3D Global Longitudinal Strain Research Articles

Myocardial Work Brings New Insights into Left Ventricular Remodelling in Cardio-Oncology Patients.

Serial transthoracic echocardiographic (TTE) assessment of 2D left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) are the gold standard screening methods for cancer therapeutics-related cardiac dysfunction (CTRCD). Non-invasive left ventricular (LV) pressure-strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages to evaluate the impact of cardiotoxic treatments on heart function. We prospectively assessed breast cancer female patients undergoing cancer therapy through serial monitoring by 2D and 3D TTE. Patients were evaluated at T0, T1 and T2 (before, 4–6 and 12–14 months after starting therapy, respectively). Through PSL analysis, MW indices were calculated. A total of 122 patients, with a mean age of 54.7 years, who received treatment with anthracyclines (77.0%) and anti-HER2 (75.4%) were included. During a mean follow-up of 14.9 ± 9.3 months, LVEF and GLS were significantly diminished, and 29.5% developed CTRCD. All MW indices were significantly reduced at T1 compared with baseline and tended to return to baseline values at T2. Global work index and global work efficiency showed a more pronounced variation in patients with CTRCD. The presence of more than one cardiovascular risk factor, obesity and baseline left atrium volume were predictors of changes in MW parameters. In conclusion, breast cancer treatment was associated with LV systolic dysfunction as assessed by MW, with its peak at 4–6 months and a partial recovery afterwards. Assessment of myocardial deformation parameters allows a more detailed characterization of cardiac remodelling and could enhance patient screening and selection for cardioprotective therapeutics.

Magnetic resonance derived regurgitant fraction, 3D vena contracta area, and B-natriuretic peptide: the most accurate prognostic markers in patients with chronic asymptomatic aortic regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic 17-28265A. Background The optimal timing of surgical treatment is challenging in asymptomatic patients with severe aortic regurgitation (AR). A significant number of patients undergoing aortic valve surgery as per current guidelines have irreversible left ventricular (LV) myocardial damage with a negative impact on their long-term postoperative outcome. Purpose We aimed to determine the value of magnetic resonance-, advanced echocardiography–derived indices and serum B-natriuretic peptide level (BNP) to identify patients with chronic asymptomatic AR who are at risk of early disease progression. Methods We prospectively enrolled a group of asymptomatic patients with pure chronic severe AR, without an indication for surgical treatment as per the current guidelines, in a multicenter study. Baseline examination consisted of serum BNP level analysis, comprehensive echocardiography including 3D vena contracta area (VCA) and 2D global longitudinal strain (GLS), and a comprehensive MRI including regurgitant fraction (RF) measurement; all imaging data were analyzed in Corelab. Patient follow-up was every 6 months. The primary endpoint was a new guideline-directed indication for surgical treatment. Results In total, 129 patients were enrolled between 2015 and 2019, the endpoint occurred in 43 patients during a median follow-up of 1375 (IQR 1041-1783) days. Baseline clinical data did not differ between patients with the endpoint (surgical group) and stable patients (medical group). Baseline BNP levels were significantly higher in the surgical group (55 vs. 21 ng/L, P = 0.008). MRI-derived LV ejection fraction was not different (61 vs 61 %, P = 0.815) at baseline while both CMR-derived end-systolic and end-diastolic LV volumes were significantly higher in the surgical group (all P < 0.01). Both baseline 3D VCA and 2D GLS were different between the surgical and medical groups (33 vs. 25 mm2, P = 0.006 and 18 vs 19 %, P = 0.07). Magnetic resonance derived RF was significantly higher in the surgical group (46 vs 32 %) with P < 0.01. A combined model including independent markers such as BNP (cut-off > 31 ng/L), MRI RF (cut-off value > 34 %), 3D VCA (cut-off value 36 mm2) or 2D GLS (cut-off value < 17 %) showed the highest predictive accuracy (P = 0.002) to predict the primary endpoint. (Figure 1). Conclusion A combination of baseline parameters of AR severity (3D VCA, MRI-derived RF) and myocardial impairment (2D GLS, serum BNP level) present an accurate tool for the identification of patients with chronic asymptomatic AR who are at risk of early disease progression. Abstract Figure 1

Three dimensional myocardial deformation parameters are associated with functional capacity in hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Three-dimensional (3D) echocardiography is an emerging tool for assessment of left ventricular function, with a promising role in the evaluation of cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is often associated with reduced exercise capacity. The aim of this study was to evaluate the importance of 3D myocardial deformation parameters as predictors of exercise capacity in HCM patients (P). Methods This prospective study enrolled P with HCM. Each P underwent a comprehensive transthoracic echocardiogram including 3D speckle-tracking to measure global longitudinal, radial and circumferential strain, twist, torsion and global area strain. Functional capacity was objectively assessed by treadmill cardiorespiratory exercise testing. Results 83 patients with HCM, 50 (60%) male, mean left ventricular ejection fraction (LVEF) of 68 ± 7%, 27 (33%) with obstructive HCM (LV outflow tract [LVOT] gradient of 89 ± 60 mmHg). Impairment in LV myocardial deformation parameters was significantly correlated with lower peak VO2: global longitudinal 3D strain (r=-0.397, p < 0.001), global radial 3D strain (r = 0.336, p = 0.003) and global circumferential 3D strain (r=-0.353, p = 0.002) (Figure 1). Impaired LV twist was significantly correlated with inferior peak VO2 (r = 0.264, p = 0.033) (Fig.2) and peak circulatory power (r = 0.371, p = 0.003). Torsion impairment also significantly associated with lower peak VO2 (r = 0.285, p = 0.021), circulatory power (r = 0.380, p = 0.002), time to ventilatory anaerobic threshold (VAT) (r = 0.369, p = 0.003) and (VE/VCO2 slope)/peak VO2 ratio (r=-0.316, p = 0.012). Furthermore, global area strain impairment showed significant relation with decreased peak VO2 (r=-0.368, p = 0.001), lower exercise duration (r=-0.384, p = 0.001), time to VAT (r=-0.404, p < 0.001), circulatory power (r=-0.272, p = 0.032) and (VE/VCO2 slope)/peak VO2 ratio (r = 0.391, p = 0.002). LV twist (r=-0.135, p = 0.284), torsion (r=-0.120, p = 0.341) and global area strain (r = 0.152, p = 0.235) impairment did not correlate with VE/VCO2 slope. Exercise capacity was not associated with LV mass index (r = 0.209, p = 0.095), LV end-diastolic volume (r = 0.058, p = 0.639), maximum wall thickness (r = 0.041, p = 0.744), LVEF (r=-0.092, p = 0.458), 2D global longitudinal strain (r=-0.024, p = 0.848) or peak LVOT gradient (r=-0.006, p = 0.964). In a subanalysis examining only the nonobstructive (nHCM) P, we found that peak VO2 had a superior correlation with global longitudinal 3D strain (r=-0.420, p = 0.004), global radial 3D strain (r = 0.356, p = 0.016) and global circumferential 3D strain (r=-0.357, p = 0.016) as well as LV twist (r = 0.300, p = 0.046) and torsion (r = 0.336, p = 0.024). Conclusion Although P with HCM often have supranormal LVEF, 3D speckle-tracking echocardiographic imaging has the potential to demonstrate subclinical impairment of LV function. Impaired LV 3D strain, twist, torsion and global area strain were associated with reduced exercise capacity, particularly in nHCM P. Abstract Figure. Peak VO2 and 3D strain parameters Abstract Figure. LV twist, torsion and global area strain

Relationship between 3D and 2D global longitudinal strain in patients with acute myocardial infarction after percutaneous revascularization

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): This research was funded by “Iuliu Haţieganu” University of Medicine and Pharmacy, Dept. of Cardiology, Cluj-Napoca, Romania. This paper was published under the frame of European Social Found, Human Capital Operational Programme 2014-2020, project no. POCU/380/6/13/125171 Introduction Impaired longitudinal strain (GLS) is associated with increased wall stress following acute myocardial infarction (MI). However, little is known about the relationship between three-dimensional (3D)-GLS and two-dimensional (2D)-GLS. The aim of this study was to evaluate the relationship between 3D-GLS and 2D-GLS and also the association of 3D-GLS with specific biomarkers (NT-proBNP and Troponin) in patients with acute MI following percutaneous revascularization (PCI). Methods We included 100 patients with acute MI after successful PCI with a left ventricular ejection fraction (LVEF) >40%. 2D-GLS and 3D-GLS were assessed using speckle-tracking echocardiography and plasma concentrations of NT-proBNP and high sensitive troponin were analyzed. Results The patients had a mean age of 67.1 ± 13.1 years. 69 patients were diagnosed with ST-elevation MI (STEMI). Mean 3D-GLS was of -9.44 ± 4.35% and mean 2D-GLSwas of -10.1 ± 3.9%. 3D-GLS showed a strong correlation with 2D-GLS (r=-0.57, p < 0.001) and LVEF (r=-0.58,p < 0.001), a moderate correlation with NT-proBNP (r = 0.22), but no correlation with Troponin (r = 0.19). There was no difference (paired t-test) between 3D-GLS and 2D-GLS (p = 0.56, mean of differences of 0.65), but the limits of agreement were wide (-6.8% and 8.11%). Conclusion 3D-GLS showed small bias compared to 2D-GLS, but wide limits of agreement. The correlation between 3D-GLS and NT-proBNP was only moderate in acute MI. 3D-GLS might offer additional advantages in patients with complex geometry after acute MI due to faster data acquisition and lack of geometric assumption,but future studies are needed to confirm its role. Abstract Figure. Relationship between 3D and 2D GLS Abstract Figure. Corresponding Bland-Altman plots

Echocardiographic assessment of ventricular function in chronic HCV patients receiving direct antiviral therapy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Hepatitis C virus (HCV) infection is still a major public health burden in many parts of the world (1). Globally, an estimated 58 million people have chronic hepatitis C virus infection, with about 1.5 million new infections occurring per year (2). Treatment for chronic HCV infection has evolved from interferon (IFN)-based therapy to direct-acting antivirals (DAAs) (3,4). With the development of DAA, treatment of HCV became better-tolerated and highly effective (5,6). Several studies have attempted to explore their cardiac side effects, especially their impact of left ventricular (LV) function; however, these studies were limited by their design and the methods of assessment (7-10). Aim In this prospective study we aimed at evaluating the short effects of DAAs on left ventricular functions using 3D Echocardiography. Methods Patients with HCV infection planned to receive combination therapy of Sofosbuvir 400 mg daily plus Daclatasvir 60 mg daily for 12 weeks were assessed by echocardiography before starting and after 3 months after completion of treatment. Patients with other systemic or cardiac conditions or structural heart disease were excluded. Assessment of LV volume and EF was performed by 3D quantification and global longitudinal strain (GLS). Right ventricle size was assessed by 2D and systolic function was evaluated by TAPSE, S` and FAC. Results In 102 patients who were followed up at 3 months after DAA therapy, We found an increase in increase in both LV end diastolic dimensions and volumes (p∼0.02 & p∼0.045 respectively) as well as end systolic volumes (p∼0.005). There was no significant difference in neither LV systolic function as assessed by EF and GLS (62.25 ± 5.15 vs. 62.35 ± 5.77, p∼0.850, -22.97 ± 2.93 vs. -22.83 ± 2.59, p∼0.546 respectively), nor in diastolic function (p∼0.546). However, subgroup analyses revealed a significant negative correlation between age and GLS (P∼0.022) as well as the number of cardiovascular risk factors (P∼0.039). Hypertension was found to be the only predictor of the decrease in GLS in the regression analysis of risk factors (p∼0.001). There was no significant change in RV size and systolic function at follow up. Conclusions There was no significant change in LV systolic or diastolic function before and after DAA therapy as measured by EF and GLS. Nonetheless, subgroup analysis suggests a drop in GLS in older patients and those with more cardiovascular risk factors. An increase in LV size was also noted while no significant effect was noted with regards to RV size and function.

Comprehensive evaluation of left ventricular deformation using speckle tracking echocardiography in normal children: comparison of three-dimensional and two-dimensional approaches

BackgroundThree-dimensional (3D) speckle tracking echocardiography (STE) can overcome some of the inherent limitations of two-dimensional (2D) STE; however, clinical experience is lacking. We aimed to assess and compare the feasibility, agreement, and reproducibility of left ventricular (LV) global longitudinal (GLS), and regional strain by 3D vs 2D STE in normal children.MethodsHealthy pediatric subjects (n = 105, age mean = 11.2 ± 5.5 years) were prospectively enrolled. Three-dimensional and 2D LV GLS, as well as regional strain in 16 myocardial segments were quantified. Bland Altman analysis, intra- class correlation coefficients (ICC), percent error and linear regression were used for agreement and correlation between the two techniques. Analysis and acquisition times were compared. Inter- and intra-observer reproducibility was assessed in 20 studies.ResultsThere was good to excellent agreement for 2D and 3D global longitudinal strain (ICC =0.82) and modest agreement for regional strain (ICC range 0.43–0.71). Both methods had high feasibility (88.6% for 2D vs 85.7% for 3D, p = 0.21), although 3D STE required significantly shorter acquisition and analysis time than 2D STE (acquisition time 1 ± 1.2 mins vs 2.4 ± 1 mins; p = 0.03, analysis time = 3.3 ± 1 mins vs 8.2 ± 2.5 mins; p = 0.001, respectively). Inter and intra-observer reproducibility was excellent for GLS by the two techniques (ICC = 0.78–0.93) but moderate to poor for regional strain (ICC = 0.21–0.64).ConclusionThree-dimensional global LV strain is as feasible and reproducible as 2D strain, with good agreement yet significantly more efficient acquisition and analysis. Regional strain is less concordant and 2D and 3D values should not be used interchangeably. 3D LV GLS may represent a viable alternative in evaluation of LV deformation in pediatric subjects.

Frequent Constriction-Like Echocardiographic Findings in Elite Athletes Following Mild COVID-19: A Propensity Score-Matched Analysis.

Background: The cardiovascular effects of SARS-CoV-2 in elite athletes are still a matter of debate. Accordingly, we sought to perform a comprehensive echocardiographic characterization of post-COVID athletes by comparing them to a non-COVID athlete cohort.Methods: 107 elite athletes with COVID-19 were prospectively enrolled (P-CA; 23 ± 6 years, 23% female) 107 healthy athletes were selected as a control group using propensity score matching (N-CA). All athletes underwent 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall vs. septal longitudinal strain (FWLS/SLS) were also measured. To describe septal flattening (SF—frequently seen in P-CA), LV eccentricity index (EI) was calculated.Results: P-CA and N-CA athletes had comparable LV and RVEDVi (P-CA vs. N-CA; 77 ± 12 vs. 78 ± 13mL/m2; 79 ± 16 vs. 80 ± 14mL/m2). P-CA had significantly higher LVEF (58 ± 4 vs. 56 ± 4%, p < 0.001), while LVGLS values did not differ between P-CA and N-CA (−19.0 ± 1.9 vs. −18.8 ± 2.2%). EI was significantly higher in P-CA (1.13 ± 0.16 vs. 1.01 ± 0.05, p < 0.001), which was attributable to a distinct subgroup of P-CA with a prominent SF (n = 35, 33%), further provoked by inspiration. In this subgroup, the EI was markedly higher compared to the rest of the P-CA (1.29 ± 0.15 vs. 1.04 ± 0.08, p < 0.001), LVEDVi was also significantly higher (80 ± 14 vs. 75 ± 11 mL/m2, p < 0.001), while RVEDVi did not differ (82 ± 16 vs. 78 ± 15mL/m2). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (91.7 ± 8.6 vs. 97.3 ± 8.2, p < 0.01). P-CA with SF experienced symptoms less frequently (1.4 ± 1.3 vs. 2.1 ± 1.5 symptom during the infection, p = 0.01).Conclusions: Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis.

Three-Dimensional Myocardial Strain for the Prediction of Clinical Events in Patients With ST-Segment Elevation Myocardial Infarction.

BACKGROUNDTwo-dimensional (2D) strain provides more predictive power than ejection fraction (EF) in patients with ST-elevation myocardial infarction (STEMI). 3D strain and EF are also expected to have better clinical usefulness and overcome several inherent limitations of 2D strain. We aimed to clarify the prognostic significance of 3D strain analysis in patients with STEMI.METHODSPatients who underwent successful revascularization for STEMI were retrospectively recruited. In addition to conventional parameters, 3D EF, global longitudinal strain (GLS), global area strain (GAS), as well as 2D GLS were obtained. We constructed a composite outcome consisting of all-cause death or re-hospitalization for acute heart failure or ventricular arrhythmia.RESULTSOf 632 STEMI patients, 545 patients (86.2%) had a reliable 3D strain analysis. During median follow-up of 49.5 months, 55 (10.1%) patients experienced the adverse outcome. Left ventricle EF, 2D GLS, 3D EF, 3D GLS, and 3D GAS were significantly associated with poor outcomes. (all, p < 0.001) The maximum likelihood-ratio test was performed to evaluate the additional prognostic value of 2D GLS or 3D GLS over the prognostic model consisting of clinical characteristics and EF, and the likelihood ratio was 15.9 for 2D GLS (p < 0.001) and 1.49 for 3D GLS (p = 0.22).CONCLUSIONSThe predictive power of 3D strain was slightly lower than the 2D strain. Although we can obtain 3D strains, volume, and EF simultaneously in same cycle, the clinical implications of 3D strains in STEMI need to be investigated further.

Subclinical LV and RV Dysfunction in Patients Recovered From COVID-19

Cardiac injury is reported acutely in hospitalised COVID-19 patients, however sustained impairment in recovered patients is unclear. We evaluated cardiac involvement in patients who had recovered from acute COVID-19 infection but had ongoing symptoms, using echocardiography (TTE). Forty-two patients with recovered COVID-19 were followed up at a median time from infection of 112 [109] days and were compared to age and gender-matched healthy controls. Traditional TTE parameters left ventricular (LV), 2D global longitudinal strain (GLS), and right ventricular (RV) free wall strain were measured. Among COVID patients, 10 (23.8%) were hypertensive, 6 (14.3%) diabetic, 2 (4.8%) had atrial fibrillation and 1 (2.4%) a history of IHD. LV wall thickness was significantly higher in the COVID-19 group (Table). LV volumes and LVEF were similar to controls; however, LV GLS was significantly worse in the COVID-19 cohort (p=0.002, Table). Similarly, RV volumes and traditional function parameters (FAC, TAPSE, S’ velocity) were similar, but RV free wall strain (RVFWS, p=0.009) and RV global strain (p=0.015) were reduced. On univariant analysis, COVID-19 infection, sex, admission to ICU, LV volume and mass and RV area were associated with LV GLS. On multivariant analysis, COVID-19 infection was the only independent determinant of LV GLS (β=0.269, p=0.008). Prior COVID-19 infection was the only independent determinant of reduced LV GLS, suggesting persisting subclinical cardiac injury even in recovered patients with ongoing symptoms.Tabled 1ParametersControlsCOVID-19p valuePW ED (mm)8.12±1.648.76±1.560.029IVS ED (mm)8.17±1.829.17±1.890.002LVEDVI (ml/m2)47.10±10.8946.70±17.280.867LVESVI (ml/m2)19.25±5.1418.91±9.210.782LVEF (%)59.40±5.2760.19±5.430.427LV GLS (%)-19.86±1.90-18.33±2.430.002TAPSE (mm)22.41±3.7721.48±4.650.300RVS' (cm/s)11.51±1.6011.93±2.090.359RV FAC (%)40.81±6.7039.79±7.980.352RVFWS (%)-27.32±4.56-24.05±5.890.009 Open table in a new tab

Comparative analysis of myocardial deformation in patients recovered from mild SARS-CoV-2 infection

During acute infection by the SARS-CoV-2 virus, myocardial involvement has been demonstrated; it is unknown if cardiovascular sequelae in patients recovered from this infection and if these are associated with global morbidity and mortality. The objective of this study was to compare myocardial deformation in patients recovered from mild SARS-CoV-2 virus infection with healthy controls. This was a cross-sectional observational study that included 33 subjects recovered from mild SARS-CoV-2 infection, who were diagnosed in the previous three to six months, and 31 healthy volunteers, both groups free of cardiovascular risk factors. The study of myocardial deformation was performed using echocardiography with the speckle tracking modality. Clinical and anthropometric variables were compared. The 2D global longitudinal strain of the left ventricle was lower in the subjects recovered from mild SARS-CoV-2 infection than the controls (-20.2% ± 2.6 v -21.6% ± 2.4; p: 0.036). Both groups presented differences in the three ventricular levels, significant at the apical level (-21.2 ± 4.0 vs -23.4% ± 4.2; p: 0.044). The effect by levels shows an inverse Takotsubo pattern. The left ventricular ejection fraction was preserved in both groups (p: 0.153). Left ventricular myocardial deformation is affected in subjects recovered from mild SARS-CoV-2 infection, while the ejection fraction was found in normal ranges. Our study shows a potential role of global longitudinal strain in the detection of subclinical myocardial alterations in patients who had SARS-CoV-2.

Reference Ranges of Left Ventricular Hemodynamic Forces in Healthy Adults: A Speckle-Tracking Echocardiographic Study.

Background: The normal limits of left ventricular (LV) hemodynamic forces (HDFs) are not exactly known. The aim of this study was to explore the full spectrum of HDF parameters in healthy subjects and determine their physiologic correlates. Methods: 269 healthy subjects were enrolled (mean age: 43 ± 14 years; 123 (45.7%) men). All participants underwent an echo-Doppler examination. Tri-plane tissue tracking from apical views was used to measure 2D global endocardial longitudinal strain (GLS), circumferential strain (GCS), and LV HDFs. HDFs were normalized with LV volume and divided by specific weight. Results: LV systolic longitudinal HDFs (%) were higher in men (20.8 ± 6.5 vs. 18.9 ± 5.6, p = 0.009; 22.0 ± 6.7 vs. 19.8 ± 5.6, p = 0.004, respectively). There was a significant correlation between GCS (increased) (r = −0.240, p < 0.001) and LV longitudinal HDFs (reduced) (r = −0.155, p = 0.01) with age. In a multivariable analysis age, BSA, pulse pressure, heart rate and GCS were the only independent variables associated with LV HDFs (β coefficient = −0.232, p < 0.001; 0.149, p = 0.003; 0.186, p < 0.001; 0.396, p < 0.001; −0.328, p < 0.001; respectively). Conclusion: We report on the physiologic range of LV HDFs. Knowledge of reference values of HDFs may prompt their implementation into clinical routine and allow a more comprehensive assessment of the LV function.

652 Myocardial work in patients undergoing transcatheter aortic valve implantation: clinical value and implications for outcome

Abstract Aims Non-invasive myocardial work (MW) quantification has emerged in the last years as an alternative echocardiographic tool for myocardial function assessment. This new parameter provides a less loading-dependent evaluation of myocardial performance through the combined assessment of global longitudinal strain (GLS) and non-invasive left ventricle (LV) pressures. The role of MW as a marker of cardiac dysfunction and reverse remodelling in patients with severe aortic stenosis (AS) after aortic valve implantation (TAVI) has not been adequately investigated. This study aims to evaluate MW indices as early echocardiographic markers of LV reverse remodelling within a month after TAVI and their prognostic value. Methods and results We conducted a single-centre prospective study, enrolling 70 consecutive patients (mean age 80.1 ± 5.5 years) with severe AS undergoing TAVI between 2018 and 2020, selected from the EffecTAVI registry. Exclusion criteria were prior valve surgery, severe mitral stenosis, permanent atrial fibrillation, left bundle branch block (LBBB) at baseline, and suboptimal quality of speckle-tracking image analysis. Echocardiographic assessment was performed before TAVI and at 30-day follow-up. Clinical, demographic, and resting echocardiographic data were recorded, including quantification of 2D global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). LV peak systolic pressure was estimated non-invasively from the sum of systolic blood pressure and trans-aortic mean gradient. One month after the procedure, there was a significant improvement of LV GLS (−17.94 ± 4.24% vs. −19.35 ± 4.31%, before and after TAVI respectively, P = 0.002), as well as a significant reduction of GWI (2430 ± 586 mmHg% vs. 1908 ± 472 mmHg%, P &amp;lt; 0.001), GCW (2828 ± 626 mmHg% vs. 2206 ± 482 mmHg%, P &amp;lt; 0.001), and GWW (238 ± 207 mmHg% vs. 171 ± 118 mmHg%, P = 0.006). Conversely, MWE did not significantly change early after intervention (90.53 ± 6.05% vs. 91.45 ± 5.05%, P = 0.204). After TAVI, 30 patients (42.8%) developed LV dyssynchrony due to LBBB or pacemaker implantation. When the population was divided according to the presence or absence of LV dyssynchrony at 30-day follow-up, a significant reduction in GWW was found only in those without dyssynchrony (244 ± 241 vs. 141 ± 110 mmHg% with and without dyssynchrony respectively, P = 0.002). Consistently, in this subgroup, MWE significantly improved post-TAVI (90 ± 7 vs. 93 ± 5%, P = 0.002), while a trend of MWE reduction was observed in patients who developed dyssynchrony post-TAVI (91 ± 4 vs. 89 ± 5%, P = 0.164). In the overall population, a baseline value of MWE&amp;lt; 92% was associated with an increased rate of cardiovascular events (composite of all-cause death and rehospitalization for heart failure) at 1-year follow-up (22.2 vs. 3.1%, long rank, P = 0.016). Conclusions In patients with severe AS undergoing TAVI a significant reduction of GWW and improvement of MWE can be detected only in those who did not develop LV dyssynchrony. In this setting, MWE lower than 92% at baseline is associated with poor outcome. Thus, MWE could represent an alternative tool for myocardial function assessment in patients receiving TAVI.

Prognosis in patients with coronary heart disease and breath-holding limitations: a free-breathing cardiac magnetic resonance protocol at 3.0\xa0T

Background and purposeConventional cardiac magnetic resonance (CCMR) imaging is usually performed with breath-holding (BH), which is adverse in patients with BH limitations. We explored the ability of a free-breathing CMR (fCMR) protocol to prognosticate in patients with coronary heart diseases (CHD) and limited BH ability.MethodsSixty-seven patients with CHD and limited BH abilities were prospectively enrolled in this study. All patients underwent comprehensive fCMR imaging at 3.0 T. The fCMR protocols included compressed sensing (CS) single-shot cine acceleration imaging, and motion-corrected (MOCO), single-shot late gadolinium enhancement (LGE) imaging. Image quality (IQ) of the cine and LGE images was evaluated based on the 5-point Likert scale. The value of fMRI in providing a prognosis in patients with CHD was assessed. Statistical methods included the T test, Mann–Whitney test, Kappa test, Kaplan–Meier curve, Log-rank test, Cox proportional hazard regression analysis, and receiver operating characteristic curves.ResultsAll IQ scores of the short axis CS-cine and both the short and long axes MOCO LGE images were ≥ 3 points. Over a median follow-up of 31 months (range 3.8–38.2), 25 major adverse cardiovascular events (MACE) occurred. In the univariate analysis, infarction size (IS), left ventricular ejection fraction (LVEF), 3D-Global peak longitudinal strain (3D-GPLS), heart failure classification were significantly associated with MACE. When the significantly univariate MACE predictors, added to the multivariate analysis, which showed IS (HR 1.02; 95% CI 1.00–1.05; p = 0.048) and heart failure with preserved EF (HR 0.20; 95% CI 0.04–0.98; p = 0.048) correlated positively with MACE. The optimal cutoff value for LVEF, 3D-GPLS, and IS in predicting MACE was 34.2%, − 5.7%, and 26.1% respectively, with a sensitivity of 90.5%, 64%, and 96.0% and specificity of 72%, 95.2%, and 85.7% respectively.ConclusionsThe fCMR protocol can be used to make prognostic assessments in patients with CHD and BH limitations by calculating IS and LVEF.

3D Echocardiography - A Useful Method for Cardiovascular Risk Assessment in End-Stage Renal Disease Patients.

Patients with chronic kidney disease (CKD) have an increased risk of premature mortality, mainly due to cardiovascular causes. The association between hemodialysis and accelerated atherosclerosis has long been described. The ankle-brachial index (ABI) is a surrogate marker of atherosclerosis and recent studies indicate its utility as a predictor of future cardiovascular disease and all-cause mortality. The clinical implications of ABI cut-points are not well defined in patients with CKD. Echocardiography is the most widely used imaging method for cardiac evaluation. Structural and functional myocardial abnormalities are common in patients with CKD due to pressure and volume overload as well as non-hemodynamic factors associated with CKD. Our study aimed to identify markers of subclinical cardiovascular risk assessed using ABI and 2D and 3D echocardiographic parameters evaluating left ventricular (LV) structure and function in patients with end-stage renal disease (ESRD) (patients undergoing dialysis), patients after kidney transplantation and non-ESRD patients (control). In ESRD, particularly in hemodialysis patients, changes in cardiac structure, rather than function, seems to be more pronounced. 3D echocardiography appears to be more sensitive than 2D echocardiography in the assessment of myocardial structure and function in CKD patients. Particularly 3D derived end-diastolic volume and 3D derived LV mass indexed for body surface appears to deteriorate in dialyzed and transplanted patients. In 2D echocardiography, myocardial mass represented by left ventricular mass/body surface area index (LVMI) appears to be a more sensitive marker of cardiac structural changes, compared to relative wall thickness (RWT), left ventricle and diastolic diameter index (LVEDDI) and left atrial volume index (LAVI). We observed a generally favorable impact of kidney transplantation on cardiac structure and function; however, the differences were non-significant. The improvement seems to be more pronounced in cardiac function parameters, peak early diastolic velocity/average peak early diastolic velocity of mitral valve annulus (E/e´), 3D left ventricle ejection fraction (LV EF) and global longitudinal strain (GLS). We conclude that ABI is not an appropriate screening test to determine the cardiovascular risk in patients with ESRD.

The Echocardiographic Parameters of Systolic Function Are Associated with Specific Metabolomic Fingerprints in Obstructive and Non-Obstructive Hypertrophic Cardiomyopathy.

The purpose of this study was to assess whether metabolomics, associated with echocardiography, was able to highlight pathophysiological differences between obstructive (OHCM) or non-obstructive (NOHCM) hypertrophic cardiomyopathy. Thirty-one HCM patients underwent standard and advanced echocardiography; a plasma sample was collected for metabolomic analysis. Results. Patients with OHCM compared with subjects with NOHCM had higher values of 2DLVEF (66.5 ± 3.3% vs. 60.6 ± 1.8%, p < 0.01), S wave (7.6 ± 1.1 vs. 6.3 ± 0.7 cm/s, p < 0.01) and 3D global longitudinal strain (17.2 ± 4.2%, vs. 13.4 ± 1.3%, p < 0.05). A 2-group PLS-Discriminant Analysis was performed to verify whether the two HCM groups differed also based on the metabolic fingerprint. A clear clustering was shown (ANOVA p = 0.014). The most discriminating metabolites resulted as follows: in the NOHCM Group, there were higher levels of threitol, aminomalonic acid, and sucrose, while the OHCM Group presented higher levels of amino acids, in particular those branched chains, of intermediates of glycolysis (lactate) and the Krebs cycle (fumarate, succinate, citrate), of fatty acids (arachidonic acid, palmitoleic acid), of ketone bodies (2-OH-butyrate). Our data point out a different systolic function related to a specific metabolic activity in the two HCM phenotypic forms, with specific metabolites associated with better contractility in OHCM.

Abstract 11363: Pericardial Constriction-Like Echocardiographic Findings in Elite Athletes Following Mild Covid-19 Infection: A Propensity Score-Matched Analysis

Introduction: The cardiovascular effects of COVID-19 in elite athletes is still a matter of intense scientific debate. Hypothesis: We sought to perform a comprehensive echocardiographic characterization of post-COVID athletes by comparing them to a non-COVID athlete cohort. Methods: 107 elite athletes with COVID-19 were prospectively enrolled (P-CA; 23±6 years, 23% female) 107 healthy athletes were selected as a control group using propensity score matching (N-CA). All athletes underwent 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also measured. To describe septal flattening (SF - frequently seen in P-CA), LV eccentricity index (EI) was calculated. Results: P-CA and N-CA athletes had comparable LV and RVEDVi (P-CA vs N-CA; 77±12 vs. 78±13mL/m2; 79±16 vs 80±14mL/m2). P-CA had significantly higher LVEF (58±4 vs 56±4%, p&lt;0.001), while LVGLS values did not differ between P-CA and N-CA (-19.0±1.9 vs -18.8±2.2%). EI was significantly higher in P-CA (1.13±0.16 vs 1.01±0.05, p&lt;0.001), which was attributable to a distinct subgroup of P-CA with a prominent SF (n=35, 33%), further provoked by inspiration. In this subgroup, the EI was markedly higher compared to the rest of the P-CA (1.29±0.15 vs 1.04±0.08, p&lt;0.001), LVEDVi was also significantly higher (80±14 vs 75±11 mL/m2, p&lt;0.001), while RVEDVi did not differ (82±16 vs 78±15mL/m2). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (91.7±8.6 vs 97.3±8.2, p&lt;0.01). P-CA with SF experienced symptoms less frequently (1.4±1.3 vs. 2.1±1.5 symptom during the infection, p=0.01). Conclusions: COVID-19 infection might be frequently associated with a constriction-like physiology in elite athletes.

Prognostic role of global longitudinal strain by feature tracking in patients with hypertrophic cardiomyopathy: The STRAIN-HCM study

BackgroundThe assessment of myocardial fiber deformation with cardiac magnetic resonance feature tracking (CMR-FT) has shown to be promising in terms of prognostic information in several structural heart diseases. However, little is known about its role in hypertrophic cardiomyopathy (HCM). Aims of the present study were: 1) to assess the prognostic role of CMR-FT derived strain parameters in patients with HCM. MethodsCMR was performed in 130 consecutive HCM patients (93 males, mean age (54 ± 17 years) with an estimated 5-year risk of sudden cardiac death (SCD) <6% according to the HCM Risk-SCD calculator. 2D- and 3D-Global Radial (GRS), Longitudinal (GLS) and Circumferential (GCS) Strain was evaluated by FT analysis. The primary outcome of the study was a composite of major adverse cardiac events (MACE) including SCD, resuscitated cardiac arrest due to ventricular fibrillation (VF) or hemodynamically unstable ventricular tachycardia (VT), and hospitalization for heart failure. ResultsAfter a median follow-up of 51.7 (37.1–68.8) months, 4 (3%) patients died (all of them suffered from SCD) and 36 (28%) were hospitalized for heart failure. After multivariable adjustment for clinical and imaging covariates, among all strain parameters, only GLS remained a significant independent predictor of outcome events in both the model including 2D strain (HR 1.12, 95% CI 1.03–1.23, p = 0.01) and the model including 3D strain (HR 1.14, 95% CI 1.01–1.30, p = 0.04). The addition of 2D-GLS into the model with clinical and imaging predictors resulted in a significant increase in the C-statistic (from 0.48 to 0.65, p = 0.03). ConclusionCMR-FT derived GLS is a powerful independent predictor of MACE in patients with HCM, incremental to common clinical and CMR risk factors including left ventricular ejection fraction and late gadolinium enhancement.

Frequent constriction-like echocardiographic findings in elite athletes following mild COVID-19: in the grasp of SARS-CoV-2?

The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (N-CA) cohort.One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF – frequently seen in P-CA), LV eccentricity index (EI) was measured.P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs N-CA; 77±12 vs 78±13mL/m2; 79±16 vs 80±14mL/m2, respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p<0.001) and GLS (−18.2±1.8 vs −17.6±2.2%, p<0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p<0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p<0.001).In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m2, p<0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m2). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p<0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p<0.05) or chest pain (0 vs 15%, p=N/A) less frequently during the course of the infection; however, the presence of a mild pericardial effusion was more common (41 vs 12%, p<0.01).Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings.Funding AcknowledgementType of funding sources: None. Post-Covid athlete with SF

3D global longitudinal strain is the best predictor of late cardiotoxicity in non-Hodgkin's lymphoma

Abstract RCHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) in non-Hodgkin's lymphoma (NHL) has a high risk of cardiotoxicity, with increased morbidity and mortality. Aim To define new parameters, such as 3D LV deformation, arterial stiffness and biomarkers able to detect late cardiotoxicity. Methods 54 patients (26 men, 57±10 years) with NHL, scheduled to receive RCHOP, with LVEF&amp;gt;50%, were assessed at baseline, after the 4th cycle of RCHOP and 2 years after completion of therapy. Assessment included 3D echocardiography for LV EF and deformation - longitudinal, radial, circumferential, area strain (LS, RS, CS, AS), Arteriograph for pulse wave velocity (PWV) and biomarkers (troponin I, NT-pro-BNP). Cardiotoxicity was defined as a decrease of LVEF &amp;lt;50%, with &amp;gt;10% from the baseline value. Results 11 patients (group I) developed cardiotoxicity, while 43 patients did not (group II) (LVEF decreased from 59±3 to 56±2 vs 58±3 to 47±2, p&amp;lt;0.0001). From baseline to 2 years there was a significant reduction of LS, CS and AS, and an increase of arterial stiffness and troponin I; however, changes were greater in group I vs group II (p=0.001) (see table). Even if NT-pro-BNP increased from baseline to 2 years, no significant changes were found between group I and II. Decrease of 3D LVEF correlated with changes of LS, AS, PWV, and troponin (r=0.64, r=0.42, r=−0.37 and r=−0.29, p&amp;lt;0.05). LS reduction after the 4th cycle was the best independent predictor for LVEF decrease after 2 years from therapy completion (R2=0.43, p=0.001); thus, decrease of LS with more than 26% after the 4th RCHOP cycle predicted late cardiotoxicity, after 2 years, with a sensitivity of 87% and specificity of 71% (AUC=0.867). Conclusion Assessment of 3D myocardial deformation, arterial stiffness and biomarkers is able to detect late cardiovascular toxicity, and to predict further decline of LVEF in patients with NHL. LS is the best independent predictor for late cardiotoxicity. Funding Acknowledgement Type of funding sources: None. 123 Cardiovascular toxicity parameters

3D-Speckle Tracking Echocardiography for Assessment of Coronary Artery Disease Severity in Stable Angina Pectoris

Background: Stable angina pectoris is a common disease that may cause disability. Echocardiography is the leading and feasible cardiac imaging in patients with cardiac disease. An early evaluation of patients with complex coronary lesions plays an important role in the prognosis and selection of treatment strategy. Objective: To evaluate the feasibility and accuracy of 3D-speckle tracking echocardiography in assessment of coronary artery disease severity in stable angina pectoris. Patients and methods: The study was across sectional study include 90 patients with chronic coronary syndrome(stable angina) come to Islamic cardiac center at Al-Azhar University for coronary angiography on clinical basis indications between period from April 2019 to May 2020.The patients were classified into two groups after according to the results of coronary angiography. Group (I): Case group include 60 patients with different coronary lesions in angiography, and Group (II): control group include 30 patients with normal coronary angiography. The group (I) subsequently divided into two subclasses after coronary angiography according to the Gensini score. Group (IA) non-critical stenosis ( 0-19) , group (IB) critical stenosis (≥ 20). Results: There was no statistically significant difference between patients and control groups as regard demographic data and risk factors( age , gender, diabetes mellitus, hypertension, smoking ,family history and dyslipidemia) .There was no statistically significant difference between group (I) &group(II) as regard their Echo parameters left atrial diameter ( LAD) , left ventricular end diastolic diameter (LV EDD), left ventricular end systolic diameter (LV ESD) , left ventricular end systolic volume (LV ESV )and left ventricular ejection fraction (LV EF%) . There was statistically significant decrease in group(I) compared to group(II) as regard their 3D speckle parameters global longitudinal strain ( GLS%)( -12.35% ± 2.7% versus -20.2% ±1.19%) , global circumferential strain( GCS%)(-19.23% ± 4.18% versus -26.57% ± 1.3%), global radial strain (GRS% )(23.48 ± 3.32% versus 53.67% ± 2.99%) and global area strain (GAS%)(-23.98% ± 4.14% versus -31.93 ± 1.28%) . Also there was significant decrease in critical stenosis group (IB) as regard 3D speckle parameters in comparison with non-critical stenosis group (IA). Conclusion: 3D-STE is a noninvasive and handy parameter that has the potential to improve the value of echocardiography in the detection of the coronary artery disease (CAD) and to provide more information for clinical physicians. It could be expected to identify severe coronary stenosis in chronic coronary syndrome (CCS) patients even when resting wall motion and left ventricular ejection fraction were normal. It shows good sensitivity and specificity with best values for global area strain (GAS).