3D Left Ventricular Ejection Fraction Research Articles

Myocardial scar and left ventricular ejection fraction classification for electrocardiography image using multi-task deep learning

Myocardial scar (MS) and left ventricular ejection fraction (LVEF) are vital cardiovascular parameters, conventionally determined using cardiac magnetic resonance (CMR). However, given the high cost and limited availability of CMR in resource-constrained settings, electrocardiograms (ECGs) are a cost-effective alternative. We developed computer vision-based multi-task deep learning models to analyze 12-lead ECG 2D images, predicting MS and LVEF < 50%. Our dataset comprises 14,052 ECGs with clinical features, utilizing ground truth labels from CMR. Our top-performing model achieved AUC values of 0.838 (95% CI 0.812–0.862) for MS and 0.939 (95% CI 0.921–0.954) for LVEF < 50% classification, outperforming cardiologists. Moreover, MS predictions in a prevalence-specific test dataset recorded an AUC of 0.812 (95% CI 0.810–0.814). Extracted 1D signals from ECG images yielded inferior performance, compared to the 2D approach. In conclusion, our results demonstrate the potential of computer-based MS and LVEF < 50% classification from ECG scan images in clinical screening offering a cost-effective alternative to CMR.

Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real-world practice.

Guidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real-world practice. We evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF. Among 35641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n=5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n=15933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n=3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%-68.1%) among sonographers and 51.6% (46.5%-59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55-7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35-.40). Use of 3DE LVEF in real-world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.

Changes in vascular function and correlation with cardiotoxicity in women with newly diagnosed breast cancer undergoing HER2-directed therapy with and without anthracycline/cyclophosphamide.

The objective of this study was to assess the effect of HER2-directed therapy (HER2-Tx) on peripheral vasoreactivity and its correlation with cardiac function changes and the additive effects of anthracycline/cyclophosphamide (AC) therapy and baseline cardiovascular risk. Single-centre, prospective cohort study of women with newly diagnosed stage 1-3 HER2-positive breast cancer undergoing HER2-Tx +/- AC. All participants underwent baseline and 3-monthly evaluations with Endo-Peripheral Arterial Tonometry (Endo-PAT), vascular biomarkers [C-type natriuretic peptide (CNP) and neuregulin-1 beta (NRG-1β)], and echocardiography. Cardiotoxicity was defined as a decrease in the left ventricular ejection fraction (LVEF) of >10% to a value <53%. Of the 47 patients enrolled, 20 (43%) received AC in addition to HER2-Tx. Deterioration of reactive hyperaemia index (RHI) on Endo-PAT by ≥20% was more common in patients receiving HER-Tx plus AC than HER2-Tx alone (65% vs. 22%; P = 0.003). A decrease in CNP and log NRG-1β levels by 1 standard deviation did not differ significantly between the AC and non-AC groups (CNP: 20.0% vs. 7.4%; P = 0.20 and NRG-1β: 15% vs. 11%; P = 0.69) nor did GLS (35% vs. 37%; P = 0.89). Patients treated with AC had a significantly lower 3D LVEF than non-AC recipients as early as 3 months after exposure (mean 59.3% (SD 3) vs. 63.8% (SD 4); P = 0.02). Reactive hyperaemia index and GLS were the only parameters correlating with LVEF change. Combination therapy with AC, but not HER2-Tx alone, leads to a decline in peripheral vascular and cardiac function. Larger studies will need to define more precisely the causal correlation between vascular and cardiac function changes in cancer patients.

Diastolic function is more sensitive than GLS in identifing cardiotoxicity. The SAFE trial results

Abstract Echocardiographic measures of diastolic dysfunction are associated with an increased risk of incident heart failure. Previous studies have shown that changes in diastolic function occur with anthracycline cancer therapy. However, they did not incorporate the newest classification of diastolic function nor evaluated the association with subsequent declines in systolic function. Design The SAFE trial is a four-arm, randomized, phase 3, double-blind, placebo-controlled, national multicentric study. Recruitment was conducted between July 2015 and June 2020. Patients with breast cancer were eligible if they had indication to primary or postoperative systemic therapy using an anthracycline-based regimen. Known cardiovascular disease or high-risk features were exclusion criteria. Cardioprotective therapy (bisoprolol(B), ramipril(R), or both drugs, as compared to placebo(P)) was administered for 1 year since chemotherapy initiation or until the end of trastuzumab therapy in the case of HER2-positive patients. Each drug was systematically titrated, up to the target dose of B(5 mg OD), R(5 mg OD), if tolerated. The primary endpoint was defined as any subclinical impairment (worsening ≥10%) of 3D left ventricular ejection fraction and global longitudinal strain (GLS) at the end-of-therapy (EOT) and at 2-year follow-up (EOF). Individual measures indicative of diastolic function (mitral E/A ratio, septal and lateral e’ velocities, indexed LA volume, TR velocity, and E/e’ ratio) were recorded and diastolic function was graded according to the 2016 ASE/EACVI guidelines. Results Out of 262 women (median age 48 years; range, 24-75 years) enrolled and treated, 222 patients completed the pre-planned cardiological assessment at 24 months. Baseline demographic, tumor, and cardiovascular profiles were similar between the study arms. All patients received anthracyclines, 217 also received taxane, and 77 adjuvant trastuzumab. Forty-nine patients were treated with neoadjuvant chemotherapy, 154 with adjuvant endocrine therapy, and 124 had postoperative radiation therapy. At EOT GLS worsened by 10% or greater in 57% of patients in the P arm, 20%, 13%, and 18% in the R, B, and R+B arms, respectively (P&amp;lt; 0.05). At EOF GLS worsened by 10% or greater in 65 % of patients in the P arm, 13%, 9%, and 10% in the R, B, and R+B arms, respectively (P&amp;lt; 0.05). In all patients, diastolic function was normal at baseline. Changes in any diastolic parameter were not significant (Table). AT EOT 9% of the patients with &amp;lt;10% GLS decrease showed diastolic dysfunction (22% in P arm, 8%, 6%, and 4% in the R, B, and R+B arms, respectively, P&amp;lt;0.05). At EOF 78% of patients with ≥10% GLS decrease showed diastolic dysfunction (Figure). Our findings provide evidence that 1. abnormal diastolic function precedes systolic dysfunction, 2 there are significant changes in diastolic function grade over time, 3. cardioprotective therapy may be useful in low-risk breast cancer patients.TableFigure

Surgical Outcomes of Repairing Ebstein Anomaly: A Single-Center Experience

Background: Ebstein anomaly (EA) is a rare congenital disorder of the tricuspid valve (TV), accounting for about one percent of congenital heart defects. Considering highly variable anatomy, diverse corrective surgical methods are currently utilized. Cone reconstruction provides a near anatomic tricuspid restoration method that has triggered enthusiasm for early repair over recent years. Objectives: In the current study, we aimed to evaluate the clinical and echocardiographic features and outcomes of patients who underwent surgical correction of EA in our referral center. Methods: In this study, we reviewed the medical records of 35 patients with EA who underwent cone repair or TV replacement and had accessible echocardiographic data before and at least one year following the corrective surgery. The patients were evaluated for residual tricuspid regurgitation (TR) severity, right ventricular (RV) size, RV fractional area change (FAC), left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVEDD), and 2D left ventricular ejection fraction (LVEF) before and after the operation. Results: Mean age of the patients was 29.49 ± 9.13 years, and 54.3% of them were female. Twenty-one (60%) patients underwent cone repair, and 14 were subjected to TV replacement. Seven (20%) patients required reoperation; redo TV repair was conducted in three patients (8.6%); two (5.7%) patients underwent biologic TV replacement; mechanical TV replacement was performed in one patient (2.9%) who had degenerative biologic TVs, and one patient (2.9%) was subjected to redo-operation due to mechanical TV malfunction. Positive changes in the means of RV-FAC and 2D-LVEF were statistically significant in all patients irrespective of the type of surgery (P &lt; 0.001), but changes in the means of RV size (P = 0.38) and LVESD (P = 0.302) were not statistically significant. There was a significant increase in functional RV size in both groups of patients who underwent repair (P = 0.063) or replacement (P = 0.02). Conclusions: The present study revealed satisfactory post-op results for cone TV repair in patients with EA, evidenced by reduced TR severity and improved biventricular functional parameters. Assessing the durability of the outcomes of cone TV repair needs longer-term follow-ups.

Intraoperative Augmented Rotation and Circumferential Strain Compensate for Reduction of Left Ventricular Longitudinal Function After On-Pump CABG Surgery

Left ventricular (LV) longitudinal function is reduced after on-pump coronary artery bypass grafting (CABG), while global LV function often is preserved. There are only limited data on the underlying compensatory mechanism. Therefore, the authors aimed to describe intraoperative changes of LV contractile pattern by myocardial strain analysis. A prospective observational study. At a single university hospital. A total of 30 patients scheduled for isolated on-pump CABG with an uneventful intraoperative course and preoperative preserved LV and RV function, sinus rhythm, without more-than-mild heart valve disease, or elevated pulmonary pressure. Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Echocardiographic evaluation was performed under stable hemodynamics, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤0.1 µg/kg/min. EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2-dimensional (2D) and 3-dimensional (3D) LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global circumferential strain (GCS), LV global radial strain (GRS), LV apical rotation (aRot), LV basal rotation (bRot), and LV twist. Strain analysis was feasible in all included patients after termination of cardiopulmonary bypass (T2). Although there were no significant differences in the values of conventional echocardiographic parameters during the intraoperative interval, GLS deteriorated significantly after CABG compared to pre-bypass assessment (T1 v T2, -13.4% ± 2.9 v -11.8% ± 2.9; p=0.007). GCS improved significantly after surgery (T1 v T2, -19.4% (IQR -17.1% to -21.2%) v -22.8% (IQR -21.1% to -24.7%); p < 0.001) as well as aRot (T1 v T2, -9.7° (IQR -7.1° to -14.1°) v -14.5° (IQR -12.1° to -17.1°); p < 0.001), bRot (T1 v T2, 5.1° (IQR 3.8°-6.7°) v 7.2° (IQR 5.6°-8.2°); p=0.02), and twist (T1 v T2, 15.8° (IQR 11.7°-19.4°) v 21.6° (IQR 19.2°-25.1°); p < 0.001), while GRS remained unchanged. There were no significant changes in the values of GLS, GCS, GRS, aRot, bRot, or twist, as well as in the values of 2D and 3D LV EF before and after sternal closure (T2 v T3). Beyond evaluation of longitudinal LV strain, measurements of circumferential and radial strain, as well as LV rotation and twist mechanics, were feasible in the intraoperative course of this study. Reduction of longitudinal function after on-pump CABG was compensated intraoperatively by improvement of GCS and rotation in the authors' group of patients. Perioperative assessment of GCS, GRS, as well as rotation and twist, might provide deeper insight into perioperative changes of cardiac mechanics.

Comparison of Left Ventricular Global Longitudinal Strain with Ejection Fraction as a Predictor for Peri-operative IABP Insertion in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: A Pilot Study.

Prophylactic use of intra-aortic balloon pump (IABP) mainly depends on left ventricular (LV) systolic function. Global longitudinal strain (GLS) is a robust prognostic parameter for LV strain. It has proved to be more sensitive than LV ejection fraction (EF) as a measure of LV systolic function and is a strong predictor of outcome. To determine whether GLS can be used as a reliable marker and its cut-off value for IABP insertion in patients undergoing elective off-pump coronary artery bypass grafting (OPCABG). A prospective observational clinical study which included 100 adult patients scheduled for elective OPCABG. Two-dimensional (2D) speckle tracking echocardiography (STE)-estimated GLS was computed and compared with LV EF measured by three dimensional (3D) echocardiography for the insertion of IABP. The intensive care unit (ICU) parameters were correlated with echocardiographic parameters to predict early post-operative outcome. IABP insertion correlates better with GLS (post-revascularization > pre-revascularization) than with 3D LV EF. Receiver operating characteristic (ROC) curve analysis revealed the highest area under the curve (AUC, 0.972) with a cut-off value of > -9.8% for GLS compared to 3D LV EF (AUC, 0.938) with a cut-off value of ≤ 44%. ICU parameters show better correlation with E/e'> GLS > WMSI than 3D LV EF. GLS is a better predictor of IABP insertion compared to 3D LV EF in patients undergoing OPCABG.

Left Ventricular Global Longitudinal Strain Following Acute ST-Elevation Myocardial Infarction - A Comparison of Primary Coronary Angioplasty and Tenecteplase-Based Pharmacological Reperfusion Strategy.

In the setting of acute ST-elevation myocardial infarction (STEMI), reperfusion therapy with primary percutaneous coronary intervention (PCI) performed by an experienced team or pharmacological reperfusion with thrombolytic therapy is highly recommended. Standard echocardiographic measurement of the left ventricular ejection fraction (LVEF) is widely used to assess left ventricular global systolic function. This study was designed to compare the assessment of global left ventricular function by standard LVEF and global longitudinal strain (GLS) in the two well-known reperfusion strategies. We conducted a retrospective single-center observational study in 50 patients with acute STEMI who underwent primary PCI (n = 25) and Tenecteplase (TNK)-based pharmacological reperfusion therapy (n = 25). The primary outcome was left ventricle (LV) systolic function after primary PCI, as assessed by two-dimensional (2D) GLS using speckle-tracking echocardiography (STE), as well as LVEF using standard 2D echocardiogram using Simpson's biplane method. Overall mean age was 53.7 ± 6.9 years with 88% male gender. The mean door-to-needle time was 29.8 ± 4.2 min in the TNK-based pharmacological reperfusion therapy arm, and the mean door-to-balloon time was 72.9 ± 15.4 min in the primary PCI arm. LV systolic function was significantly better in the primary PCI arm as compared to the TNK-based pharmacological reperfusion therapy, both by 2D STE (mean GLS: -13.6 ± 1.4 vs. -10.3 ± 1.2, P ≤ 0.001) and LVEF (mean LVEF: 42.2 ± 2.9 vs. 39.9 ± 2.7, P = 0.006). There were no significant differences in mortality and inhospital complications in both groups. Global LV systolic function is significantly better after primary coronary angioplasty as compared to TNK-based pharmacological reperfusion therapy when assessed by routine LVEF and 2D GLS in the setting of acute STEMI.

COMPARISON OF GLOBAL LONGITUDINAL STRAIN WITH LEFT VENTRICULAR EJECTION FRACTION AS A PREDICTOR FOR IABP INSERTION IN PATIENTS UNDERGOING OFF-PUMP CORONARY ARTERY BYPASS GRAFTING: A PILOT STUDY

<h3>Objective</h3> Prophylactic use of intra-aortic balloon pump (IABP) mainly depends on left ventricular (LV) systolic function. Global longitudinal strain (GLS) is the most studied parameter for LV strain. It has proved to be more sensitive than LV ejection fraction (EF) as a measure of LV systolic function and is a strong predictor of outcome. The primary aim was to determine whether GLS can be used as a reliable marker and its cut-off value for IABP insertion in patients undergoing elective off-pump coronary artery bypass grafting (OPCABG). The secondary aim was to correlate echocardiographic parameters with intensive care unit (ICU) parameters to predict early post-operative outcome. <h3>Design</h3> A prospective observational clinical study. <h3>Setting</h3> Single university hospital. <h3>Participants</h3> 100 adult patients scheduled for elective OPCABG. <h3>Intervention</h3> None <h3>Measurements and Main Results</h3> 2D speckle tracking echocardiography (STE) estimated GLS was computed and LV EF measured by 3D echocardiography. The study predicted that IABP insertion correlates better with GLS (post-revascularization > pre-revascularization) than with 3D LV EF. Receiver operating characteristics (ROC) curve analysis revealed highest area under the curve (AUC, 0.972) with cut-off value of > -9.8% for GLS with maximum combined sensitivity and specificity compared to 3D LV EF (AUC, 0.938) with cut-off value of ≤44%. ICU parameters show better correlation with E/e'> GLS > WMSI than 3D LV EF. <h3>Conclusion</h3> GLS is a better predictor of IABP insertion compared to 3D LV EF in patients undergoing OPCABG.

INTRAOPERATIVE NON-INVASIVE LEFT VENTRICULAR MYOCARDIAL WORK INDICES IN PATIENTS UNDERGOING ON-PUMP CORONARY ARTERY BYPASS SURGERY

<h3>Objective</h3> Non-invasive echocardiographic analysis of left ventricular (LV) myocardial work (MW) enables insights into cardiac mechanics, contractility, and efficacy beyond ejection fraction and global longitudinal strain. MW incorporates myocardial deformation and loading conditions into its analysis and correlates well with invasively measured myocardial work outside the operative setting. However, there are no reports on the use of this method by transesophageal echocardiography (TEE) in patients undergoing coronary artery bypass graft (CABG) surgery. Therefore, we aim to describe the intraoperative course of this novel assessment tool of ventricular function in these patients and compare it to conventional two- and three-dimensional echocardiographic parameters and strain analysis. <h3>Design and Method</h3> Twenty-five patients scheduled for isolated on-pump CABG surgery with preoperative preserved left and right ventricular function and a complication-free intraoperative course, were included into this prospective observational trial. TEE was performed intraoperatively after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3) using General Electric Vivid E95 echocardiography machines and 6VT-D TEE probes. All measurements were performed under stable hemodynamic conditions, in sinus rhythm or atrial pacing and vasopressor support with Norepinephrine ≤ 0.1 µg/kg/min. EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D- and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW) and LV global work efficiency (GWE). <h3>Results</h3> Myocardial work 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). GWI declined significantly after surgery (T1 v T2, 1224±312mmHg% v 940±267mmHg%; p<0.001) as well as GCW (T1 v T2, 1460±312mmHg% v 1244±336 mmHg%; p=0.005). GWW increased after CABG (T1 v T2, 143mmHg% (IQR 99-183) v 251mmHg% (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 was no significant change in the values of 2D- and 3D-EF, GLS, GWI, GCW, GWW and GWE before and after sternal closure (T2 v T3). <h3>Conclusions</h3> Intraoperative non-invasive echocardiographic assessed left ventricular myocardial work analysis appears feasible in this study. In our small sample with 25 CABG patients, strain and myocardial work analysis showed a deterioration of left ventricular function. In the short-term period after uncomplicated on-pump CABG, global and constructive myocardial work was decreased, while wasted work was increased, resulting in a less efficient left ventricle. None of these aspects was detected by two- and three-dimensional ejection fraction. Therefore, myocardial work analysis might be a more sensitive parameter in detecting myocardial dysfunction by TEE in the perioperative setting.

Myocardial protection with glucose-insulin potassium in patients with acute coronary syndromes requiring coronary artery bypass grafting: A case series

Emergent cardiac surgery in patients with acute coronary syndrome (ACS) is always a challenging task for surgeons, anesthesiologists and patients. As “time is muscle,” early revascularization by percutaneous coronary intervention (PCI) has been largely advocated to salvage myocardial ischemic cells. In cases judged not suitable for PCI, on-pump coronary artery bypass grafting (CABG) is indicated with cardioplegic arrest and eventually anesthetic preconditioning to enhance myocardial protection. In these high-risk emergent procedures, adjuvant interventions to cardioplegic arrest are aimed to maximize the chance of cardiac functional recovery. Although the infusion of glucose-insulin-potassium (GIK) has demonstrated interesting cardioprotective effects in animal models of myocardial ischemia and in patients undergoing elective cardiac surgery, this cardioprotective strategy has not yet been adopted largely and has been ignored so far in emergent myocardial revascularization procedures. In this case series, we describe the effects of GIK on left ventricular performance assessed by transesophageal echocardiography in four patients with ACS who required emergent CABG surgery. The GIK solution of 20 g glucose, 20 UI insulin and 10 mEq potassium chloride was infused twice over 30 min, first after anesthesia induction and later after aortic unclamping. The systolic performance was assessed after anesthesia induction and after each GIK infusion using the 3D left ventricular ejection fraction, as well as the global longitudinal and circumferential strain. The diastolic function was assessed based on mitral inflow patterns (E-and A-waves) as well as flow propagation velocity.

Global longitudinal strain: an early marker for cardiotoxicity in patients treated for breast cancer.

Patients treated with anthracyclines and trastuzumab are at increased risk of developing heart failure. Early diagnosis and treatment may prevent irreversible left ventricular (LV) dysfunction. This study investigates whether subclinical deterioration of global longitudinal strain (GLS) is amore reliable early predictor for LV dysfunction than three-dimensional (3D) LV ejection fraction (LVEF). Adult patients receiving anthracyclines and trastuzumab for breast cancer who had serial echocardiographic follow-up were included in this retrospective study. The primary endpoint was the necessity to temporarily pause chemo- or immunotherapy due to declining LVEF (decline in 3D LVEF of > 10percentage points to < 53%). Linear mixed-effects models were used to assess the longitudinal evolution of 3D LVEF and GLS over time. Fifty-one women were included, mean age 54 (50.5-57.6) years, with atotal of 216 follow-up echocardiograms (mean follow-up 1.1 ± 0.45years). GLS and 3D LVEF were significantly correlated (Spearman's rho: -0.36, p < 0.001). Adecrease in GLS significantly predicted alower LVEF on the subsequent echocardiogram [ß -0.6, 95% confidence interval (CI) (-1.0 to -0.2), p < 0.006]. Conversely, prior LVEF did not significantly predict GLS on the subsequent echocardiogram [ß -0.04, 95% CI -0.1 to -0.01, p = 0.12]. Nine patients reached the primary endpoint. On average, patients who reached the primary endpoint had arelative decrease of 15% GLS at day 205 and an absolute 10% decrease of LVEF to LVEF < 53% at day 235. GLS is able to identify subclinical LV dysfunction earlier than 3D LVEF measurement in women undergoing treatment for breast cancer with anthracyclines followed by trastuzumab.

Utility and futility of MitraClip implantation in secondary mitral regurgitation in a real-world population: the role of 3D transthoracic echocardiography

Abstract Introduction Two recent prospective trials have been published, reporting opposite results on the efficacy and utility of the MitraClip (MC) procedure in patients with secondary mitral regurgitation (SMR). A ratio between the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) ≥0.150 by two-dimensional (2D) transthoracic echocardiography (TTE) has been proposed to identify patients with disproportionate SMR, who would benefit from MC. Purpose To assess the prognostic role of clinical and echocardiographic parameters in a real-world population of SMR patients undergoing the MC procedure at our Institute. Methods Ninety-two patients underwent MC implantation. We retrospectively reviewed their clinical, and laboratory data, as well as 2D and three-dimensional (3D) TTE, and intraoperative transoesophageal echocardiography (Figure 1). The primary endpoint was a composite of cardiovascular death and/or hospitalisation for heart failure within 12-months follow-up. Results Thirty-one patients reached the endpoint (EP+), 61 did not (EP−). Demographics and anti-remodelling drugs were similar in EP+ and EP. Among comorbidities and laboratory data, EP+ significantly differed from EP− in smoking history, and extracardiac artery disease prevalence (65% vs. 39%, and 39% vs. 16%, respectively); EuroScoreII (12.2% vs. 5.2%); NYHA class ≥3 (94% vs. 69%); haemoglobin (12±2 vs. 13±2 g/dL), and brain natriuretic peptide levels (855 [426–1500] vs. 357 [170–902] pg/mL). At 2D TTE no significant difference emerged, including the SMR grade, except for the tricuspid annular plane systolic excursion (Figure 2). Biventricular 3D ejection fraction was significantly lower in EP+ vs. EP− (Figure 2). Residual intraoperative SMR grade after MC deployment was 1.9±0.6 in EP+ vs. 1.3±0.5 in EP− (p&amp;lt;0.001). Conclusion The proposed cut-off for EROA/LVEDV ratio may be suboptimal for predicting the MC utility in real-world populations. Rather, prognosis may be more influenced by the patient's pre-operative clinical status, right ventricular systolic function, 3D left ventricular ejection fraction, and by the success of the procedure. Funding Acknowledgement Type of funding sources: None.

Baseline left atrial reservoir strain provides independent and incremental prognostic value in predicting chemotherapy related cardiotoxicity

Abstract Background Currently, few baseline imaging biomarkers can predict chemotherapy induced cardiotoxicity (CTx). The early identification of CTx is critically important as it determines the prospect of LV function recovery (1). Purpose We aimed to determine if baseline left atrial (LA) reservoir strain (LAS) is predictive of CTx. Methods We performed retrospective analysis of the SUCCOUR study, an international multicentre randomized controlled trial. CTx was defined as an asymptomatic drop of &amp;gt;10% in left ventricular ejection fraction (LVEF) compared to baseline to &amp;lt;55%. LAS analysis was performed using semi-automated speckling tracking of the LA in the four and two chamber views using EchoPAC. Analysis was performed at one year follow up. Cox proportional hazard analysis, c-statistics and Akaike information criterion (AIC) statistical analysis was performed. Results After excluding 78 with inadequate images, 229 were included in the analysis. Most participants were female (n=215, 94%), with a mean age of 54±12 years. Median follow up was 1.02 years (IQR 0.98–1.07). A smoking history was the commonest cardiac risk factor (n=68, 30%). Breast cancer was the main cancer type (n=205, 90%). The mean baseline 3D LVEF, LV global longitudinal strain (GLS), LAS, and LA volume index (LAVI) were 61±4%, 20.6±2.5%, 28.6±7.9%, and 28±9ml/m2, respectively. Participants that developed CTx had a lower LAS at baseline compared to those that did not (25.5±7.4% vs 29.0±7.9% respectively; p=0.027). At 1-year follow-up, 29 patients (13%) developed CTx. On univariable Cox proportional hazard analysis, higher baseline LAS was associated with a lower risk of CTx (HR 0.95, 95% CI 0.90–0.99; p=0.026) but other parameters including baseline GLS was not (p=0.17). In nested Cox models (Figure 1), adding LAS significantly improved the model's predictive accuracy for CTx compared to other clinical and imaging parameters. When LAS was added to the same models it showed improvements in the c-statistics and AIC score (Figure 1). Conclusion Baseline LAS is an independent and incremental predictor of CTx. LAS could be used for baseline risk stratification in oncology patients who receive potentially cardiotoxic chemotherapy. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): GE Healthcare

Pathophysiological alterations of left ventricular myocardial systolic function during normal pregnancy assessed by speckle tracking echocardiography: a prospective cohort echocardiography study.

By using conventional echocardiographic indices, cardiac pumping function remains unaltered during pregnancy. However, two-dimensional speckle tracking echocardiography (2D-STE) can detect subclinical changes of myocardial function even in patients with normal and stable left ventricular ejection fraction (LVEF).The aim of this study was to evaluate LV systolic performance during normal low risk pregnancy by using both conventional 2D and 3D echo indices and 2D-STE. One hundred and twelve pregnant women without any history of heart disease were prospectively recruited. They underwent serial echocardiographic evaluation in each pregnancy trimester and 6 months after delivery (time indicated as 1,2,3 and 4). 2D LVEF, 3D LVEF, LV global longitudinal strain (LVGLS), LV global circumferential strain (LVGCS) and LV-twist were measured and compared to the control group (c). 2D-LVEF and 3D-LVEF were not significantly different among the three trimesters, postpartum and controls. LVGLS progressively decreased during pregnancy (1st :21.71 ± 2.13%, 2nd : 21.20 ± 2.30%, 3rd : 19.82 ± 2.10%, 4th : 21.81 ± 2.05%, c: 21.71 ± 2.2%, overall p < 0,001) which receded during puerperium. No significant difference was noted in LVGCS (1st : 18.08 ± 5.54%, 2nd : 18.57 ± 3.41%, 3rd :18.20 ± 3.33%, 4th : 17.95 ± 3.39%, c: 18.8 ± 2.2%, p > 0.3). LV-Twist was significantly higher in the 1st trimester compared to controls (p = 0.04) and remained constantly high during the rest of the pregnancy and puerperium (1st :13.80 ± 5.09°, 2nd :13.46 ± 5.35°, 3rd :13.58 ± 4.32°, 4th :13.37 ± 4.26°, c: 11.5 ± 4.3°). In low risk individuals with normal pregnancy, a redistribution of force occurs especially in the 3rd trimester. Longitudinal strain decreases, while torsional movement of the heart increases and counterbalances the temporal change of longitudinal systolic function. These changes would probably reflect the pathophysiological alterations related to pregnancy.

New advances in medical imaging technology for the evaluation of anthracycline-induced cardiotoxicity.

New advances in medical imaging technology for the evaluation of anthracycline-induced cardiotoxicity.

Serial changes in left ventricular myocardial deformation in sepsis or septic shock using three-dimensional and two-dimensional speckle tracking echocardiography.

BackgroundThis study aimed to investigate the serial changes in left ventricular (LV) myocardial deformation in patients with sepsis using three-dimensional (3D) and two-dimensional (2D) speckle tracking echocardiography (STE).MethodsIn this single-center, prospective, and observational study, we included 59 patients diagnosed with sepsis or septic shock in the intensive care unit and 40 healthy controls. Left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (GLS), and global circumferential strain (GCS) assessed by 3D STE and 2D STE were obtained on the first, third, fifth, seventh to the tenth day after sepsis or septic shock.ResultsIn patients with sepsis or septic shock, 3D and 2D LVEF were not different at each time point. GLS and GCS obtained by 3D STE and 2D STE decreased on the first day compared with the healthy group (all P < 0.01). Compared with the values on the first day, GLS and GCS further decreased on the third day, while 3D and 2D LVEF did not differ. 3D and 2D STE strains were lowest on the third day and gradually improved on the seventh to the tenth day compared with values on the third day. When compared with values on the first day, 3D and 2D GLS gradually improved on the seventh to the tenth day, whereas 3D and 2D GCS on the seventh to the tenth day was not different. Although 3D and 2D STE strains were significantly increased on the seventh to the tenth day, they were not fully recovered to normality.ConclusionAlthough patients with sepsis or septic shock demonstrated gradual improvements in 3D and 2D STE parameters during the ten-day period, LV myocardial strain was not fully recovered to normality by the seventh to the tenth days. 3D and 2D strain imaging, used as a helpful tool for monitoring the evolution of myocardial deformation, can provide clinicians with a useful additional imaging parameter.

P133 UTILITÀ DEL MYOCARDIAL WORK NELLA VALUTAZIONE ECOCARDIOGRAFICA MULTIPARAMETRICA DI PAZIENTI CON CARCINOMA MAMMARIO

Abstract Background The aim of our study was to assess subclinical cardiac effects of anthracyclines (ANTs) in women treated for breast cancer (BC). Methods We enrolled 46 female patients with BC undergoing adjuvant treatment with anthracycline–containing chemotherapy (CT) followed by taxane (paclitaxel/docetaxel). Patients underwent physical examination, electrocardiogram (ECG) and standard transthoracic echocardiography (TTE) including evaluation of diastolic and systolic function, measured as left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (GLS) and myocardial work (MW) expressed as global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE). The parameters were measured at baseline (T0) and at 3 months (T1) and 6 months (T2) follow up. Results All patients completed the chemotherapy cycles. No significant cardiovascular adverse events were observed during treatment. Neither 2D left ventricular ejection fraction (LVEF) nor E/e’ ratio evaluation at TDI were significantly changed after treatment. Conversely, GLS was significantly reduced at T1 and T2 since baseline (GLS – 19,99 % IQR –20,6 –19,3 % at T0 vs –17,88 % IQR –18,8 –16,9 % at T1, p &amp;lt; 0,00 1 and –16,71 % IQR 17,6 –15,7 % at T2, p &amp;lt; 0,001). Consensually, a significant reduction in myocardial work was also measured (GWI 2115 mmHg% IQR 1888 – 2342 mmHg% at T0 vs 1714 mmHg% IQR 1557 – 1870 mmHg% at T1, p &amp;lt; 0,0001 and 1694 mmHg% IQR 1482 – 1907 mmHg% at T2, p &amp;lt; 0,0001). Conclusion Our study demonstrates that evaluation of myocardial work allows very early detection of subclinical cardiac damage induced by chemotherapy, consensually to the reduction of the GLS. A multiparametric assessment of the myocardial function, including myocardial work and GLS, could improve the accuracy of risk stratification of cardiotoxicity in patients undergoing ANTs treatment.

The variability of 2D and 3D transthoracic echocardiography applied in a general population : Intermodality, inter- and intraobserver variability.

Assessment of the left ventricular (LV) function by three-dimensional echocardiography (3DE) is potentially superior to 2D echo echocardiography (2DE) for LV performance assessment. However, intra- and interobserver variation needs further investigation. We examined the intra- and interobserver variability between 2 and 3DE in a general population. In total, 150 participants from the Copenhagen City Heart Study were randomly chosen. Two observers assessed left ventricular ejection fraction (LVEF), end-diastolic (EDV) and end-systolic volumes (ESV) by 2DE and 3DE. Inter-, intraobserver and intermodality variabilities are presented as means of difference (MD), limits of agreement (LoA), coefficient of correlation (r), intraclass correlation coefficients (ICC). The lowest MD and LoA and highest r- and ICC-values was generally seen among the 3D acquisitions, with the 3D EDV interobserver as the best performing estimate (r = 0.95, ICC = 0.94). The largest MD, LoA and lowest r- and ICC-values was found in the interobserver 2D LVEF (r = 0.76, ICC = 0.63. For the intraobserver analysis, there were statistically significant differences between observations for all but 3DE EDV (p = 0.06). For interobserver analysis, there were statistically significant differences between observers for all estimates but 2DE EDV (p = 0.11), 3D ejection fraction (p = 0.9), 3DE EDV (p = 0.11) and 3D ESV (p = 0.15). Three-dimensional echocardiography is more robust and reproducible than 2DE and should be preferred for assessment of LV function.

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.