Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is associated with higher incidence of cardiovascular death. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging.

OBJECTIVE

The aim of this study was to investigate the incremental value of resting deformation analysis in predicting positive results for myocardial ischemia during stress transthoracic echocardiography in patients with end-stage CKD.

METHODS

Sixty-one patients (mean age: 62.3 ± 11.8, 65.7% men) with end-stage CKD were included in the study. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSE) protocol. Positive results of DSE were defined as stress-induced left ventricular (LV) wall motion abnormalities.

RESULTS

The study cohort had normal or mildly impaired systolic function: mean LV ejection fraction (EF) was 49.2% (±10.4) and mean LV global longitudinal strain (GLS) was 14.4% (±4.5). Half of our population had impaired left atrial (LA) strain: mean LA reservoir, conduit, and contractile reserve were 24.1% (±12.6), 10.6% (±5.9), and 13.6% (±9.2), respectively. DSE was positive for ischemia in 55.7%. A significant negative association with DSE results was found for LV EF, LV GLS and the conduit phase of LA strain. Both LV and LA dimensions showed positive correlation with presence of ischemia in DSE. Multivariate logistic regression analysis showed that LV GLS was independently associated with DSE (p = 0.007), after controlling for covariates, with high diagnostic accuracy.

CONCLUSION

Resting LV deformation could predict positive results during DSE, thus may be useful to better identify renal patients who might benefit from coronary artery screening.

Multimodality Imaging in a Patient With Double Aortic Arch Undergoing Transcatheter Aortic Valve Implantation: J Am Coll Cardiol Case Rep 2024;29:102224

[This retracts the article DOI: 10.1016/j.jaccas.2024.102224.].

Multimodality Imaging in a Patient With Double Aortic Arch Undergoing Transcatheter Aortic Valve Implantation

Double aortic arch is a rare congenital malformation often identified as an incidental finding during routine imaging. In our case, we describe aortic hemodynamics of double aortic arch in a patient with severe aortic stenosis and the procedural process of transcatheter aortic valve implantation.

The Contemporary Role of Speckle Tracking Echocardiography in Cirrhotic Cardiomyopathy

Cirrhotic cardiomyopathy (CCM) is characterized by elevated cardiac output at rest, an inability to further increase contractility under stress, and diastolic dysfunction. The diagnosis of CCM is crucial as it can lead to complications during liver transplantation. However, its recognition poses challenges with conventional echocardiography techniques. Speckle tracking echocardiography (STE), particularly global longitudinal strain (GLS), is a novel index that enhances the diagnostic efficacy of echocardiography for both ischemic and non-ischemic cardiomyopathies. GLS proves more sensitive in identifying early systolic dysfunction and is also influenced by advanced diastolic dysfunction. Consequently, there is an expanding scope for GLS utilization in cirrhotic cases, with newly updated diagnostic criteria for CCM incorporating GLS. Specifically, systolic dysfunction is now defined as either a left ventricular ejection fraction below 50% or an absolute GLS below 18%. However, conflicting data on GLS alterations in liver cirrhosis patients persist, as many individuals with advanced disease and a poor prognosis exhibit a hyperdynamic state with preserved or increased GLS. Consequently, the presence of CCM, according to the updated criteria, does not exhibit a significant association-in the majority of studies-with the severity of liver disease and prognosis. Furthermore, information on other indices measured with STE, such as left atrial and right ventricular strain, is promising but currently limited. This review aims to offer a critical assessment of the existing evidence concerning the application of STE in patients with liver cirrhosis.

Speckle tracking echocardiography and β-thalassemia major. A systematic review

Heart disease is among the primary causes of morbidity and mortality in β-thalassemia major (β-TM). Conventional echocardiography has failed to identify myocardial dysfunction at an early stage among these patients, thus speckle tracking echocardiography (STE) has been lately used. The objectives of this review were to 1) identify all published studies having evaluated myocardial strain among β-TM patients, 2) gather their results, 3) compare their findings and 4) propose recommendations based on these data. Literature search was conducted in PubMed, SCOPUS and Cohrane Library. Data regarding left ventricular global longitudinal (LV-GLS), circumferential (LV-GCS) and radial strain (LV-GRS), right ventricular longitudinal strain (RV-GLS), left and right atrial strain were extracted. Thirty-five studies (34 original articles and 1 meta-analysis) have met the inclusion criteria. LV-GLS has been reported being worse in patients compared to controls in 13 of 21 studies, LV-GCS in 7 of 11 studies, LV-GRS in 6 of 7 studies, RV-GLS in 2 of 3 studies and left atrial strain in all case-control studies. Myocardial iron overload (MIO) patient subgroups had worse LV-GLS in 6 of 15 studies, LV-GCS in 2 of 7 studies and LV-GRS in none of 7 studies. A small number of studies suggest left atrial strain correlation with electrical atrial ectopy and atrial fibrillation. It is suggested that STE should be applied supplementary to conventional echocardiography for early identification of myocardial dysfunction among β-TM patients. Potential myocardial strain utilities could be screening for myocardial iron overload, left ventricular diastolic dysfunction and atrial fibrillation.

Novel Anti-Inflammatory Therapies in Coronary Artery Disease and Acute Coronary Syndromes

Evidence suggests that inflammation plays an important role in atherosclerosis and the consequent clinical presentation, including stable coronary artery disease (CAD) and acute coronary syndromes (ACS). The most essential elements are cytokines, proteins with hormone-like properties that are produced by the immune cells, endothelial cells, platelets, fibroblasts, and some stromal cells. Interleukins (IL-1β and IL-6), chemokines, interferon-γ (IFN-γ), and tumor necrosis factor-alpha (TNF-α) are the cytokines commonly associated with endothelial dysfunction, vascular inflammation, and atherosclerosis. These molecules can be targeted by commonly used therapeutic substances or selective molecules that exert targeted anti-inflammatory actions. The most significant anti-inflammatory therapies are aspirin, statins, colchicine, IL-1β inhibitors, and IL-6 inhibitors, along with novel therapies such as TNF-α inhibitors and IL-1 receptor antagonists. Aspirin and statins are well-established therapies for atherosclerosis and CAD and their pleiotropic and anti-inflammatory actions contribute to their efficacy and favorable profile. Colchicine may also be considered in high-risk patients if recurrent ACS episodes occur when on optimal medical therapy according to the most recent guidelines. Recent randomized studies have also shown that therapies specifically targeting inflammatory interleukins and inflammation can reduce the risk for cardiovascular events, but these therapies are yet to be fully implemented in clinical practice. Preclinical research is also intense, targeting various inflammatory mediators that are believed to be implicated in CAD, namely repeated transfers of the soluble mutant of IFN-γ receptors, NLRP3 inflammasome inhibitors, IL-10 delivery by nanocarriers, chemokine modulatory treatments, and reacting oxygen species (ROS) targeting nanoparticles. Such approaches, although intriguing and promising, ought to be tested in clinical settings before safe conclusions can be drawn. Although the link between inflammation and atherosclerosis is significant, further studies are needed in order to elucidate this association and improve outcomes in patients with CAD.

Lipoprotein(a) as a Predictive Biomarker and Therapeutic Target for Acute Coronary Syndromes

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in Western societies, despite the significant advances that have improved primary and secondary prevention. Hence, several novel biomarkers have been identified as potential diagnostic and therapeutic targets which could improve outcomes even when traditional risk factors are well-controlled. Lipoprotein (a) [Lp(a)] has pro-atherogenic, pro-thrombotic, and pro-inflammatory properties, and its levels are relatively constant and genetically predetermined. Several epidemiological studies have associated high Lp(a) with increased risk for acute coronary syndromes (ACS) even when other CAD risk factors are included in the multivariate analysis. However, until recently, specific therapeutic options targeting Lp(a) were not associated, and thus, Lp(a) is currently used as a risk and treatment modifying biomarker with guidelines suggesting the intensified treatment of low-density lipoprotein in intermediate- to-high-risk patients with increased Lp(a) levels. Lately, specific treatment options targeting Lp(a) have become available and include antisense oligonucleotides and small-interfering RNA, which induce a robust reduction of Lp(a). Results of ongoing phase-3 trials will answer whether Lp(a) will become a biomarker specifically treated to reduce the burden of cardiovascular mortality. The scope of this review article is to present the current evidence regarding the use of Lp(a) as a biomarker, predictive of increased CAD risk, and to discuss the future perspectives on pharmaceutical reduction of Lp(a) as a therapeutic target in high-risk patients.

Lipoprotein-associated phospholipase A2 in coronary artery disease

Abstract:

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in western societies. Therefore identification of novel biomarkers to be used as diagnostic or therapeutic targets is of significant scientific interest. Lipoprotein-associated phospholipase A2 (Lp-PLA2) is one such protein shown to be involved in endothelial dysfunction, vascular inflammation and atherogenesis. Several epidemiological studies have associated high Lp-PLA2 activity with increased risk for CAD even when other CAD risk factors or inflammation markers were included in the multivariate analysis. These findings were strengthened by the results of relevant meta-analyses. However, randomized trials failed to establish Lp-PLA2 as a therapeutic target. Specifically, pharmaceutical inhibition of Lp-PLA2 when compared to the placebo failed to demonstrate significant association with improved prognosis of patients with stable CAD or after an acute coronary syndrome (ACS). This review focuses on the available data that have investigated the potential role of Lp-PLA2 as a biomarker for CAD.

HFA-PEFF score as a prognostic factor in patients with liver cirrhosis

Introduction

Cardiovascular complications of liver cirrhosis which are frequently referred to as cirrhotic cardiomyopathy (CCM), include high cardiac output, reduced afterload and diastolic dysfunction. However, there are only scarce or even conflicting data about the prognostic significance of CCM. HFA-PEFF score is a diagnostic score for heart failure with preserved ejection fraction (HFpEF), which has prognostic value in HFpEF patients. It has functional, morphological and biomarker domains and the score may vary from 0 to 6. Score of 5 or 6 is diagnostic of HFpEF in symptomatic patients. No study has calculated HFA-PEFF score in cirrhotic patients to date.

Purpose

The purpose of this prospective study was to calculate HFA-PEFF score in cirrhotic patients, correlate it with disease severity and determine its prognostic significance.

Methods

A total number of 92 consecutive cirrhotic outpatients were prospectively examined and 72 fulfilled the inclusion criteria. Patients older than 75 years old or patients with ejection fraction (LVEF) <50%, coronary artery disease, moderate or severe valvular heart disease, atrial fibrillation, ongoing alcohol consumption, hepatocellular carcinoma and poor acoustic window were excluded. In all patients a thorough echocardiographic examination was performed, BNP or NT-pro-BNP levels were measured and subsequently HFA-PEFF score was calculated. MELD score was used to define the severity of cirrhosis. The median follow-up was 20 months and the study end-point was defined as the composite of all-cause death.

Results

Mean age was 58.5±8.3 years, 52 (72.2%) were males, median Meld score was 12.9 (8.5–16.3) and mean LVEF was 61.1±5.4%. HFA-PEFF score was 5 or 6 in 38 (52.8%), 2–4 in 27 (37.5%) and 0 or 1 in 9 (9.7%) patients. According to Spearman's coefficient analysis, HFA-PEFF score was correlated with MELD score (rho=0.566, p<0.001), but not with age, systolic blood pressure (SBP) and heart rate. The survival analysis stratified by the HFA-PEFF score [low, score 0–4 (N=34) vs. high, score 5–6 (N=38)] indicated that the HFA-PEFF score successfully predicted all cause two-year survival (log-rank test p<0.001). According to the Cox-regression proportion hazard models HFA-PEFF score as a continuous variable correlated with six-month, one year and two year survival. When HFA-PEFF was treated as a categorical variable, hazard models were significant for the one and two-year survival. The multivatiate COX regression survival analysis showed that the increased HFA-PEFF score (low: score 0–4, N=34 vs high: score 5–6, N=38) was significantly associated with decreased two-year survival when patient age, gender and MELD score are taken into account [HR=3.659 (1.068–12.536), p=0.039].

Conclusions

HFA-PEFF score is high among patients with liver cirrhosis, especially those with increased disease severity. HFA-PEFF score is associated with survival even when adjusting for the severity of the cirrhosis.

Funding Acknowledgement

Type of funding sources: None.

The natural history of idiopathic chronic large asymptomatic non-inflammatory pericardial effusions

Background/Introduction

Pericardial effusions (PEFs) are a challenging and often troublesome pericardial syndrome. The most recent 2015 ESC guidelines on pericardial diseases recommend drainage in cardiac tamponade or suspected bacterial/ neoplastic etiology (class IC), which should also be considered in large, idiopathic chronic PEFs.

Purpose

In this work we assessed the natural history of asymptomatic, idiopathic, chronic, C-reactive protein (CRP) negative, large PEFs.

Methods

We assessed retrospectively consecutive patients referred to the pericardial unit of our institution with idiopathic (without definite underlying etiology after extensive work-up), chronic (>3 months), large (maximal effusion diameter at end-diastole >2cm), asymptomatic, without evidence of ongoing pericardial inflammation (without CRP elevation or evidence of pericardial inflammation with cardiac magnetic resonance imaging) PEFs. To define the natural history of this condition, only patients with a follow-up of at least 2 years were included. The change in the PEF diameter from the first evaluation to the last follow-up namely: regression (complete or decrease from large to moderate/small), progression with symptoms appearance requiring drainage, or stability over time (defined as variation of PEF diameter <5mm, but still in the range of large), was assessed. Follow-up according to our institutional protocols was performed every 3 months and included clinical examination and focused echocardiography.

Results

Thirty patients fulfilled the inclusion criteria and were analyzed. No patient was receiving anti-inflammatory treatment during follow-up. Nevertheless, 12 patients (40%) had received from their attending physicians a course of anti-inflammatory treatment (non-steroidal anti-inflammatory drugs, glucocorticoids, colchicine and combinations) before enrollment, without or with temporary results. The mean age of this study population was 64.9 (±16.1) years and the mean follow-up was 49.8 (±17.8) months. Women were numerically more often affected compared to men (57% vs. 43%, p=0.465). History of pericarditis was reported in 13% of cases. The mean maximal PEF diameter was 24.5mm (±3.3) and the median disease duration at first evaluation was 15.5 (7–57) months. Concerning outcome, the effusion size remained stable in 24 out of 30 patients (80%), regressed in 4 (13%,) and increased in size requiring drainage due to symptoms onset in the remainder 2 (7%). During follow-up 2 patients (7%) with stable in size effusions died from non-cardiac causes.

Conclusions

According to this study results the outcome of idiopathic, chronic, large, asymptomatic and without evidence of inflammation PEFs is overall favorable. Patients should be reassured about the benign course of this condition but at the same time, advised to seek medical care should symptoms appear, for a timely intervention with pericardial drainage.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular mechanics among beta-thalassemia major patients

Introduction

Right ventricular function among β-thalassemia (β-TM) patients is affected by both pulmonary circulation pressure and primary iron deposition on right ventricular myocardium.

Purpose

In our study we aimed to detect the presence of impaired right ventricular function and right ventricle to pulmonary circulation (RV-PC) coupling by applying novel echocardiographic techniques among these patients.

Methods

47 β-TM patients (mean age 39.02±8.76 years, 48.9% male sex) and 24, age and sex matched, healthy controls were examined by transthoracic echocardiography. Conventional echocardiographic parameters were estimated (LVEF, E/e' ratio, left atrial volume index (LAVI), right ventricular systolic pressure (RVSP), S' wave of tricuspid annulus), alongside with deformation indices (left atrial strain at reservoir phase (LASr), right ventricular free wall (RVfw) and 4 chamber (RV4c) strain), as well as RV-PC coupling expressed as S'/RVSP, RVfw/RVSP and RV4c/RVSP. T2* was calculated by cardiac magnetic resonance imaging in β-TM patient group.

Results

E/e' ratio, LVEF, LAVI, RVSP, LASr, RVfw, RV4c, S'/RVSP, RVfw/RVSP and RV4c/RVSP differed significantly between patients and controls (Table 1). T2* did not correlate with either right ventricular deformation indices or RV-PC coupling indices. A correlation was found regarding LASr with both S'/RVSP (r=0.383, p=0.008) and RV4c/RVSP (r=−0.388, p=0.007) but not with RVfw/PVSP (Table 2).

Conclusions

Right ventricular deformation indices were found to be impaired in β-TM patients compared to controls, but they do not seem to be associated with myocardial iron load (T2* index). RV-PC coupling was also found to be impaired among patients and a correlation was found between RV-PC indices and left atrial strain. The latter suggests that the presence of atrial cardiomyopathy in β-TM patients could be associated with the impaired RV-PC coupling.

Funding Acknowledgement

Type of funding sources: None.

Deformation analysis in advanced chronic kidney disease: an important prognostic indicator

Background

Chronic kidney disease (CKD) is associated with a higher incidence of cardiovascular manifestations, particularly in patients with advanced renal impairment on long-term dialysis. Cardiac deformation analysis, assessed by speckle tracking echocardiography has been shown to be a significant prognostic index in various specific populations.

Objective

To assess the prognostic value of deformation analysis measurements including both systolic parameters as left ventricular (LV) global longitudinal strain, and diastolic indices as left atrial (LA) strain, in patients with end-stage renal disease.

Methods

We enrolled 67 patients (mean age 62.3±11.8, 65.7% men) with end-stage renal disease. Patients with a confirmed diagnosis of pre/existing cardiac conditions, such as obstructive coronary artery disease, heart failure, severe arrhythmias or severe valvular disease were excluded from the study. A comprehensive transthoracic echocardiography study was performed at baseline. All images were stored digitally and subsequent analysis was performed offline. LV global longitudinal strain (GLS) and LA strain were calculated semi-automatically using dedicated software. The primary endpoints of the study were major adverse cardiovascular events such as all-cause mortality, cardiovascular mortality, myocardial infarction, and hospitalizations for cardiac adverse events. The median follow-up was five years.

Results

The study population had normal or mildly impaired systolic function with a mean LV ejection fraction (EF) of 49.17% (±10.41) while 70% of patients had reduced LV GLS, mean 14.35% (±4.49). Regarding LA parameters, 50% of our cohort had impaired LA strain: mean LA reservoir, LA conduit, and LA contractile reserve were 24.11% (±12.61), 10.56% (±5.88), and 13.60% (±9.15) respectively. The 5-year cumulative event-free survival was 58.2% (±6.7), while 30% of major events occurred in the first 2 years after baseline. Age had a moderate correlation with poor prognosis (p=0.013). Of the echocardiographic parameters LV EF, LV GLS, the conduit phase of LA strain, LA volume and various doppler parameters related to diastolic function, such as mitral E/A ratio and late mitral diastolic velocity A, were found to have a significant negative association with total prognosis (p=0.003, p=0.02, p=0.048, p=0.045, p=0.008, and p=0.017 respectively). Logistic regression analysis showed that of the different echocardiographic parameters LV EF, LV GLS, and the conduit phase of LA strain were significantly associated with the overall prognosis (p=0.009, p=0.007, p=0.05). The conduit element of LA strain was the strongest predictor among them (OR=0.77 p=0.04).

Conclusion

Left ventricular systolic and diastolic dysfunction is a significant prognostic indicator in patients with end stage renal disease. Assessing cardiac mechanics with speckle tracking echocardiography could provide valuable information in this specific population.

Funding Acknowledgement

Type of funding sources: None.

Left atrial deformation indices in β-thalassemia major patients

The presence of atrial cardiomyopathy in β-thalassemia major (β-TM) patients complicates their clinical condition. The diagnosis is challenging even with cardiac magnetic resonance (CMR) imaging. Novel echocardiographic techniques are applied to increase the diagnostic yield. Fifty-six β-TM patients and thirty age and sex-matched controls were included in the present cross-sectional study. Heart rate, PR duration, and P axis were measured by electrocardiography, left ventricular ejection fraction (LVEF) and end-diastolic diameter (LVEDD), ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e'), left atrial volume index (LAVI), left atrial strain at reservoir (LASr), conduit (LAScd) and contraction (LASct) phases respectively, left ventricular global longitudinal strain (GLS) by echocardiography, and T2* calculation in patient group by CMR. PR duration, LVEF, LAVI, E/e', GLS, and left atrial deformation parameters differed between patients and controls (p <0.05). In patient group, left atrial strain was correlated with PR duration, LAVI, E/e', GLS, and T2* (p <0.05). T2* was correlated only with left atrial deformation indices (p <0.05). Patients with a history of atrial fibrillation were older, had lower heart rate, prolonged PR, increased E/e' and LAVI, and impaired left atrial strain (p <0.05). LASct differed relative to the presence of atrial fibrillation and myocardial iron overload. Atrial strain could be of clinical use in the early detection of atrial cardiomyopathy. An impaired LASct could identify β-TM patients with undetected episodes of atrial fibrillation. Finally, left atrial strain may be helpful in myocardial iron load estimation.

Fluid and Salt Balance and the Role of Nutrition in Heart Failure

The main challenges in heart failure (HF) treatment are to manage patients with refractory acute decompensated HF and to stabilize the clinical status of a patient with chronic heart failure. Beyond the use of medications targeted in the inhibition of the neurohormonal system, the balance of salt and fluid plays an important role in the maintenance of clinical compensation in respect of renal function. In the case of heart failure, a debate of opinion exists on salt restriction. Restricted dietary sodium might lead to worse outcomes in heart failure patients due to the activation of the neurohormonal system and malnutrition. On the contrary, positive sodium balance is the primary driver of water retention and, ultimately, volume overload in acute HF. Some recent studies reported associations of decreased salt consumption with higher readmission rates and increased mortality. Thus, the usefulness of salt restriction in heart failure management remains debated. The use of individualized nutritional support, compared with standard hospital food, was effective in reducing these risks, particularly in the group of patients at high nutritional risk.

Left atrial reservoir strain may be a load independent index of diastolic dysfunction in liver cirrhosis patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cirrhotic cardiomyopathy is characterized by high cardiac output, reduced peripheral resistance and diastolic dysfunction. Specifically, diastolic dysfunction has been correlated with the prognosis in liver cirrhotis patients independently of the disease severity. Left atrial reservoir strain (LASr) is a novel index which is inversely correlated with left ventricular end-diastolic pressure, but has not been adequately studied in cirrhotic patients.

Purpose

To investigate the correlations between LASr and diastolic function or disease severity in cirrhotic patients.

Methods

  Echocardiographic analysis of 51 consecutive cirrhotic patients was performed and images were analyzed off-line. LASr was calculated semi-automatically using dedicated software and was feasible in 49 patients.  Clinical and biochemical examination was used to assess severity of liver disease by calculating MELD-Na score.

Results

Mean age was 58.0± 8.6 years, 37 (75.5%) were males, mean MELD-Na score was 15.6 ±7.5 and mean LASr was 39.7 ±12.5. LASr correlated with age (r=-0.415, p = 0.003), LAVI (r=-0.329, p = 0.022), e’ (r = 0.476, p = 0.001), E/e (r=-0.401, p = 0.004) and GLS (r=-0.388, p = 0.006), but not with ejection fraction, stroke volume or MELD-Na score.  MELD-Na score correlated with ejection fraction (r = 0.316, p = 0.029), stroke volume (r = 0.549, p &lt; 0.001), left atrial volume index (r = 0.575, p &lt; 0.001), GLS (r = 0.521, p &lt; 0.001), right atrial end systolic area (r = 0.368, p = 0.011) and right ventricular diameter (r = 0.541, p &lt; 0.001) reflecting high cardiac output state in patients with advanced cirrhosis. LASr was significantly lower in patients with E/e’ &gt;14 (22.5 ± 13.6) when compared to patients with E/e’ 8-14 (37.3± 10.6, p = 0.039) and E/e’&lt;8 (44.7± 12.0, p = 0.003). The two latter groups also differed significantly (p = 0.034). LASr correlation with E/e’ was the only statistically significant correlation in a multiple regression model including left ventricular end diastolic volume, ejection fraction and left atrial volume (B=-1.371, P = 0.023). Correlation of LASr with MELD-Na score remained non-significant.

Conclusion

LASr correlates inversely with E/e’ ratio in liver cirrhotic patients, but does not correlate with load dependent echocardiographic parameters and disease severity. Hence in this special population, LASr may be an earlier and more specific index of diastolic dysfunction than traditional echocardiographic indices. Further studies are needed to examine the prognostic significance of LASr in cirrhotic patients.

Deformation analysis in post-hospitalised patients with moderate SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

SARS-CoV-2 infection is associated with multiple cardiac manifestations (1,2). Global longitudinal strain (GLS) by speckle tracking echocardiography (STE) is a novel transthoracic echocardiography (TTE) measure of myocardial deformation, which could early recognize subclinical cardiac injury in COVID-19 patients (3,4).

Purpose

We aimed to explore GLS profiles in post-hospitalized COVID-19 patients to identify features of eventual subclinical cardiac injury and to investigate the possible correlation with the severity of infection.

Methods

We enrolled 33 patients (mean age 59.2 ± 13, 64% men) with positive SARS-CoV-2 RT-PCR, hospitalized for moderate COVID-19 disease, with no admission to intensive care unit. Patients were submitted to TTE 1-2 months after discharge.  Images were anonymised and analysed offline by two accredited cardiologists. Clinical parameters and laboratory findings from hospitalization were also collected.  Acute myocardial infarction and pulmonary embolism were exclusion criteria.

Results

Mean duration of hospitalization was 12.9 ± 8.0 days. Study population had normal systolic function with a mean LV ejection fraction 58.6% (±3.6) while the majority of patients had relative low values of LV global longitudinal strain, mean 15.2% (±2.3). Arterial hypertension was present in 51.5% of patients and a history of previous myocardial infarction was referred in 6.1% of the population. Only 24.2% of patients had elevated troponin levels during the previous in-hospital period (mean maximal value of hs-troponin  was 18.1 ±16.6 pg/mL) whereas  81.8% had abnormal D-Dimers values (mean 2424 μg /L, range ±2825) and 93.1% had high hs-CRP values (138.2 ±92.0 mg/L) . Duration of hospitalization had strong significant correlation with D-Dimers (rho: 0.708, p: &lt;0.001) and hs CRP (rho:0383, p:0.028) and  marginal association with troponin ( rho: 0.335, p:0.056). Moreover, global longitudinal strain showed significant association with duration of hospitalization (rho:-0.545, p: 0.007). Traditional systolic indices as LVEF and the various diastolic parameters  showed no significant association with severity of disease reflected by the duration of hospitalization and the other clinical and laboratory biomarkers.

Conclusion

Cardiac manifestations of SARS-CoV-2 infections could be present in mild to moderate disease and seems to associate with the severity of infection. The novel echocardiographic parameters such as GLS could add valuable information and identify  possible subclinical cardiac injury often unrecognized by traditional TTE examination.

The prognostic value of left atrial strain in patients with end stage renal disease on dialysis

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic kidney disease (CKD) is associated with higher incidence of cardiovascular death especially as the disease progresses and the patients undergo long term dialysis treatment (1). Left ventricular (LV) dysfunction evaluated by cardiac deformation measurements with speckle tracking echocardiography seems to have an important prognostic role in several different specific populations (2-4).

Purpose

Τhe prognostic value of strain analysis measurements, including the novel diastolic parameters such as left atrial (LA) strain, in patients with end-stage renal disease on dialysis (stage 5 CKD).

Methods

 67 patients (mean age 62.3 ± 11.8, 65.7% men) with stage 5 CKD (45 on hemodialysis and 22 on peritoneal dialysis) were enrolled in the study protocol. The mean duration of dialysis was 102.48 ± 84.98 months. Patients were submitted to a transthoracic echocardiogram at rest and dobutamine stress contrast echo (DSCE) protocol. Mean follow-up lasted five years.

Results

The majority of the study population had normal or mildly impaired systolic function with a mean LV ejection fraction 49.17% (±10.41) while 70% of the patients had impaired LV global longitudinal strain, (mean 14.35%, ±4.49). Regarding LA strain parameters the mean LA reservoir, LA conduit, and LA contractile reserve were 24.11%(±12.61), 10.56% (±5.88) and 13.60% (±9.15) respectively. Thus 50% of the population had impaired LA strain. DSCE was positive for ischemia in 55.7%. The 5-year cumulative event-free survival was 58.2% (±6.7), while 30% of major events happened during the first 2 years after DSCE (see Figure). Logistic regression analysis showed that of the various echocardiographic parameters LV ejection fraction, LV global longitudinal strain, and the conduit phase of LA strain were significantly associated with DSCE result and total prognosis (p = 0.009, p = 0.007, p = 0.05, and p = 0.005, p = 0.049, p = 0.043, respectively). The conduit element of LA strain notably was the strongest predictor among them(OR = 0.76 p = 0.05 and OR = 0.72 p = 0.043, respectively).

Conclusion

 Left ventricular diastolic dysfunction is an important prognostic factor among patients with advanced CKD under long-term dialysis.  The novel echocardiographic parameters such as LA strain couldadd valuable information to the overall cardiac evaluation of this specific population. Abstract Figure.

Dobutamine stress echocardiography during covid-19 pandemic: impact on volume and positivity rates in a tertiary hospital

Funding Acknowledgements

Type of funding sources: None.

Introduction

The emergence of coronavirus 2019 infection (covid-19) was accompanied by severe social and economic restrictions and applied significant pressure to the healthcare systems. The first pandemic wave started in March to May 2020 and was characterized by the peak of confinement measures and lockdown application. The second wave started in September and peaked in November to December 2020 and was characterized by improved healthcare organization but significant burden for the hospitals and intensive care units. Dobutamine stress echocardiography (DSE) is used for evaluation of ischemia in patients with known or suspected coronary artery disease.

Purpose

To compare DSE volume and positivity rates between 2019 and 2020 time periods in a department of a public tertiary hospital.

Methods

We retrospectively analysed DSE studies performed in our department in 2020 including the peak of covid-19 restrictions and compared the data to the 2019.

Results

Volume of DSE studies decreased from 1516 in 2019 to 996 in 2020 (-34.3%). The study volume reduction was greater in April (-93.7%) and May (-54.5%) when the covid-19 restrictions were at the peak. Great decreases were also recorded in November (-46.8%) and December (-53.5%) when the second wave of covid-19 disease emerged. Conversely, small increases were recorded in September (7.1%) and October (10.6%) (figure 1). Regarding positivity rates, a statistically non-significant increase was recorded (33.6% vs 34.2% in 2019 and 2020 respectively, p = 0.73). Interestingly a statistically significant increase in positivity levels was recorded during the period March to May 2020 compared to the same period of 2019 (44.7% vs 36.9%, p = 0.029). On the contrary, positivity rates were decreased at the period September to December (27.1% vs 34.2%, p = 0.019) (figure 2).

Conclusions

Volume of DSE studies was significantly reduced in 2020 when compared to 2019 during respective peaks of the pandemic and the accompanying restriction measures. Positivity rates were higher during the first pandemic wave, possibly due to decreased hospital attendance of mildly symptomatic patients in combination with stricter admission criteria at the emergency department. Lower positivity rates during the second pandemic wave possibly reflect an adjustment of both healthcare systems and patients to the new conditions imposed by the covid-19 pandemic. Abstract Figure 1  Abstract Figure 2

The fundamental role of stress echo in evaluating coronary artery disease in specific patient populations

Stress echocardiography (SE) was initially used for assessing patients with known or suspected coronary heart disease by detecting and evaluating myocardial ischemia and viability. The implementation of SE has gradually been extended to several cardiovascular diseases beyond coronary artery disease, and SE protocols have been modified and adapted for the detection of coronary artery disease (CAD) or other cardiovascular diseases in specific patient populations. This review attempts to summarize current data concerning SE implementation and clinical value in these specific and diverse populations: patients with an intramural course of a coronary artery - known as a myocardial bridge, chronic severe or end-stage hepatic disease, chronic severe or end-stage kidney disease, cardiac allograft vasculopathy, patients scheduled for solid-organ transplantation and other intermediate and high-risk surgery and, finally, patients treated with anticancer drugs or radiotherapy.

Transthoracic ultrasound; seeking the heart in a patient with a large left-sided cirrhotic hydrothorax

A case of a patient with liver cirrhosis and a large left-sided pleural effusion displacing the heart rightward is presented and the best views to acquire images enabling evaluation of the cardiac function are highlighted. Understanding the modified intrathoracic anatomy in patients with pleural effusions enables quick and focused assessment and can shorten evaluation time while preserving high image quality.

Left atrial deformation parameters among beta-thalassemia major patients

Introduction

Atrial cardiomyopathy is present in a significant proportion of beta thalassemia major (β-TM) patients, complicating their clinical condition. The diagnosis of atrial cardiomyopathy is challenging using conventional echocardiographic techniques.

Purpose

In our study we aimed to identify the presence of atrial cardiomyopathy by applying novel echocardiographic techniques in these patients.

Methods

56 β-TM patients (mean age 39.3±9 years, 50% male sex) and 30, age and sex matched, healthy controls were examined by transthoracic echocardiography. Conventional echocardiographic parameters were estimated alongside with deformation indices (left atrial strain at reservoir (LASr), conduit (LAScd) and contraction (LASct) phase respectively as well as left ventricular global longitudinal strain (GLS)). T2* was calculated by cardiac magnetic resonance imaging in β-TM patients.

Results

LAVI, E/e' ratio, GLS and left atrial deformation parameters differed between patients and controls. In patient group, left atrial deformation indices were correlated with LAVI, E/e' ratio, GLS and T2* (Table 1). GLS was also correlated with LAVI, but not with T2* or E/e' ratio. T2* was correlated only with left atrial deformation indices. Patient with prior episodes of atrial fibrillation were older, had increased E/e' and LAVI and impaired left atrial deformation indices but did not differ in terms of GLS or T2* (Figure 1). Patients with iron overload differed only in terms of left atrial deformation parameters.

Conclusions

Atrial deformation indices could be of clinical use in the early detection of atrial cardiomyopathy. Impaired left atrial strain may be associated with silent atrial fibrillation and be indicative of myocardial iron overload.

Funding Acknowledgement

Type of funding sources: None. Correlation tableScatter plot of T2* and LASr

Eosinophilic Myocarditis in a Patient With Strongyloides stercoralis Infection

A 40-year-old woman with a pulmonary embolism, central nervous system infarcts, and eosinophilia was referred for evaluation. Findings on echocardiography and cardiac magnetic resonance were consistent with eosinophilic myocarditis with left ventricular involvement. Further examination led to the diagnosis of Strongyloides stercoralis infection, and treatment with ivermectin and rivaroxaban resulted in clinical, laboratory, and cardiac imaging improvement. (Level of Difficulty: Intermediate.).

The combined use of electrocardiography, echocardiography and cardiac magnetic resonance imaging in left atrium evaluation among beta-thalassemia patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Beta-thalassemia major (β-TM) patients are subjected to iron overload as a consequence of chronic blood transfusions. The redundant iron affects, among other organs, the heart resulting in myocardial dysfunction. Iron deposition does not only affect ventricular myocardium but atrial myocardium as well. According to current practice, the overall myocardial iron status is estimated by calculating T2* at the middle section of the ventricular septum using cardiac magnetic resonance imaging (CMR). Current CMR technology limits the direct estimation of atrial iron status. 

Purpose

The current study evaluates left atrial function by novel echocardiographic techniques and correlates these findings with CMR data.

Methods

37 β-TM patients (mean age 41.17 years (SD = 8.33), 51.4% male), were subjected to electrocardiography, echocardiography and CMR imaging and P wave axis, PR segment duration, left atrial volume index (LAVI), left atrial strain at reservoir phase (LASr) and T2* were measured. 

Results

No correlation between T2* and LASr (r = 0.253, p = 0.131) or T2* and LAVI (r = 0.044, p = 0.796) were found. However, a correlation was found between the echocardiographic parameters LAVI and LASr (r = -0.676, p &lt;0.001). P wave axis did not correlate with any other parameter, while PR segment duration was correlated with LASr (r = -0.399, p = 0.015). Regression analysis revealed correlation between LAVI and LASr (r2 = 0.457, p &lt;0.001).

Conclusions

The current study suggests that despite the undisputed contribution of CMR in left ventricular iron load estimation, it may be less accurate in atrial iron status estimation. Considering the limitations of current CMR technology regarding the iron status of the thin atrial and right ventricular walls, our study highlights the role of speckle tracking in combination with CMR imaging for a more comprehensive evaluation of β-TM patients.

Correlation table P axis PR segment T2* LAVI LASr P axis 0,151 (p = 0,373) 0,112 (p = 0.,508) -0,140 (p = 0,410) -0,117 (p = 0,489) PR segment 0,151 (p = 0,373) 0,051 (p = 0,766) 0,278 (p = 0,096) -0,399 (p = 0,015) T2* 0,112 (p = 0.,508) 0,051 (p = 0,766) 0,044 (p = 0,796) 0,253 (p = 0,131) LAVI -0,140 (p = 0,410) 0,278 (p = 0,096) 0,044 (p = 0,796) -0,676 (p &lt;0,001) LASr -0,117 (p = 0,489) -0,399 (p = 0,015) 0,253 (p = 0,131) -0,676 (p &lt;0,001) T2*: obtained by cardiac magnetic resonance imaging LAVI left atrial volume index (ml/m2) LASr left atrial strain at reservoir phase Abstract Figure. Correlation between LASr and T2*

Correlation of global longitudinal strain with disease severity in liver cirrhosis

Funding Acknowledgements

Type of funding sources: None.

Introduction/purpose

Cirrhotic cardiomyopathy is characterized by high cardiac output, reduced peripheral resistance and diastolic dysfunction and has been correlated with cirrhosis severity and prognosis. Global longitudinal strain (GLS) is a sensitive marker of cardiac dysfunction which is considered relatively independent of preload and afterload conditions and thus may be of high diagnostic significance in this special population. We sought to investigate alterations of GLS relating to disease severity in cirrhotic patients.

Methods

Echocardiographic analysis of 51 consecutive cirrhotic patients was performed. Images were acquired and analyzed off-line. GLS was calculated with a semi-automatic way using dedicated software.  Clinical and biochemical examination were used to assess severity of liver disease by calculating Child-Pugh class (class C patients have more severe disease than class B and A patients) and MELD-Na score (increased score as the disease progresses).

Results

Mean age was 58.4 ± 8.7 years, 38 (74.5%) were males. Among patients, 22 (43.1%) were Child-Pugh class A, 17 (33.3%) Child-Pugh B and 12 (23.5%) Child-Pugh C and mean MELD-Na score was 15.3 ± 7.5. Mean left ventricular end-systolic volume (LVEDV) was 117 ± 29ml, mean stroke volume (SV) 72.5 ± 19.9ml , mean left ventricular ejection fraction (LVEF) 61.0 ± 5.0%, mean systolic blood pressure (SBP) 128 ± 13mmHg, mean ratio of peak transmitral to peak annular (septal) velocity during early diastole (E/e’ ratio) 10.4 ± 4.5, mean left atrial volume index (LAVI) 37.4 ± 11.8 ml/cm2  and mean GLS -21.6 ± 2.6%. GLS of Child-Pugh class A patients (-20.3 ± 2.4) was higher (less negative) than GLS of Child-Pugh class B (-22.2 ± 2.2) and class C (-23.0 ± 2.8) patients. Difference between groups B and C was non-significant (figure). Severity of cirrhosis as determined by higher MELD-Na score correlated with LAVI (r = 0.592, p &lt; 0.001), SV (r = 0.554, p &lt; 0.001), GLS (r=-0.441, p = 0.001) and LVEDV (r = 0.428, p = 0.002). GLS correlated with SV (r=-0.369, p = 0.008) but not with preload (LVEDV), or afterload (SBP). In a linear regression model, GLS was independently associated with Meld-Na score when adjusting for age, SBP, LVEDV and NASH etiology [B=-0.139 (-0.252; -0.025), p = 0.018].

Conclusions

GLS is lower (more negative) in patients with liver cirrhosis as disease progresses a relation not affected by preload and afterload conditions. Further research works are required to explain the underlying pathophysiology and to assess prognostic significance of reduced GLS values in patients with advanced cirrhosis.

Abstract Figure. GLS stratified by Child-Pugh score

Cardiac Masses: The Role of Cardiovascular Imaging in the Differential Diagnosis

Cardiac masses are space occupying lesions within the cardiac cavities or adjacent to the pericardium. They include frequently diagnosed clinical entities such as clots and vegetations, common benign tumors such as myxomas and papillary fibroelastomas and uncommon benign or malignant primary or metastatic tumors. Given their diversity, there are no guidelines or consensus statements regarding the best diagnostic or therapeutic approach. In the past, diagnosis used to be made by the histological specimens after surgery or during the post-mortem examination. Nevertheless, evolution and increased availability of cardiovascular imaging modalities has enabled better characterization of the masses and the surrounding tissue. Transthoracic echocardiography using contrast agents can evaluate the location, the morphology and the perfusion of the mass as well as its hemodynamic effect. Transesophageal echocardiography has increased spatial and temporal resolution; hence it is superior in depicting small highly mobile masses. Cardiac magnetic resonance and cardiac computed tomography are complementary providing tissue characterization. The scope of this review is to present the role of cardiovascular imaging in the differential diagnosis of cardiac masses and to propose a step-wise diagnostic algorithm, taking into account the epidemiology and clinical presentation of the cardiac masses, as well as the availability and the incremental value of each imaging modality.

Electrocardiographic parameters among beta-thalassemia major patients

Background/Introduction

The majority of beta thalassemia major (β-TM) patients suffer from cardiac disorders, while a significant proportion of them die suddenly. Twelve-lead and signal-averaged electrocardiography are simple, inexpensive, readily available tools for identifying an unfavorable arrhythmiological substrate by detecting the presence of arrhythmias, conduction abnormalities and late potentials (LPs) in these patients.

Methods

47 β-TM patients and 30 healthy controls were submitted to twelve-lead and signal-averaged electrocardiography. Basal rhythm, heart rate, PR interval duration, QRS complex duration and morphology, QTc interval duration and prevalence of LPs were recorded.

Results

β-TM patients demonstrated a more prolonged PR segment (167.74 msec vs. 147.07 msec) (p=0.043), a higher prevalence of PR prolongation (21.05% vs. 0%) (p=0.013) and a higher prevalence of LPs (18/47, 38.3% vs. 2/30, 6.7%) (p=0.002) compared with controls. In particular, every single SAECG parameter significantly differed among patients compared with controls. Among patients, left ventricular ejection fraction was marginally lower and QTc more prolonged among LPs positive subgroup compared with LPs negative subgroup. The prevalence of atrial fibrillation among b-TM patients was estimated at 10.64%.

Conclusions

β-TM patients have a higher prevalence of a prolonged PR segment, atrial fibrillation and LPs. Twelve-lead and SAECG performance was feasible in all subjects and constitutes a readily available tool for assessing myocardial electrophysiological alterations in this patient group, that could have significant impact on survival and quality of life with timely application of appropriate treatment.

Funding Acknowledgement

Type of funding source: None

Twelve-lead and signal-averaged electrocardiographic parameters among beta-thalassemia major patients

BACKGROUND

The majority of beta thalassemia major (β-TM) patients suffer from cardiac disease, while a significant proportion of them die suddenly. Twelve-lead and signal-averaged electrocardiography (SAECG) are simple, inexpensive, readily available tools for identifying an unfavorable arrhythmiological substrate by detecting the presence of arrhythmias, conduction abnormalities, and late potentials (LPs) in these patients.

METHODS

A total of 47 β-TM patients and 30 healthy controls were submitted to 12-lead and signal-averaged electrocardiography. Basic electrocardiographic parameters and prevalence of LPs were recorded. Basic echocardiographic parameters were estimated by transthoracic echocardiography. T2* was calculated by cardiac magnetic resonance imaging wherever available.

RESULTS

β-TM patients demonstrated a more prolonged PR interval (167.74 msec vs 147.07 msec) (P = .043), a higher prevalence of PR prolongation (21.05% vs 0%) (P = .013), and a higher prevalence of LPs (18/47, 38.3% vs 2/30, 6.7%) (P = .002) compared with controls. The prevalence of atrial fibrillation among b-TM patients was estimated at 10.64%. Patients had also greater E/e' ratio (8.35, SD = 2.2 vs 7, SD = 2.07) (P = .012) and LAVI (30.7 mL/m2, SD = 8.76 vs 24.6 mL/m2, SD = 6.57) (P = .002) than controls. Regression analysis showed that QTc and LAVI could correctly predict the presence of LPs in the 80.9% of the patients.

CONCLUSIONS

β-TM patients have a higher prevalence of a prolonged PR interval, atrial fibrillation, and LPs. Twelve-lead and SAECG performance was feasible in all subjects and constitutes a readily available tool for assessing myocardial electrophysiological alterations in this patient group.

Severity of heart failure and health-related quality of life in beta-thalassemia patients: a cross-sectional study

Cardiovascular complications account for a substantial increase in morbidity and mortality in beta-thalassemia patients. Many patients have structural heart disease, and some of them present with symptomatic heart failure (HF). Quality of life (QOL) of beta-thalassemia patients is lower than that of the general population. The aim of our study was to explore the relationship between HF stages and QOL in beta-thalassemia patients. Seventy-three consecutive adult beta-thalassemia patients took part in this cross-sectional study. Stages of HF, classified with increasing severity as A, B, and C, were determined based on ACC/AHA guidelines. QOL was assessed using the SF-36 questionnaire. Fifteen patients had stage C HF, twenty-eight had stage B HF, and the remaining were considered stage A patients, as beta thalassemia is a predisposing factor for HF. All QOL domains except for bodily pain were significantly lower in stage C patients than in stage A patients. Stage C patients had significantly lower QOL scores for physical functioning, role physical, and social functioning domains than stage B patients. Stage B patients' QOL differed from stage A patients only in the vitality domain. In the multiple regression analysis which took several demographic and clinical factors into account, stage of HF was the most important factor associated with QOL, and negatively and significantly related to five QOL domains, namely physical functioning, role physical, general health, social functioning, and vitality. In conclusion, QOL is negatively affected by the severity of heart failure in beta-thalassemia patients.

P1768 The value of global longitudinal strain in non-alcoholic steatohepatitis-associated cirrhosis

Introduction

Non-alcoholic steatohepatitis (NASH) in patients with metabolic syndrome is a common cause of cirrhosis and has been associated with increased cardiovascular mortality. In patients with liver cirrhosis systolic or diastolic dysfunction can be observed and is independent of the cirrhosis etiology. Only few studies using newer echocardiography indices such as Global Longitudinal Strain (GLS) have been published in cirrhotic patients.

Purpose

To evaluate GLS in patients with NASH cirrhosis when compared to other etiologies.

Methods

A total of consecutive 36 cirrhotic patients aged 18-70 were included in our study. Standard speckle-tracking software was used for offline analysis of standard apical views and GLS was calculated. Stroke Volume Index (SVI) was calculated with the Simpson method and a standard 2D, Doppler and Tissue Doppler examination was performed in all patients.

Results

Median age of the study population was 58 (IQR 50-64) years, 78% were male and 17% had ascites. Cirrhosis was considered decompensated in 21 (58%) of patients. The 28%, 42% and 19% had NASH-associated, alcoholic and viral etiology of cirrhosis, respectively. Median ejection fraction (EF) was 60% (IQR: 57%; 65%) and GLS was -21.1% (-19.7%; -23.1%) in the total population. Absolute value of GLS was lower in patients with NASH cirrhosis compared to other etiologies (p = 0.009) (figure 1). EF, SVI, left atrial volume index (LAVI), E/e’ ratio and mitral annular velocity (e’) did not differ significantly between those with NASH associated cirrhosis and the rest. GLS values were significantly correlated with EF (r=-0.588, p = 0.002), SVI (r=-0.469, p = 0.016) and BNP levels (r=-0.571, p = 0.007), but not with age, left ventricular end diastolic volume, left atrial volume index, E/e’, mitral annular velocity and blood pressure. According to a multivariable linear regression model, NASH etiology [B = 2.1 (0.6; 3.7), p = 0.008)] and EF (per 10% increase) [B=-1.7 (-3.3; -0.2), p = 0.03)] were the only independent factors associated with GLS values in cirrhotic patients.

Conclusions

GLS values are within normal limits in cirrhotic patients but seem to be affected in patients with NASH associated cirrhosis. Further studies are needed to assess the prognostic implications of this finding.

Abstract P1768 Figure 1

Cardiac Imaging in Liver Transplantation Candidates: Current Knowledge and Future Perspectives

Cardiovascular dysfunction in cirrhotic patients is a recognized clinical entity commonly referred to as cirrhotic cardiomyopathy. Systematic inflammation, autonomic dysfunction, and activation of vasodilatory factors lead to hyperdynamic circulation with high cardiac output and low peripheral vascular resistance. Counter acting mechanisms as well as direct effects on cardiac cells led to systolic or diastolic dysfunction and electromechanical abnormalities, which are usually masked at rest but exposed at stress situations. While cardiovascular complications and mortality are common in patients undergoing liver transplantation, they cannot be adequately predicted by conventional cardiac examination including transthoracic echocardiography. Newer echocardiography indices and other imaging modalities such as cardiac magnetic resonance have shown increased diagnostic accuracy with predictive implications in cardiovascular diseases. The scope of this review was to describe the role of cardiac imaging in the preoperative assessment of liver transplantation candidates with comprehensive analysis of the future perspectives anticipated by the use of newer echocardiography indices and cardiac magnetic resonance applications.

Methylmalonic acid and vitamin B12 in patients with heart failure

OBJECTIVE

Vitamin B12 deficiency among patients with heart failure (HF) may have been underestimated. High serum levels of methylmalonic acid (MMA) have been identified in several studies as an early indicator of vitamin B12 deficiency. Furthermore, MMA seems to constitute a biomarker of oxidative stress and mitochondrial dysfunction. There are scarce data regarding vitamin B12 and MMA in patients with HF. The aim of this study was to investigate vitamin B12 and MMA serum levels in patients with HF.

METHODS

One hundred five consecutive patients admitted to our hospital with symptoms and signs of acute decompensated HF were included in the study. Demographic and clinical characteristics as well as comorbidities and medical treatment before hospital admission were recorded. Transthoracic echocardiography was performed in all patients. Blood samples were collected during the first 24 hours of hospitalization and measured for complete blood count, biochemical profile, vitamin B12, N-terminal prohormone of brain natriuretic peptide, and MMA levels. Finally, 51 healthy individuals constituted the control group.

RESULTS

A total of 43.8% of patients with HF had elevated MMA levels, but only 10.5% had overt vitamin B12 deficiency, defined as serum cobalamin levels below 189 pg/ml. Mean MMA level was higher in patients with HF than in controls (33.0 ± 9.6 vs. 19.3 ± 6.3 ng/ml; p < 0.001). This difference remained significant when adjusted for age, sex, vitamin B12, and folate serum levels and kidney function (B = 14.7 (9.6-19.7); p < 0.001). MMA levels were higher in patients with acutely decompensated chronic HF than in those with newly diagnosed acute HF (34.7 ± 10.5 vs. 30.7 ± 7.8 ng/ml; p = 0.036). Correlation analysis revealed significantly negative correlation between MMA and vitamin B12 levels only in patients without comorbidities.

CONCLUSION

Patients with HF have elevated MMA levels, independent of age, gender, HF category, or comorbidities, possibly indicating subclinical vitamin B12 deficiency. Further research is needed to investigate subclinical vitamin B12 deficiency in patients with HF and/or to clarify whether MMA constitutes a biomarker of oxidative stress.

P6262Coronary microphysiology in relation to low endogenous testosterone and dietary habits in andropause men with erectile dysfunction

Background

Coronary flow reserve (CFR) in the presence of non-obstructive coronary artery disease displays the ability of microcirculation to augment flow to the myocardium. Endogenous total testosterone (TT) exhibits vasodilator effects and the Mediterranean diet (Med-diet) promotes cardiovascular health. Erectile dysfunction (ED) in a milieu of subclinical microvascular damage often coexists with the decline of endogenous testosterone of the aging male population.

Purpose

To investigate the effects of male hypogonadism in CFR and the relation between the Med-diet and the TT of the andropause middle aged men with ED.

Methods

190 non-diabetic male patients with ED (mean age: 56yo) enrolled the study. Significant epicardial coronary artery disease was excluded after a negative for ischemia dobutamine stress echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140μg/kg/min over 6 minutes). Measurements by the pulse wave Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was estimated as ratio between peak diastolic flow velocity following drug infusion and rest. CFR ratio ≥2 is considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am and hypogonadism was considered when TT <3,5 ng/ml. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Finally, carotid – femoral pulse wave velocity (PWV) was assessed as index of central vascular stiffness (sphygmocor device).

Results

In bivariate analysis CFR ratio (mean value: 2,35) was positively related to TT (p<0,001, r=0,9), the SHIM-5 and the Med-diet score (p<0,05 for both r=0,45 and r=0,5 respectively).On the contrary, it was negatively related to the PWV (p<0,05, r=−0,35). Med-diet was related to the SHIM-5 score (p=0,01, r=0,363) and to TT (p=0,02, r=0,46). In multiple linear regression analysis relation of CFR to TT remain significant (p<0,01) after adjustment for age, body mass index (BMI), LDL, PWV, smoking habits and systolic blood pressure. We further stratified our population in to hypogonadics (HYPO, n=38, 20%) and patients with normal TT levels. Poor adherence to the Med-diet was the only factor related to hypogonadism (independent sample t-test p=0,005) as compared with age, BMI and smoking.

Conclusion

In middle aged men with ED endogenous testosterone enhances coronary microcirculation. Moreover the Med-diet regime may blunt the fall of androgens during andropause independently of other life-style parameters. We emphasize on this culinary preference to assist coronary microvascular physiology and maintain hormonal balance.

P4983Safety of dobutamine stress contrast echocardiography; a single-center experience of 15 years

Introduction

Dobutamine stress contrast echo (DSCE) is an accurate method for the diagnosis of coronary artery disease (CAD). Scarcity of serious adverse events has led to its establishment as a popular method for the diagnosis of CAD and to its increased use beyond CAD. However, data regarding the safety of single-line dobutamine and contrast infusion are limited. The aim of our study was to assess the safety of a DSCE protocol using a single line of intravenous access.

Methods

Over a 15-year period (2004–2018), 34,675 patients underwent DSCE in our department, which was performed using 10–20–30–40–50 μg/kg/h of dobutamine with dosage increase every three minutes, while atropine up to 1mg could also be administered. Two commercially available contrast agents were used at rest and at peak in all patients and a single intravenous line was used for infusion of dobutamine, atropine and contrast agents. Demographic data, risk factors and information concerning the most common cardiovascular or allergic adverse events were available for all patients. Finally, the adverse events of DSCE were compared with respective events reported by relevant studies in order to determine the safety of our method.

Results

Mean age of patient population was 63.9 (SD: 11.4 years), while 67.9% of patients (n=23,544) were males. There were 22,731 hypertensive patients (65.6%), 9,256 diabetics (26.7%), 21,683 patients (62.5%) had dyslipidemia, 11,760 (33.9%) were smokers and 10,437 (30.1%) had a positive family history of CAD. Adverse events were reported in 876 patients (2.5%). Allergic reaction was reported in 69 patients (0.2%). We recorded 643 patients (1.85%) with non-sustained VT or frequent premature ventricular ectopic beats and 154 patients (0.44%) with AF or SVT episodes leading to protocol termination. In 24 patients (0.07%) with sustained VT, antiarrhythmic drugs were given intravascularly, while in 10 patients (0.03%) with VT or VF, resuscitation was needed. No death was reported. Frequency of life threatening adverse events reported by relevant studies did not differ significantly when compared to the present results.

Conclusion

DSCE protocols involving single line infusion of dobutamine, atropine and ultrasound enhancing agents are safe, since adverse event rates are low and do not differ significantly to rates reported for unenhanced DSE by other relevant studies. Implementation of such protocols in clinical practice may increase patient comfort and cost-effectiveness and should therefore be encouraged.

P2642Optimal blood pressure control in relation to target organ physiology in hypertensive men with erectile dysfunction

Background

Target organ damage (TOD) in essential hypertension relates to an adverse prognosis. Middle aged men are considered a population group where cardiovascular risk typically augments and erectile dysfunction (ED) that frequently accompanies both entities refers to a subclinical vascular damage process.

Purpose

To identify the optimal blood pressure (BP) levels in middle aged hypertensive males with ED in relation to TOD.

Methods

258 ED males (mean age: 56 yo) with essential hypertension under medical treatment enrolled the study. All underwent 2D echocardiography and carotid ultrasound evaluation to determine left ventricular mass index (LVMI) and intima – media thickness (IMT) respectively. Carotid – femoral pulse wave velocity (PWV) and augmentation index (AIx) were also assessed as indices of central vascular stiffness and wave reflection physiology (complior & sphygmocor devices). Office brachial blood pressure (BP) measurements where performed according to the current guidelines and an average of three consecutive values was computed. Erectile dysfunction was assessed by using the SHIM-5 score (range 0–25, lower values display a pronounced dysfunction).

Results

In bivariate analysis brachial systolic blood pressure (bSAP) was positively and strongly associated with LVMI (r=0,6), PWV (r=0,65), AIx (r=0,67, all p<0,001) and IMT (p<0,05, r=0,55). Erectile performance as assessed by the SHIM-5 score was negatively related to PWV, AIX and IMT (r=−0,58, r=−0,45 and r=−0,65 all p<0,001) pointing out the underlying vascular detriment. Interestingly, there were no such correlations regarding the diastolic blood pressure values. Multiple linear regression analysis was performed and the relation of bSAP with LVMI, PWV, AIx and IMT remained significant after adjustment for age, BMI, smoking habits and presence of diabetes mellitus (all p<0,05). We further subdivided our population into three groups according to the values of office bSAP for normal blood pressure (≤129mmHg, n=143,55%), high normal (130–139mmHg, n=59, 23%) and high (≥140mmHg, n=56,22%). In patients with high-normal bSAP, the parameters of PWV and LVMI were significantly higher than in patients with normal BP (independent sample t-test, p: 0,032 and 0,016 respectively). Patients of the high bSAP group as expected, had more extensive cardiac and vascular damage (LVMI, PWV and AIx).

Conclusion

In essential hypertensive middle aged men with erectile dysfunction, guiding therapy toward normal systolic blood pressure values as compared to the high normal benefits target organ physiology. It is clinically important to identify this vascular patients group in order to adjust regimens and further therapeutic strategies.

P1503Decrement of vortex formation time during dobutamine stress echo

Background

Vortex Formation Time (VFT) is a novel index of systolic and diastolic function which may be also affected by left ventricular geometry, but has never been evaluated during dobutamine stress echocardiography (DSE) protocols. We sought to investigate the changes in VFT during DSE protocol.

Methods

DSE was performed in 50 consecutive patients. Patients with poor acoustic window, atrial fibrillation, cardiac valve disease or pacemaker were excluded. Apical four and apical two chamber views were acquired and the following parameters were calculated off- line without knowledge of DSE result both at rest and at peak: left ventricular end-diastolic and end-systolic volume, stroke volume, ejection fraction, stroke work, e and a wave peak velocity and VTI, TDI-derived mitral annular early diastolic velocity at the lateral wall and mitral valve diameter. VFT calculated according to the following equation: VFT = [4 *(1 − β) * α3 * EF]/π, where α = (LVEDV/α3)(1/3) and is affected by ventricular geometry and β = VTIa-wave/(VTIe wave + VTIa-wave) reflecting the atrial filling fraction.

Results

Median age of the study population was 61 [53–72], 38 men (76%) and 13 (26%) had an old myocardial infarction. Fifteen patients (30%) were positive for myocardial ischemia during DSE. At rest, median LVEDV was 121.5ml (101.8–148.0), median EF (%): 59.9 [54.4–64.1], median atrial filling fraction: 0.43 [0.40–0.48], median mitral valve diameter (cm): 2.8 [2.6–3.0] and median VFT: 2.44 [1.74–3.10]. At peak, median LVEDV was 102.0ml [86.4–122.3] median EF (%) 65.7 [58.8–69.8], median atrial filling fraction: 0.67 [0.59–0.73], median mitral valve diameter (cm): 2.7 [2.5–2.9] and median VFT: 1.45 [1.05–1.88]. VFT decreased in the whole population (Wilcoxon rank test, p<0.001) (figure 1A) and when patients were stratified according to test result. Median VFT decrease was significantly higher in patients with a positive DSE (50%) than in patients with negative DSE (39%) (Mann- Whitney U test, p=0.048) (figure 1B).

Figure 1

Conclusion

The VFT decreased significantly during DSE and most prominently in patients with ischemic response. This may indicate the deterioration of left ventricular diastolic or systolic function as well as change in left ventricular geometry during DSE protocol.

Unusual symptomatic late onset presentation of aberrant right subclavian artery: report of two cases and short literature review

Aberrant subclavian arteries are congenital vascular anomalies that usually do not cause any symptoms. When symptomatic they are considered as a rare cause of dysphagia. This presentation is known as dysphagia lusoria. They are diagnosed by barium swallow or contrast-enhanced computed tomography, although it may be an incidental finding. Management varies from life modifications and drug therapy to surgical intervention. We report two cases of the unusual form of late onset symptomatic presentation because of the presence of aberrant right subclavian artery. Main symptom was chest pain without dysphagia. Due to age and medical comorbidities both patients where managed conservatively.