3D LVEF Research Articles

Mechanical dyssynchrony in patients with chronic heart failure and left bundle branch block

Background. The main problem in patient selection for cardiac resynchronization therapy (CRT) is the lack of unified approaches to the definition of mechanical dyssynchrony (MD) and selection criteria, particularly, in patients with left bundle branch block (LBBB).Aim: To study mechanical dyssynchrony indices and three-dimensional Echo (3DE) criteria of global and local contractility function in patients with chronic heart failure (CHF) and LBBB during different types of isolated left ventricle (LV) pacing.Methodology and Research Methods. The experimental intraoperative study involved 88 points obtained from 12 patients with CRT class IA indications and LBBB. During isolated LV pacing as part of CRT implantation procedure endocardial and epicardial pacing were obtained. Transesophageal Echo (TEE) cineloops recording and paced QRS complex morphology registrations by means of LabSystem Pro Electrophysiological Recording System (Bard Electrophysiology, USA) were performed during each stimulation episode. Philips Qlab 10 software was used for TEE data analysis.Results. The global (3D EF, 23.8 [22; 28.4], GLS, –5.33% [10.90%; –15.4%]) and local contractility (ExсAvg 3.5 [2.1; 5.6]) criteria and dyssyncrony indices (SDI-16, 14.9 [8.9; 23.1]) showed severe systolic dysfunction and intraventricular dyssynchrony – typical signs in this patient group, and differed significantly (3D EF, p = 0.003; GLS, p = 0.004; ExcAvg, p < 0.001; Tmsv-6 SD, р = 0.03) depending on the stimulation method and site. A moderate direct correlation between SDI-16 and the QRS duration (common electical dyssynchrony criterium) and inverse correlation with ExcAvg and 3D LVEF also describes LV response.

Relationship between the right ventricular function and MECKI score in patients with advanced heart failure

Abstract Background Three- dimensional echocardiography (3DE) is an attractive technique for assessment of RV wrapping around the conical left ventricle and MECKI score is a strong predictor of prognosis in patients with advanced heart failure. Purpose We aimed to evaluate the relationship between the right ventricular function obtained by 3DE and MECKI Score in patients with advanced heart failure. Methods The Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score was calculated by an online free calculator using parameters peak oxygen uptake (% predicted value) and VE/CO2 slope values obtained by CPET, blood samples such as hemoglobin, sodium, MDRD and left ventricular ejection fraction (LVEF).(1) Results The 43 patients with sinus rhythm who were candidates for heart transplantation or left ventricular assist device (LVAD) therapy between June 2022 and January 2023 were included in the study. The majority of the patients were male (% 81). The mean 3D LV EF was % 22 ± 3.8, the mean value for peak VO2 max obtained by CPET was 15 ± 5.8 ml/kg/min and the median value for VE/CO2 slope was 34 (24-99). When the right ventricular parameters were compared according to the median value of 34, the right ventricle was larger and parameters of the right ventricular systolic function were worse in patients with the higher VE/CO2 slope values. (Figure 1). The mean value for percentage of predicted peak VO2 max was % 52 ± 16 and the median for the MECKI Score was 9.3 (1.8-86). By univariate and multivariate regression analyses, only the 3D RV basal diameter was found independently associated with peak VO2 max. Also, the VECO2 slope was found independently associated only with 3D RV TAPSE. Also these two parameters, 3D RV basal diameter and 3D RV TAPSE were found independent predictors of MECKI score. In ROC analysis, the cut off value 40.9 mm for 3D RV basal diameter to predict MECKI score with sensitivity and specificity were % 90 and % 68 , respectively (AUC:0.792). Also, AUC was 0.784 for the cut off value of 7.7 mm for 3D RV TAPSE with the sensitivity % 90 and specificity % 81. (Figure 2). Conclusion The major findings in this study were RV basal diameter was an independent predictor of the peak VO2 max value and RV 3D TAPSE was an independent predictor of the VECO2 slope. These results suggest that, while the basal diameter of the right ventricle, in other words, the size of the right ventricle effects peak oxygen consumption, the O2 transport and utilization, 3D TAPSE, namely systolic function of the right ventricle effects the ability to remove C02 from the whole body. Also these two parameters were found independent predictors of the MECKI score which is a strong predictor of prognosis in patients with advanced heart failure.Figure 1Figure 2

Abstract 11685: Effects of Pectus Excavatum Surgical Repair on Cardiac Volumes and Systolic Function as Assessed by 3D Transesophageal Echocardiography

Introduction: The consequences of external cardiovascular compression and cardiac displacement from pectus excavatum (PEx) are debated. The complex geometry of the right (RV) and left ventricle (LV) along with distortion from the extrinsic chest deformity pose significant limitations to reliable assessment of LV and RV volumes and function using transthoracic 2D-echocardiography in this population. Hypothesis: A 3D-echocardiography approach can reliably assess the effects of external cardiac compression and the benefits of surgical correction on RV and LV function in PEx patients. Methods: Adult patients undergoing minimally invasive repair of PEx between Oct-2021 and Feb-2023 were included in this prospective study. Intraoperative transesophageal (TEE) 6 beat full volume video loops incorporating LV and RV were captured and compared before and after surgical correction of the PEx. TomTec Software® was used for offline 3D/4D reconstruction ( Figure 1 shows changes in 3D RV and LV shape pre- and post-surgery). Result: The study included 102 patients (mean age of 32.1 ±11.8 years; Haller index 4.9 ±2.5; 60.8% males). Post PEx repair, there was a significant (p<0.001) increase in the 3D RV volumes, RV ejection fraction (EF), RV stroke volume and RV strain ( Figure 1 ). Additionally, there was a significant improvement in 3D LVEF, 3D LV strain (longitudinal and circumferential), LV twist, and torsion ( Figure 1 ). Conclusion: In this PEx cohort, 3D/4D TEE imaging demonstrated significant increases in RV volumes and in RV and LV systolic function after surgical repair. These findings support the negative cardiovascular consequences of PEx compression and benefits of surgical repair.

Three-dimensional echocardiographic left ventricular strain analysis in Fabry disease: correlation with heart failure severity, myocardial scar, and impact on long-term prognosis.

Fabry disease (FD) is a multisystemic lysosomal storage disorder caused by a defect in the alpha-galactosidase A gene that manifests as a phenocopy of hypertrophic cardiomyopathy. We assessed the echocardiographic 3D left ventricular (LV) strain of patients with FD in relation to heart failure severity using natriuretic peptides, the presence of a cardiovascular magnetic resonance (CMR) late gadolinium enhancement scar, and long-term prognosis. 3D echocardiography was feasible in 75/99 patients with FD [aged 47 ± 14 years, 44% males, LV ejection fraction (EF) 65 ± 6% and 51% with hypertrophy or concentric remodelling of the LV]. Long-term prognosis (death, heart failure decompensation, or cardiovascular hospitalization) was assessed over a median follow-up of 3.1 years. A stronger correlation was observed for N-terminal pro-brain natriuretic peptide levels with 3D LV global longitudinal strain (GLS, r = -0.49, P < 0.0001) than with 3D LV global circumferential strain (GCS, r = -0.38, P < 0.001) or 3D LVEF (r = -0.25, P = 0.036). Individuals with posterolateral scar on CMR had lower posterolateral 3D circumferential strain (CS; P = 0.009). 3D LV-GLS was associated with long-term prognosis [adjusted hazard ratio 0.85 (confidence interval 0.75-0.95), P = 0.004], while 3D LV-GCS and 3D LVEF were not (P = 0.284 and P = 0.324). 3D LV-GLS is associated with both heart failure severity measured by natriuretic peptide levels and long-term prognosis. Decreased posterolateral 3D CS reflects typical posterolateral scarring in FD. Where feasible, 3D-strain echocardiography can be used for a comprehensive mechanical assessment of the LV in patients with FD.

P125 LEFT ATRIAL AND VENTRICULAR STRAIN, AND 3D–ECHOCARDIOGRAPHY FOR SUBCLINICAL CHEMOTHERAPY–RELATED CARDIAC DYSFUNCTION IDENTIFICATION IN PATIENTS WITH BREAST CANCER

Abstract Cardio–oncology is a recent rapid–developing multidisciplinary approach created by oncologists in accordance with cardiologists with the objective to minimize the adverse cardiovascular effects of contemporary cancer therapy and to maximize the benefits that can be obtained from it. Pre–treatment cancer therapy–related cardiovascular toxicity (CTR–CVT) risk assessment can be performed using HFA–ICOS risk assessment tools, in addition to a careful clinical history analysis, physical examination, ECG, biomarkers, and echocardiography. In our study, the analysis of standard and advanced echocardiographic parameters (left atrial strain or LAS, left ventricular global longitudinal strain or GLS, and 3D echocardiography) were performed at baseline, at three, six, and 12 months timepoints. A number of 53 female patients with breast cancer, scheduled to receive chemotherapy, was enrolled. All patients had basal 3D LVEF values ≥ 50% and a basal GLS &amp;gt; –18,5%. Statistically significant reductions (p&amp;lt;0,001) in 3D LVEF at three, six, and 12 months compared to baseline were found, and in all cases 3D LVEF levels were within the reference values (3D LVEF ≥ 50%). GLS and atrial strain parameters (LASr and LASct) were significantly reduced compared to the baseline at 3 months (GLS p&amp;lt;0.01; LASr p&amp;lt;0,001; LASct p&amp;lt;0,001), 6 months (GLS p&amp;lt;0.05; LASr p&amp;lt;0,001; LASct p&amp;lt;0,001) and 12 months (GLS p&amp;lt;0.01; LASr p&amp;lt;0,05; LASct p&amp;lt;0,01). Moreover, 10 patients out of 53 (18,87%) had asymptomatic cardiotoxicity (expressed by &amp;gt;15% of GLS reduction compared to baseline) after 12 months, and 17 out of 53 patients (32,08%) had atrial dysfunction (expressed by &amp;gt;15% of LASr reduction compared to baseline) after three months. Although atrial dysfunction was not statistically significant in predicting asymptomatic cardiotoxicity (p=0.12), patients with atrial dysfunction at three months have a 3,7 times greater risk of developing asymptomatic cardiotoxicity at 12 months. With our analysis, we found that HFA–ICOS risk score could be considered a predictor of cardiotoxicity at 12 months (p&amp;lt;001). Further studies will be conducted, in order to expand the population and to confirm our results.

Left Ventricular Systolic Function After 3 Months of SGLT2 Inhibitor Therapy in Heart Failure Patients with Reduced Ejection Fraction.

Not much is known about the effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on echocardiographic parameters of left ventricular (LV) systolic function in patients with heart failure and reduced ejection fraction (HFrEF).We prospectively included 59 outpatients with HFrEF: 41 patients received SGLT2i with OMT (SGLT2i+ group), whereas eighteen patients received OMT without SGLT2i (SGLT2i- group). Myocardial work index (MWI), 3D ejection fraction (3D LVEF), and global longitudinal strain (GLS) were measured at baseline and after 3 months following treatment. At 3-month follow-up, the SGLT2i+ group showed significantly greater improvement in MWI than the SGLT2i- group. In both groups, there was a significant improvement in 3D LVEF and LV GLS, circulating NT-proBNP levels, and NYHA functional class, with significantly greater improvement in the SGLT2i+ group.In conclusion, the addition of SGLT2i to fully optimized background medical therapy resulted in a greater improvement of LV systolic function among outpatients with HFrEF.

920 ASSOCIATION OF OUTCOME WITH LEFT VENTRICULAR VOLUMES AND EJECTION FRACTION MEASURED WITH TWO-AND THREE-DIMENSIONAL ECHOCARDIOGRAPHY IN PATIENTS REFERRED FOR ROUTINE, CLINICALLY INDICATED STUDIES

Abstract Background LV volumes and LVEF measured by 3DE are more accurate and repeatable than those calculated with 2DE. However, the added prognostic value of 3DE LV volumes and EF remains to be clarified. Objectives To analyze if the left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have an incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory. Methods We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59±18 years) with various clinical indications referred for a routine clinical study. Results LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6±1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse otcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the association of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC= 0.84, p&amp;lt;.001) more than 2DE LVEF (HC= 0.814, p&amp;lt;0.001). The association of CD with the cumulative endpoint (HC= 0.64, p=0.002) was augments more by 3DE LV EDV (HC= 0.786, p&amp;lt;0.001), end-systolic volume (HC= 0.801, p&amp;lt;0.001), and EF (HC= 0.84, p&amp;lt;0.001) than by the correspondent 2DE parameters (HC= 0.786, HC= 0.796, and 0.84, allp&amp;lt;0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ2=98.3 vs. χ2=77.1; p&amp;lt;0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for cardiac death than when using 2DE reference values (3DE LVEDV: χ2=15.9, p&amp;lt;0.001 vs. χ2=10.8, p=0.001; 3DE LVESV: χ2=24.4, p&amp;lt;0.001 vs. χ2=17.4, p=0.001). Conclusions 3DE LVEF and ESV showed stronger association with outcome than 2DE parameters LVEF measured by 3DE had a prognostic discriminatory power than 2D LVEF. Moreover, 3DE LV volumes threshold values for LV dilation had a higher discriminatory power and prognostic value than the corresponding 2DE values reported in current guidelines.

Myocardial work-A new tool for early detection of rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone chemotherapy induced-cardiotoxicity in hematological patients.

Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (RCHOP) chemotherapy in non-Hodgkin's lymphoma (NHL) has risk of cardiotoxicity. To determine the role of myocardial work and biomarkers in subclinical diagnosis and prediction of cardiotoxicity. The 130 NHL patients (52 ± 9 years, 62% men) scheduled for RCHOP, with LVEF>50%, were evaluated at baseline, after third cycle and chemotherapy completion for 3D LVEF, 2D myocardial deformation (longitudinal, radial, circumferential strain - LS, RS, CS) and myocardial work (global constructive work, waste work, work index and work efficiency - GCW, GWW, GWI, GWE). NT-pro-BNP and troponin I were determined. After chemotherapy ended, 37 patients (28%) (group I) developed asymptomatic cardiotoxicity (8 mild form, 25 moderate form, 4 severe form); 93 patients (group II) did not. After third cycle, all patients had decreased LS, CS, RS, GCW, GWI, GWE and increased GWW, persistent after chemotherapy completion, with significant changes in group I. After third cycle, GWE and GCW were the best independent predictors for LVEF reduction; GWE decrease with>5% after third cycle predicted cardiotoxicity after chemotherapy completed (91% sensitivity, 94% specificity). In NHL, myocardial work can diagnose subclinical cardiotoxicity and predict LVEF decline. These parameters should be used for sensitive evaluation of myocardial function during chemotherapy.

Intraoperative Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing On-Pump Coronary Artery Bypass Surgery

Noninvasive echocardiographic analysis of left ventricular (LV) myocardial work (MW) enables insights into cardiac mechanics, contractility, and efficacy beyond ejection fraction (EF) and global longitudinal strain (GLS). However, there are limited perioperative data on patients undergoing coronary artery bypass graft (CABG) surgery. The authors aimed to describe the feasibility and the intraoperative course of this novel assessment tool of ventricular function in these patients, and compare it to conventional 2-dimensional (2D) and 3-dimensional (3D) echocardiographic parameters and strain analysis. A prospective observational study. At a single university hospital. Twenty-five patients with preoperative preserved LV and right ventricular function, sinus rhythm, without significant heart valve disease or pulmonary hypertension, and an uncomplicated intraoperative course scheduled for isolated on-pump CABG surgery. Transesophageal echocardiography (TEE) was performed intraoperatively after the induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). All measurements were performed under stable hemodynamic conditions, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. The EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LVEF, LV GLS, LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). The MW analysis was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF during the intraoperative interval, GLS deteriorated significantly after CABG compared to assessment after induction of anesthesia (T1 v T2, -13.3 ± 3.0% v -11.6 ± 3.1%; p=0.012). The GWI declined significantly after surgery (T1 v T2, 1,224 ± 312 mmHg% v 940 ± 267 mmHg%; p < 0.001), as well as GCW (T1 v T2, 1,460 ± 312 mmHg% v 1,244 ± 336 mmHg%; p=0.005). The GWW increased after CABG (T1 v T2, 143 mmHg% (IQR 99-183) v 251 mmHg% (IQR 179-361); p < 0.001), and GWE decreased (T1 v T2, 89% (IQR 85-92) v 80% (IQR 75-87); p < 0.001). There were no significant changes in the values of 2D and 3D EF, GLS, GWI, GCW, GWW, and GWE before and after sternal closure (T2 v T3). The intraoperative analysis of noninvasive echocardiographically-assessed LV MW indices is feasible. In the short-term period after uncomplicated on-pump CABG, GLS, as well as global and constructive MW, decreased, whereas wasted work increased, resulting in a less efficient left ventricle. None of these aspects was detected by conventional echocardiographic parameters. Therefore, strain and MW analysis might be more sensitive parameters in detecting myocardial dysfunction by TEE in the perioperative setting, adding information on perioperative cardiac energetics.

Assessment Of Left and Right Ventricular Functions In Overweight and Obese Females by Different Echo-Doppler Modalities

Abstract Aim of work Assessment of left and right ventricular functions in overweight and obese females using different echo-Doppler modalities. Methods This study included 32 obese females (group I), 26 overweight females (group II) -both of them have no chronic illnesses- in addition to 25 healthy females (group III) as a control group. All of them had hsCRP level measured. The following parameters were measured using 2D echocardiography: LA, Ao, LA/Ao ratio, LV measures included LV dimensions, 2D LVEF, 2D LV global longitudinal strain (LVGLS), average LV Sm, Em, Am, LV E/Em ratio, LV E, A and LV E/A ratio. RV measures included LV dimensions, RV FAC, RV Tei index, TAPSE, RV Sm, Em, Am, Em/Am ratio, RV E, A, E/A ratio and PASP. Results hsCRP, LA, Ao, LV dimensions, Average LV Am, E/Em, RVD1, RV Tei and PASP were significantly higher in group I compared to group III, but group I had significantly lower LV E/A, LV Sm, Em, LVGLS, RV E/A, Em/Am and RVGLS compared to group III. Group II had significantly higher hsCRP, Ao and RV Tei and significantly lower LV E/A ratio and LV Em compared to group III. On the other hand, group, I had significantly lower average Sm, LVGLS and RVGLS than group II but no significant difference detected between two groups as regard LV and RV diastolic function. Pulse, BMI, BSA, waist circumference, waist to hip ratio, hsCRP were negatively correlated with LVGLS and RVGLS. Cut-off values for BMI showed good sensitivity and specificity to predict impaired LVGLS and RVGLS. Cut-off point 31.9 kg/m2 for impaired LVGLS with sensitivity 80%, specificity 76.81% and p value &amp;lt;0.001, cut-off point &amp;gt;30.73kg/m2 for impaired RVGLS with sensitivity 80%, specificity 69.57% and p value 0.001. Waist circumference was the most sensitive predictor for impaired LVGLS and hsCRP for impaired RVGLS. Conclusion Isolated obesity and overweight are independent predisposing factors for impaired LV and RV systolic and diastolic dysfunctions. TDI and 2D STE are good echo-Doppler modalities to detect subclinical effects on LV and RV functions. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Dissociation between two-dimensional and three-dimensional echocardiography – clinical implications

Abstract Objectives To investigate the agreement between two-dimensional (2DE) and three-dimensional echocardiography (3DE) in a general population, along with clinical impact of the differences. Background Left ventricular ejection fraction (LVEF) has prognostic value and is used to guide cardiac treatment. The preferred technique is two-dimensional (2D) echo, although three-dimensional (3D) echo is more accurate when compared to MRI. Our study evaluates the agreement between 2D and 3D LVEF and the potential clinical impact of disagreements. Methods Study population ware participants from the Copenhagen City Heart Study, who underwent 2DE and 3DE between 2011–2014. Means of difference (MD) were assessed in participant groups with a LVEF below 40%, 40–50%, and above 50%. Age-adjusted Cox proportional hazard ratios (HR) were calculated for all-cause mortality, major adverse cardiovascular event (MACE) and cardiac event of any kind. Results In total 2554 participants from the Copenhagen City Heart Study were included. Median age was 58.3 (IQR: 44.2–69.8) years and 1137 (44.5%) were male. Mean LVEF in 2D was 56.6% (95% CI: 56.4–56.9%) and 52.0% (95% CI: 51.7–52.4%) in 3D, p&amp;lt;0.05. MD increased the further LVEF deteriorated: −14.9% (95% CI: −16.0 to −13.9%) (LVEF &amp;lt;40%), −9.3% (95% CI: −9.8 to −8.9%) (LVEF 40–50%) and −1.2% (95% CI: −1.6 to −0.9%) (LVEF ≥50%). 2DE overestimated the LVEF relative to 3D in 1824 (71.4%) instances. 3D LVEF &amp;lt;40% was associated with a HR for all-cause mortality of 2.58 (95% CI: 1.55–4.31, p&amp;lt;0.05), MACE: 1.90 (95% CI: 1.22–2.98, p&amp;lt;0.05) and cardiovascular event: 1.61 (95% CI: 1.04–2.48, p&amp;lt;0.05). HR for 2D LVEF &amp;lt;40% 0.84 (95% CI: 0.21–3.41, p=0.80) (all-cause), 3.12 (95% CI: 1.64–5.94, p&amp;lt;0.05) (MACE) and 2.68 (95% CI: 1.42–5.09, p&amp;lt;0.05) (cardiovascular event). Conclusion With declining LVEF, 2D echo is prone to significantly overestimate LVEF and a 3D LVEF less than 40% is associated with excess all-cause mortality but less with MACE and cardiovascular events when compared to 2D LVEF. Funding Acknowledgement Type of funding sources: None.

Early impairment of left ventricular longitudinal and radial deformation in primary mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant TE 137/2020 Background. In primary mitral regurgitation (PMR) left ventricular (LV) remodeling is an adaptive process with prognostic significance. Aim. To characterize LV deformation parameters related to PMR severity for a better understanding of LV pathophysiology, in patients with mild to severe PMR and preserved LV ejection fraction (EF). Methods. 48 patients (56 ± 14 years, 42% men) with PMR (mild - 12 patients, moderate - 12 patients, severe - 24 patients) and 50 age and sex matched-controls (56 ± 12 years, 48% men) were analyzed by 2-dimensional speckle-tracking echocardiography (2D STE) for LV endo, mid, and epicardial longitudinal strain (LS); endo, mid, and epicardial circumferential strain (CS); and radial strain (RS). LV volumes and EF, and LA volumes and emptying fraction (EmF) were measured by 3D echocardiography. MR severity was quantified by vena contracta (VC), PISA radius, MR regurgitant volume, and EROA measurements, according to the 2021 ESC guidelines. Results. 3D LVEF had no significant difference between PMR patients and controls (p= 0.11). From control subjects to mild, moderate, and severe PMR, there was a progressive reduction of LS and RS (Figures 1 and 2), but not of CS. By 2D STE multilayer analysis, when compared to controls, PMR patients had decreased endo-, mid-, and epi-LS (p &amp;lt; 0.04), with a compensatory increase of endo-LS in mild PMR (Figure 2). Basal, middle, and apical segments LS decreased similarly and progressively from control subjects to PMR patients (p &amp;lt; 0.01). In addition, in patients with PMR only LS, but not RS or CS, correlated with MR severity (PISA radius, VC, and MR regurgitant volume: r= -0.43, r= -0.32, r= -0.38, all p &amp;lt; 0.01), and LA function (EmF: r = -0.41, p &amp;lt; 0.01). Conclusion. When compared to normal subjects, patients with PMR and preserved LVEF have altered LV longitudinal and radial deformation, with preserved circumferential strain. All longitudinal layers and all LV segments were similarly affected. Only longitudinal strain correlates with MR severity and atrial function. Our study suggests that a comprehensive evaluation of the LV deformation should be included in the assessment of patients with PMR, in order to identify early stages of LV dysfunction, starting even from mild MR. Abstract Figure. LV deformation - PMR vs controls Abstract Figure. Multilayer LS in PMR patients

A 3D-TTE left atrial function study in cardio-oncology patients

Abstract Introduction Transthoracic Doppler echocardiography (TTE) remains the standard imaging method to evaluate cancer therapeutics-related cardiac dysfunction (CTRCD). 3D-TTE with strain analysis is a novel technique, proved useful for earlier detection of left ventricular (LV) function impairment. However, diastolic and left atrial (LA) function impact is less studied. Purpose To assess LA volumetric and LA strain (LAS) features by 3D-TTE in cardio-oncology patients. Methods A prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D and 3D-TTE. Standard 2D, 3D-TTE and LAS parameters were evaluated, including longitudinal (LALS) and circumferential strain (LACS) during conduit (cd), contraction (ct) and reservoir (r) phases. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). CTRCD was defined as an absolute decrease in 2D LVEF &amp;gt;10% to a value &amp;lt;54% or a relative decrease in 2D GLS &amp;gt;15%, according to literature. P with previous cancer treatment, coronary artery disease, significant valvular disease, and atrial arrhythmias were excluded. Results 98 P (mean age 54.6±12.0 years-old), mostly treated with anthracyclines (78.6%, cumulative dose 268.2±77.6mg/m2), anti-HER (70.4%) and radiotherapy (80.6%) were included. 2D LV and LA volumes had a significantly raise from baseline to T1 (2D LVEDV 82.2±18.8 vs 91.9±18.8 mL, p=0.019 and LA 43.3±12.9 vs 49.8±13.3 mL, p=0.005). 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality. 2D GLS was also impaired at T1 (−19.9±2.6% vs −18.6±3.1%, p=0.009). During a mean follow-up of 14.1±8.1months, 31 P (31.6%) developed CTRCD. 3D LV and LA volumes also globally increased at T1 comparing to baseline with partially recovery at T2. Maximum LA volume was significantly higher at T1 (39.1±9.3 vs 43.6±10.6 ml, p=0.024). 3D LA ejection fraction (T0 53.7±9.7%, T1 53.4±8.6%, T2 49.9±8.6%, pT0-T2=0.039) and LAS values tended to progressively worse during TH. LA dilation (vol&amp;gt;34ml/m2) at baseline was correlated to dysfunction in contraction phase at T1 (LACSct −19.6±8.6 vs −17.3±4.6%, p=0.024). LACSr has substantially decreased from baseline to T2 (31.4±11.6 vs 27.0±10.4%, p=0.05). In univariate analysis, delta LALSr (T1-T0) was a predictor of CTRCD (mean −5.2% vs 1.9%, p=0.05). Conclusion CTRCD was frequent during the earlier phase of breast cancer treatment. LA function was also affected, mirroring LV volumetric and functional changes. Diastolic dysfunction, assessed through LA reservoir strain, was impaired in association with CTRCD. 3D-TTE usefulness in the surveillance and monitoring of CTRCD goes beyond systolic LV function assessment, allowing a detailed LA function analysis. Funding Acknowledgement Type of funding sources: None.

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

Assessment of Subclinical Deterioration of Right Ventricular Function by Three-Dimensional Speckle Tracking Echocardiography in Breast Cancer Patients Undergoing Anthracycline-Based Chemotherapy.

ObjectiveThis study was aimed at assessing the longitudinal strain changes of RV function using three-dimensional speckle tracking echocardiography (3D STE) in breast cancer patients receiving anthracycline chemotherapy.Patients and MethodsA total of 95 women with breast cancer receiving epirubicin (360 mg/m2) underwent 3D STE at baseline, the end of chemotherapy and 12 months after chemotherapy. 3D STE assessment included RV ejection fraction (EF), LV global longitudinal strain (GLS), RV GLS, and RV free wall longitudinal strain (RV FWLS). Meanwhile, serum hs‐cTnI and NT-proBNP were measured. Chemotherapy-related cardiac dysfunction (CTRCD) was defined as an absolute decrease in 3D LVEF > 10% to a value <50%, while a percent reduction of 3D LV GLS > 15% indicated subclinical CTRCD.ResultsSubclinical CTRCD occurred in 10 (10.5%) patients during follow-up. Compared to baseline, the 3D GLS of LV and GLS and FWLS of RV decreased significantly at 12months after chemotherapy (all p<0.01). Variations of 3D RV GLS and RV FWLS had a good discrimination for predicting subclinical CTRCD. The variation of 3D RV FWLS was the only independent predictor of subclinical CTRCD (OR, 1.37; 95% CI, 1.12–2.87; p = 0.028) in multivariate analysis. The cutoff value with −17.5% of 3D RV FWLS variation had a high predictive accuracy for subclinical CTRCD, with an AUC of 0.74, 80.5% sensitivity and 65.8% specificity. The association between 3D RV FWLS and the cumulative dose of anthracyclines was calculated by Spearman’s test (r = −0.71, p < 0.001).ConclusionLongitudinal strain analysis by 3D STE allows the identification of subclinical RV dysfunction when conventional indices of RV function are unaffected. 3D RV FWLS was superior to other parameters in early detection of the development of CTRCD in breast cancer patients receiving epirubicin therapy.

Myocardial work, combined with arterial stiffness and biomarkers, are able to detect earlier and predict cardiotoxicity in non-Hodgkin lymphoma

Abstract Funding Acknowledgements Type of funding sources: None. CHOP (cyclophosphamide, doxorubicin, oncovin, prednisone) in non-Hodgkin lymphoma (NHL) is limited by risk of cardiotoxicity. Aim. To define new parameters of LV myocardial work, arterial stiffness, and biomarkers for early diagnosis and prediction of cardiotoxicity. Methods. 91 patients (34 men, 57 ± 11 years), with NHL, with LVEF &amp;gt;50%, scheduled for CHOP, were assessed at baseline, and after 4th and 8th cycle (doxorubicin total dose of 341 ± 52 mg). 3D echo was used for LVEF; 2D STE for longitudinal strain (LS) and myocardial work: global constructive work (GCW) as "the positive" work of the heart; global wasted work (GWW) as "the negative" work of the heart; global work efficiency (GWE) by formula GCW/(GCW + GWW), and global work index (GWI) as sum of GCW and GWW; echo-tracking for pulse wave velocity (PWV) and β index. Troponin I and NTproBNP were measured. Cardiotoxicity was defined as LVEF decrease &amp;lt;50%, with &amp;gt;10% from baseline. Results. After 8th cycle, 17 patients (18%) (group I) developed cardiotoxicity (3D LVEF: 63 ± 3 vs. 48 ± 1, p &amp;lt; 0.0001), whereas 74 patients (group II) did not (3D LVEF: 63 ± 2 vs. 57 ± 3, p &amp;lt; 0.0001). There was a significant reduction of LS, GCW and GWE, with an increase of GWW and arterial stiffness, starting with the 4th cycle; changes in group I were higher than in group II (p &amp;lt; 0.001) (table). Univariate analysis showed significant correlation between reduction of 3D LVEF and decrease of LS, GCW, GWE (r = 0.65; r = 0.74; r = 0.54), and increase of GWW, PWV, β index, and troponin level after 4th cycle (r=-0.44; r=-0.38; r=-0.39; r=-0.35; all p &amp;lt; 0.05). Reduction of GCW after the 4th cycle was the best independent predictor of decrease of 3D LVEF after the 8th cycle (R2 = 0.48, p = 0.001). By ROC analysis, decrease of GCW by more than 29% after the 4th cycle predicted development of cardiotoxicity after the 8th cycle of CHOP (Sb 82%, Sp 81%). Conclusion. Assessment of myocardial work, combined with arterial stiffness and biomarkers, are able to detect early chemotherapy-induced cardiotoxicity and to predict further decline of LVEF in non-Hodgkin lymphoma. Myocardial work and cardiotoxicity CHOP Group I Group II LS(-%) Baseline 4th cycle 8th cycle 22 ± 2 17 ± 1† 13 ± 2† 22 ± 2 19 ± 2† 17 ± 2±† GCW (mmHg%) Baseline 4th cycle 8th cycle 2256 ± 123 1902 ± 133† 1633 ± 167† 2278 ± 168 2104 ± 111† 1937 ± 102† GWW (mmHg%) Baseline 4th cycle 8th cycle 84 ± 4 124 ± 18† 198 ± 24† 85 ± 11 94 ± 21† 113 ± 19† GWE (%) Baseline 4th cycle 8th cycle 98 ± 1 92 ± 2† 86 ± 2† 98 ± 1 95 ± 2 94 ± 1† GWI (mmHg%) Baseline 4th cycle 8th cycle 1982 ± 155 1888 ± 136† 1723 ± 172† 2003 ± 189 1945 ± 111 1873†±102† GCW = global constructive work; GWE = global work efficiency; GWI = global work index; GWW = global waste work; LS = longitudinal strain; † p &amp;lt; 0.001

Prediction of left ventricular remodeling following ST elevation myocardial infarction: role of myocardial deformation parameters

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF - I agree that this information can be anonymised and then used for statistical purposes only Background Left ventricular (LV) remodeling after ST elevation myocardial infarction (STEMI) plays an important role in predicting the outcome of this patient group. It is also useful in assessing the benefit of revascularization. Its identification is also of clinical importance in order to set up preventive strategies for patients with adverse remodeling Purpose To find an echocardiographic predictor of LV adverse remodeling following STEMI. Materials and methods In this prospective study we included 52 consecutive patients, aged between 35-70, with STEMI treated by primary PCI. We performed conventional 2D transthoracic echocardiography for patients. In addition to conventional parameters we also measured LV global longitudinal strain (GLS) and LV mechanical dispersion using 2D speckle tracking imaging. For morphological and functional analysis of LV we used 3D echocardiography (volumes, LVEF). LV remodeling (LVR) was defined as an increase of over 15% of the LV end diastolic volume (LVEDV) at 6 months follow up. Results We found significant differences in time (baseline and 6 month follow up) between LVEF (43,08 vs 47,91, p = 0.034), LVEDV (105,95 vs 113,21, p = 0.000), LV GLS (-12.61 vs - 14,58, p = 0.01), and mechanical dispersion (61,68 vs 56,11, p = 0.00) in all patients. LV remodeling at 6 months (15% increase in LVEDV) was observed in 30 % of the included patients. At 6 months after STEMI we observed a significant difference between the two groups (remodeling vs no remodeling) regarding 3D LVEF (42.28 %vs 50.30%,p = 0.009), LVEDV (131 ml vs 109 ml, p = 0.05), GLS (-11.15 vs -16.02, p = 0.00) and LV mechanical dispersion (69.02 vs 50.54, p = 0.00). Patients with LV remodeling at 6 months after STEMI had lower LVEF, worse LV GLS and higher LV mechanical dispersion at baseline. Using ROC curve analysis we identified two cut off values, one of -11.55 for baseline LV GLS (Sb 78%, Sp 81%, AUC 0.852, CI 95%, p = 0.00) and another one of 63.7 for LV baseline mechanical dispersion (Sb 71,4%, Sp 66 %, AUC 0.762, p 0.005) to discriminate between patients with or without LV adverse remodeling at 6 months. Using linear regression analysis, we demonstrated that GLS (p = 0.00) and LV mechanical dispersion (p = 0.016) are able to predict LV remodeling in time. We also found a negative correlation between peak CK-MB levels at baseline LVEF at 6 months. Regression analysis showed that CK-MB levels at baseline could predict LVEF at 6 months (p = 0.008) Conclusion Baseline LV mechanical dispersion and LV GLS can predict LV adverse remodeling at 6 months after STEMI. These parameters could be used at baseline in order to predict worse outcome in STEMI patients. Further larger scale studies are needed to validate these findings.

Abstract 15550: Fully Automated "Hands-off" Validation of Left Ventricular Ejection Fraction in Children

Introduction: Three-dimensional echocardiography (3DE) has been shown to be superior to 2DE when quantifying chamber dimensions. However, the clinical utility of 3DE has been limited by time-consuming analysis and need for 3D-specific training. This study aims to assess the clinical utility of a “hands-off,” artificial intelligence-driven software program, Philips Dynamic HeartModelA.I. (DHM), in a pediatric population. Hypothesis: We hypothesize that this program will be able to accurately calculate LVEF in children when compared to Cardiac MRI (CMRI) used as a gold standard. Methods: To date, 10 patients (Average Age 14.8±1.9) have undergone CMRI immediately followed by echocardiography at the Children’s Hospital of Philadelphia. Echocardiographic images were analyzed via DHM without manual editing and from full-volume 3D border tracing (3DEF). We excluded 3D imaging of 2 patients due to poor image quality. 2D LVEF was also evaluated visually in all patients by three experts, and by 2D Simpson’s Biplane method. All analyses were timed with a stopwatch. Each technique was correlated with CMRI. Results: Our results showed that LVEF measured via DHM was rapid and correlated very well with CMRI (R=0.85). DHM had a stronger correlation with CMRI than Biplane, 3DEF, and visual EF (R=0.56; R=0.68; R=0.57). Moreover, DHM analysis was faster than both Biplane and 3DEF (32±8 seconds vs 100±19 seconds, p&lt;0.005; 32±8 seconds vs 98±16 seconds, p&lt;0.005) (Figure 1). Notably, 3DEF correlated very well with visual estimation by expert observers (R=0.83). Conclusions: Based on our pilot data, DHM analysis in children was faster than both 3DEF and biplane method likely due to its hands-off nature. Furthermore, its correlation with CMRI was superior to both 3DEF and Biplane. Based on further patient enrollment by us and others, this completely automated method will likely be clinically useful as it has potential to become a standard application in large volume, busy echo labs.

The distribution and relationship between 3D LVEF and 3D strain in a general population

Abstract Introduction Three-dimensional (3D) echocardiography (3DE) is currently extensively used to estimate left ventricle (LV) morphology and heart valves. However, it is underutilized in the assessment of LV function. Most likely, it is due to limited knowledge of the normal reference intervals. In order to fill this knowledge gap, studies which investigates the 3DE reference ranges in a larger cohort of a general population are needed. The objective of the current study was to study the relationship and distribution of 3D LV ejection fraction (EF) and its corresponding strain values in subjects enrolled in Copenhagen City Heart Study (CCHS). Methods The echocardiograms were acquired from CCHS subjects from 2011–2014 by using GE Vivid E9 (GE Medical, Copenhagen, Denmark), during four consecutive heart beats. Exclusion critera were missing data or measurements in 3D, poor image quality or frame rate (&amp;lt;12 fps) and, based on visual evaluation of the echocardiograms, inappropriate tracking of three or more myocardial segments in the strain analysis. The echocardiograms were analysed in 2019 on EchoPacTM v. 201 (GE Medical, Copenhagen, Denmark). Results are presented in means, interquartile ranges (IQR) and as adjusted correlation values (r2). R2 values equal to or above 0.64 (equals to r=0.8) were considered as strong correlation. LV function parameters included were LVEF, global longitudinal strain (GLS), global circumferential strain (GCS) and area strain (AS). LVEF and strain results are presented as percentages (%). The distribution and relationship between 3D LVEF, GLS, GCS and AS are visualized as scatter plots and box-whiskers plots. The statistical analysis and the visualisation of the data was performed in RStudio v. 3.5.1. P-values &amp;lt;0.005 were considered as markers for statistical significance. Results There were 2955 subject with available 3DEs in CCHS among which 1202 subjects had sufficient image quality for evaluation. The mean 3D LVEF was 54.6% (IQR: 50–60%), 3D GLS −14.5% (IQR: −13 to −16), 3D GCS −13.4% (IQR: −11 to −15) and AS −24.7% (IQR: −22 to −27). The adjusted correlation values between LVEF with strain parameters were: 0.04 (GLS), 0.37 (GCS) and 0.26 (AS), which was poor. Conclusion This study provides valuable data of the distribution of 3D LVEF and its corresponding 3D strain values in a general population. The 3D strain values are lower than the reference interval described in literature for two-dimensional echocardiography. Moreover, correlation was also found to be poor between LVEF and different strain parameters. 3D LVEF vs. 3D Strain (GLS, GCS, AS) Funding Acknowledgement Type of funding source: None

Cardioprotection using strain-guided management of potentially cardiotoxic cancer therapy: 1 year results of the SUCCOUR trial

Abstract Background Conventional criteria for diagnosis of chemotherapy-related cardiac dysfunction (CTRCD) are dependent on the recognition of heart failure (HF) symptoms and/or changes in LVEF. However, the low sensitivity of EF for minor changes in LV function may delay initiation of cardio-protective therapy (CPT). Global longitudinal strain (GLS) is a robust and sensitive marker of LV dysfunction (LVD), but existing observational data are insufficient to justify changing the diagnostic criteria for CTRCD. Purpose To identify whether GLS guidance of CPT would improve cardiac function of at risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care. Methods In this international multicenter prospective randomized controlled trial, 331 pts from 23 international sites taking anthracyclines with another risk factor for HF were randomly allocated into 166 undergoing GLS-guided (CPT for &amp;gt;12% relative reduction in GLS using Echopac software) and 165 EF-guided (CPT for &amp;gt;10% absolute reduction of EF). Pts were followed over 1 year for the primary end-point (ΔEF) with 3D echo (3DE); 2D echo (2DE) was used when 3D images were unsuitable for measurement. Development of CTRCD (EF reduction of 10% to &amp;lt;55%) was a secondary endpoint. Results Of 331 randomized patients, 24 withdrew before follow-up imaging was performed (2 died, and rest withdrew or were lost to follow-up). Among 307 patients (age 54±12 years, 94% women) with follow-up 1.0±0.2 years, 277 had breast cancer, 30 had lymphoma/leukemia. HF risk factors were prevalent: 89 (29%) had hypertension and 39 (13%) had diabetes mellitus. The most common chemotherapy regimen during this study was the combination of anthracycline and trastuzumab. The baseline 3D LVEF was 61±5%, and GLS was −20.8±3.2%. At 1 year follow-up, 31 (10%) met CTRCD and was reduced in the GLS-guided arm (Table 1), although new LV dysfunction (EF&amp;lt;55%) and change of EF were not different. Conclusion In this international multicentre trial, the incidence of CTRCD was reduced by strain-guided cardioprotection. Although the final EF and the number of pts developing EF &amp;lt;55% was not altered by strain-guided therapy, this reduces meaningful reduction of EF to the abnormal range. The results support the use of GLS in surveillance for CTRCD. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): General Electric Medical Systems