiography (TTE) highly suggested the diagnosis of CCTGA, due to atrioventricular valve displacement, with the morphological tricuspid valve closer to the apex in 4-chamber view (Figure Ib). TTE showed also dilated and dysfunctional left ventricle, mild left atrioventricular regurgitation, and normally functional right ventricle. Cardiac computed tomography emphasized a specific feature of CCTGA: the parallel emergence of aorta and pulmonary trunk, with the aortic arch crossing over the left pulmonary artery (Figure Ic). Cardiac magnetic resonance imaging confirmed dilatation and low ejection fraction of the systemic ventricle (20%), and displayed presence of trabeculations and the moderator band in the systemic ventricle (Figure Id). None of these evaluations found additional cardiac structural anomalies. Thus, patient was diagnosed with heart failure due to isolated CCTGA.

Discussions and relevance of case report. This case emphasizes a very rare cause of heart failure in adults. CCTGA is reported in 0.5-1% of all congenital diseases, especially in males. Isolated CCTGA accounts for less than 10% of all cases, and represents the phenotype that is usually diagnosed in adulthood. In the absence of associated anomalies, the prognosis of these patients is particularly affected by the occurrence of heart failure in the 4th or 5th decade of life. Meanwhile, this case highlights the importance of a multimodal approach in CCTGA, and the specific contribution of each imaging method in the process of an accurate diagnosis.

Abstract P1334 Figure I

409 Left atrial pump function assessed by speckle tracking echocardiography adds important value for the diagnosis of heart failure with preserved ejection fraction

Funding Acknowledgements

“This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III”

Background

Differentiation between heart failure with preserved ejection fraction (HFpEF) and isolated diastolic dysfunction (DD) at rest is crucial, since the prognosis is different. Symptoms are often non-specific, while NTproBNP might not be available. Increased NTproBNP is predicted by none of the currently used transthoracic echocardiographic (TTE) parameters. However, assessment of left atrial (LA) function by speckle tracking echocardiography (STE) might be a potential new marker of increased LV filling pressure.

Aim. To assess LA function by STE in HFpEF and DD, on top of the currently used TTE parameters, in order to establish the added value of LA deformation in the diagnosis of HFpEF.

Methods

70 patients were enrolled prospectively: 40 with HFpEF (68 ± 9 yrs) and 30 with DD (60 ± 10 yrs). TTE was used to assess LV ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP). STE was used to assess LA functions: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), and LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct). NTproBNP was measured in all patients.

Results

HFpEF patients had significantly higher LVEF, NTproBNP, E/E’ ratio, and sPAP, but similar LAVi compared to DD, suggesting higher LV filling pressure (Table). LA reservoir and conduit function were similar. However, LA pump function was significantly lower in HFpEF, expressed by LASRct (Tabel). NTproBNP correlated with E/E’ ratio, sPAP, and LASRct (all r = 0.44, p < 0.001), but not with LAVi. By multiple regression analysis, best predictor for NTproBNP > 125pg/ml was LASRct (r = 0.60, r2 =0.30, p < 0.001). LASRct < -1.29 (AUC = 0.82, sensitivity 75%, specificity 81%) was the only predictor of NTproBNP > 125pg/ml (Figure).

Conclusion

LA pump function is the only predictor of NTproBNP > 125pg/ml. This parameter should be incorporated in the current protocols for the diagnosis of HFpEF.

Group (N) NTproBNP ng/ml LVEF (%) E/E’ sPAP (mmHg) LAVi (ml/m2) LASr (%) LASRr LAScd (%) LASRcd LASRct HFpEF (40) 329 ± 383 62 ± 6 10.4 ± 2.7 34 ± 11 40 ± 9 25 ± 4 1.28 ± 0.3 11.6 ± 5.5 -1.37 ± 0.5 -1.07 ± 0.6 DD (30) 37 ± 26 57 ± 8 7.5 ± 1.8 23 ± 7 39 ± 11 26 ± 6 1.26 ± 0.3 11.2 ± 3.6 -1.5 ± 0.6 -1.76 ± 0.7 P value 0.001 0.008 <0.001 <0.001 0.7 0.4 0.8 0.7 0.4 <0.001

Abstract 409 Figure.