3D LVEF Research Articles

Determining LoA between Left Ventricular EF estimated from Abarquez Formula and Left Ventricular EF measured by 2D Echo

Background: The Abarquez formula (aVR QRS amplitude x 2.264) + (age x 0.645) has been offered to provide an estimate for LVEF measured by 2D Echo. However, studies aiming to establish agreement between the Abarquez formula and LVEF measured by 2D Echo are lacking.
 Aims and Objectives: The aim of this study was to compare the LVEF estimated from 12-lead ECG using the Abarquez formula with the LVEF measured using the 2DED in the following subpopulations: 18-35 years old, 36-60 years old, >60 years old, male, and female patients. To compare these two measurements, the limits of agreement (LoA) by Altman and Bland was used.
 Materials and Methods: Adult patients admitted in the VLMC from January to May 2019 with both a 12-lead ECG and a 2D Echo were included in the study. LVEF from 2D Echo and LVEF estimated using the Abarquez formula were recorded. Comparison of the two measurements was performed by Altman and Bland method using LoA at 95% confidence interval. This analysis was done using Analyse-It Software. Comparison of the mean differences between the two measurement methods was also done using STATA.
 Results: LVEF estimate using the Abarquez formula was found to significantly differ from LVEF measured using 2D Echo.
 Conclusions: The Abarquez formula cannot be used as a surrogate for LVEF measure by 2D Echo.

1029 Anthracycline and trastuzumab-induced subclinical cardiac damage and its prevention in the SAFE trial. Myocardial strain imaging and 3D echo interim analysis data

Abstract Background Benefit of anthracyclines and trastuzumab therapies on disease-free survival in breast cancer is well known. Cardiotoxicity is a feared potential complication of both drugs. It usually progresses from cardiomyocyte injury to silent left ventricular dysfunction (LVD) which often becomes symptomatic and irreversible. Therefore, its prevention and early detection are of paramount importance in these cancer patients. Purpose SAFE trial (CT registry ID: NCT2236806) is a randomized phase 3, four-arm, single-blind, placebo-controlled study that aims to evaluate the effects of Bisoprolol (B) (5 mg, twice daily), Ramipril (R) (5 mg, twice daily) or the combination of the two (R + B), compared to placebo (P), on subclinical heart heart damage. Interim data of left ventricular function monitored with 3D Echo and Myocardial Strain Imaging are presented. Methods Out of 225 patients asked to participate, 191 were enrolled (mean age 48.9 ± 9.0 years). Follow-up monitoring (at 3, 6, 12 months[m]) comprised 3D ejection fraction (3D-LVEF) and Global Longitudinal Strain (GLS). One patient had sub-acute anthracyclines cardiotoxicity. Data at one year of 123 patients were available (34 P, 28 R, 31 B, 30 R + B). Results At time 0, no significant differences in age, body mass index, hemodynamic parameters were observed among arms. Data of 3D-LVEF and GLS at time 0 and during follow-up are reported in the figure (p level versus time 0 – GLS repeated measures). There was a significant reduction in 3D LVEF and increase in GLS in P arm (3D LVEF: 3m: -3.3%, 6m: - 5.2%, 12m: -3.7%; GLS: 3m: +5,7%, 6m: +7.8%, 12m: + 7,1%). A similar, though less significant, worsening of 3D LVEF (-2.4%,-1.9%,-2.2% at 3, 6, 12m, respectively) and GLS (+2.7%, +3.2% at 3 and 6m, respectively) was found in R arm. In B and B +R arms there was a worsening at 6m (3D LVEF -2.5%, GLS +2.7%), whereas at 12m only GLS increased (+3.2%) in B, not in B + R. Arm differences were significant (repeated measures two ways) both for 3D LVEF (two-way repeated measures ANOVA, p level = 0.038, observed power 0.855) and GLS (p level = 0.002, observed power 0.973). Conclusions This interim analysis of the SAFE trial shows that demonstration of subclinical cardiotoxicity is feasible with 3D echo and myocardial strain imaging. Significant subclinical damage potentially leading to LVD is present at one year. Both B alone on in combination with R may be a successful cardioprotective strategy in patients treated with anthracyclines and trastuzumab. Abstract 1029 Figure. Time course of GLS and 3D LVEF

P206 Immediate impact of coronary revascularization on global and regional myocardial function evaluated by speckle tracking echocardiography

Abstract Funding Acknowledgements No. OnBehalf No. Background The immediate effect on myocardial function and deformation after coronary revascularization is incompletely studied. Effective revascularization along with perioperative myocardial injury compromises improved regional and global left ventricular function and leads to the risks of adverse perioperative events following coronary artery bypass grafting (CABG) surgery. Global longitudinal strain (GLS) assessed by speckle-tracking echocardiography (STE) has been reported as a better predictor and a more sensitive marker for postoperative ventricular remodeling. Purpose This study aimed to evaluate changes of left ventricular (LV) systolic function and GLS in the perioperative period during CABG and to investigate the value of GLS using two-dimensional STE in predicting short-term outcome. Methods A total of 22 patients who underwent elective CABG surgery (EuroSCORE II 1.84 ± 1.2) were evaluated. Transesophageal echocardiography was performed, 2D and three-dimensional echocardiography (3DE) data was acquired before sternotomy, before cardiopulmonary bypass (CPB), after bypass and after chest closure. LV GLS and tissue motion annular displacements (TMAD) of the mitral valves were quantified by 2D STE using CMQ software. LV volumes and ejection fraction (EF) were evaluated by 3DE at the same timepoints. Short-term outcomes were defined as death, stroke, myocardial infarction, acute kidney dysfunction, rehospitalization and repeated revascularization in a one-month period after surgery. Results Both 2D and 3DE of all patients were analyzed. The cohort had a mean age of 68.2 ± 7.2 years and 9.1% was women. Before sternotomy, GLS was -15.7 ± 2.9%. Despite little change in 3D LVEF, GLS was immediately impaired after coronary artery bypass graft (before bypass vs after chest closure, -15.9 ± 3.6% vs -13.5 ± 4.0%, P = 0.001). There was strong correlation between GLS and 3D LVEF (r=-0.77, P < 0.001), moderate correlations between GLS and absolute value of TMAD (r=-0.61, P < 0.05), between GLS and percentage of TMAD (r=-0.64, P < 0.05). Patients with poor outcome (n = 6) had a lower longitudinal strain (LS) in the apical 2-chamber (A2C) views (-14.5 ± 4.6% vs -10.8 ± 1.3%, P = 0.007) but no statistical difference between A3C and A4C views. The ROC analysis demonstrated a cut­off value -11.8% for A2C-LS to predict adverse events (AUC 0.81, P = 0.027, 95% CI 0.632-0.993), with an 83.3% sensitivity and 81.2% specificity, followed by 3D LVEF (AUC = 0.29), absolute and percentage of TMAD (AUC = 0. 21, 0.23) as less sensitive predictors of poor postoperative outcome. Conclusion Direct effects of myocardial deformation related to revascularization can be characterized by STE during CABG surgery. GLS could be a more sensitive parameter in the perioperative environment, which correlates well with LV global function assessed by 3D LVEF and TMAD. Early impairment of anterior and inferior wall myocardial strain after CABG may contribute to short-term adverse clinical outcome. Abstract P206 Figure.

P323 Early measurement of left ventricular global longitudinal strain and mechanical dispersion predict left ventricular remodeling at 5 year follow up after STEMI: pilot study

Abstract Funding Acknowledgements 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. Background Left ventricule (LV) function plays an important role in the pathophysiology of decompensation after acute ST elevation myocardial infarction (STEMI). LV remodeling (LVR) after STEMI is associated with development of heart failure, predicting poor clinical outcome therefore its identification is of clinical importance to set up preventive strategies. Prediction of the left ventricular remodeling (LVR) after STEMI in patients treated by primary PCI is challenging. Purpose Finding an echocardiographic parameter that can predict left ventricular remodeling in time after STEMI. Materials and methods In this prospective study we included 30 consecutive patients, median age 60 (37-79), 76% male, with STEMI treated by primary PCI. We performed conventional 2D transthoracic echocardiography for all included patients. In addition to conventional parameters we measured LV global longitudinal strain (GLS) and LV mechanical dispersion using 2D speckle tracking imaging technique. For morphological and functional analysis of LV we used 3D echocardiography (volumes, LVEF) considering its superiority in assessment of LV. All measurements were performed at baseline (up to 7 days after STEMI) and at 5 year follow up. LVR was defined as an increase of over 15% of the LV end diastolic volume (LVEDV) in time, at 5 years after the STEMI. Results We obtained significant differences in time (up to 7 days after STEMI vs at 5 years) between 3D LVEF (46,48 vs 51,68, p = 0.002), LVEDV (97,12 vs 107,76, p = 0.000), 2D global strain (-11.76 vs - 14,1, p = 0.00), and mechanical dispersion (65,06 vs 57,66, p = 0.00) in all patients. LV remodeling at 5 years (15% increase in LVEDV) was observed in 36,6% of the included patients. At 5 years follow up, LVEDV mean value in the remodeling group was 130 ml and in the no remodeling group 90,21 ml (p = 0.002), 3D LVEF was 48,18 vs 54,42 (p = 0.05), global strain was - 12,33 vs -15,35 (p = 0.02) and LV mechanical dispersion 66,27 vs 55,55 (p = 0.05). Therefore patients with LV remodeling in time had lower LVEF, lower global strain and higher LV mechanical dispersion at baseline. Using ROC analysis we identified two cut off values, one of -11.55 for global LV strain measured at baseline (Sb 81.8%, Sp 77%, AUC 0.776, CI 95%, p = 0.022) and the other one of 63.7 for LV mechanical dispersion at admission (Sb 72,7%, Sp 62%, AUC 0.734, p 0.05) to discriminate between patients with or without LV adverse remodeling at 5 years after STEMI. We also found, using regression analysis, that GLS and LV mechanical dispersion are able to predict LV remodeling in time. Conclusion Global longitudinal strain and left ventricular mechanical dispersion measured in the acute phase can predict which patient is likely to undergo LV remodeling at 5 years after STEMI. GLS and LV dispersion could be used as predictors for future LV adverse remodeling after STEMI. Larger scale studies are needed to validate these findings.

1180 2D and 3D assessment of the left ventricle volume and ejection fraction in a general population

Abstract Introduction In standard practice, LV volumes and EF are estimated by 2D technique. 3D echocardiographic assessment seems more reliable; however, this method has not yet been validated in the general population. Purpose To validate 3D echocardiography in a large population sample and investigate differences between 2D and 3D LVEF and volumes Methods In The Copenhagen City Heart Study, 4466 echocardiograms were available for analysis. The echocardiograms were obtained during four consecutive heartbeats in both 2D and 3D with GE Vivid E9. Offline analysis was performed on EchoPac v. 201. LVEF was calculated by the modified Simpsons Biplane Auto EF for 2D and by the 4LVQ method for 3D. Results The study included 2090 echocardiograms. The mean 2D LVEF was 57.3 ± 6.1% (IQR 54 - 61%) and 51.7 ± 7.9% (IQR 47 - 57%) by 3D. The mean end-diastolic volume (EDV) and end-systolic volume (ESV) by 2D and 3D techniques were: EDV 2D 106.1 ± 29.6 ml vs EDV 3D 128.2 ± 32.3 ml , ESV 2D 45.7 ± 15.6 ml vs. ESV 3D 45.7 ± 20.7 , p < 0.05 among all variables. The average difference of means between 2D and 3D LVEF was 5.6 ± 11.2%, -22.1 ± 56.8 ml for EDV, and -16.9 ± 32.9 ml for ESV. The correlation coefficient for LVEF was 0.42, EDV 0.76 and for ESV 0.70. Conclusion In our study, we found a significant difference in both LVEF and ventricular volumes when comparing 2D echocardiograms with 3D. 3DE had, in general, lower LVEF, higher EDV and ESV compared to 2D. Table 1: Summary of results Table 1 - Summary of results n = 2090 Variable Min Max Mean IQR (25-75) p-value LVEF, 2D (%) 18 76 57.3 ± 6.1 54-61 < 0.05 LVEF, 3d (%) 13 77 51.7 ± 7.9 47-57 < 0.05 EDV, 2D (ml) 13 275 106.1 ± 29.6 85-123.8 < 0.05 EDV, 3D (ml) 50 270 128.2 ± 32.3 106-148 < 0.05 ESV, 2D (ml) 15 150 45.7 ± 15.6 35-54 < 0.05 ESV, 3D (ml) 13 185 45.7 ± 20.7 48-74 < 0.05 LVEF: left ventricle ejection fraction, EDV: end-diastolic volume, ESV: end systolic volume, IQR: Inter-quartile range Abstract 1180 Figure 1: Correlation and BA-plot

P208 Abnormal coronary flow reserve assessed with stress echocardiography induces a reduction in transmural strain gradient and an increase in heterogeneous myocardial electrical activation

Abstract OnBehalf Echo Lab INC Background The integrated quadruple stress echo (IQ-SE) is a state-of-the-art protocol that expands the risk stratification potential of SE. The coronary flow reserve (CFVR) has pronostic implication mainly in the absence of wall motion abnormalities. Longitudinal multilayer strain analysis assesses trasmural strain gradient. The prognostic value of multilayer strain analysis alongside the IQ-SE has not been established. We aim to determine the additive value of multilayer strain analysis during IQ-SE. Methods Prospective observational study. We evaluated one hundred twenty intermediate-high risk patients without obstructive coronary artery disease (mean age 61 ± 12 years, female 43%) with IQ-SE dipyridamole at our institution. Abnormal CFVR was defined as CFVR <2. Multilayer strain analysis and mechanical dispersion, were performed during rest and stress, with an automatic frame-by-frame with speckle tracking. Results The IQ-SE was feasible in all patients. At rest, mean three-dimensional left ventricular ejection fraction (3D LVEF) was 59% (53-62) without wall motion abnormalities. Abnormal CFVR was seen in 38 patients (32%) and reduced left ventricular contractile reserve (LVCR) in 56 patients (46%). Patients with abnormal CFVR, showed a reduction in EndoLS and transmural strain gradient, and an increase in mechanical dispersion and in lung B-lines during stress. No differences were observed in 3D LVEF and LVCR. Conclusions Endocardial ischemia due to microvascular dysfunction leads to a reduction in transmural strain gradient. Adding multilayer strain analysis to IQ-SE might detect myocardial subclinical dysfunction, arrhythmic risk and pulmonary congestion due to microvascular dysfunction. Left ventricular mechanics analysis CVFR <2 (38) CVFR >2 (81) P Rest EpiLS (%) -14.9 ±4.2 -18 ± 3.7 0.001 EndoLS (%) -20.2 ± 5.9 -23.5 ± 4.5 0.001 EndoLS- EpiLS 5.1 (3.8-6.3) 5.4 (4.2-6.3) 0.27 Mechanical Dispersion (ms) 57.7 (42.2-69) 44.2 (35-54) 0.006 Stress EpiLS (%) -17.2 ± 4.8 -20 ± 4.4 0.003 EndoLS (%) -23 ± 6 -26.6 ± 5.7 0.002 EndoLS- EpiLS 5.6 (4.5-6.7) 6.3 (5.4-7.9) 0.01 Mechanical Dispersion (ms) 47 (39.5 - 59) 39 (30-54.6) 0.007 CVFR: coronary flow reserve; EpiLS: Epicardium longitudinal strain; EndoLS: endocardial longitudinal strain; EndoLS- EpiLS: trasmural strain gradient. Abstract P208 Figure. IQ-SE and Multilayer Strain

P958 Back to basis? Feasibility of standard and novel echocardiographic measurements after breast cancer surgery

Abstract Background It is recommended that breast cancer patients should undergo cardiac follow-up during chemotherapy, with clinical assessment and echocardiogram. Standard measurements are robust and reproducible, but novel echocardiography methods as global longitudinal strain (GLS) and three-dimensional (3D) echocardiography are recommended due to their superior sensitivity. These methods require high-quality images. Breast cancer surgery may lead to reduced echocardiographic image quality in this population, in addition to age, obesity and smoking. Purpose We wanted to explore the feasibility of standard and novel echo methods in an unselected breast cancer population. Methods The present study included consecutive, unselected patients referred to baseline echocardiogram at the cardio oncology outpatient clinic in a large university hospital prior to start of adjuvant chemotherapy. Data on surgery, smoking habits, age and body mass index were collected. Feasibility was defined as the presence or absence to carry out meaningful measurements of left ventricular (LV) systolic function, from standard mitral annular plane systolic excursion (MAPSE) and two-dimensional LV ejection fraction (EF), to novel GLS and 3D LVEF. Multivariable logistic regression was performed to assess the impact of relevant variables on image quality. Results 116 female patients were included. 21 % of these patients had insufficient images for novel analyses. Left sided breast implant (OR 5,77; P 0,04), age (OR 3,89; P 0,02) and daily smoking (OR 3,57; P 0,03) were found to be independently associated with insufficient image quality. Standard analyses like two-dimensional EF and MAPSE were obtainable in 99 and 97 % of the examinations, respectively. Conclusion One of five in a postoperative breast cancer population cannot undergo follow-up using novel, sensitive echocardiographic measurements. Standard measurements, however, are obtainable in almost all patients. It is therefore important that these measurements are included in cardiac follow-up during chemotherapy.

P1400 Improving ischemia diagnosis: 3D speckle-tracking stress echocardiography

Abstract Background 2D stress echocardiography (SE) is based in the visual analysis of wall motion abnormalities and it requires a trained operator. This operator-dependence has promoted the search for a semiautomatic method to reduce SE limitations and improve test accuracy. The aim of this study was to evaluate the value of 3D speckle tracking (3DSTE) in SE in patients with chest pain. Methods 44 consecutive patients with chest pain and pathological findings on CCTA (>50% stenosis or high calcium score (>400 HU) with undetermined severity) were included. These patients underwent SE with acquisition of 3DSTE at rest and at peak stress. Results Mean age was 63.9 ± 9.9 years. 90% were men. The images of the 44 patients were processed with automatic tracking and manual corrections. 11 patients developed inducible ischaemia during SE. Patients with ischaemic response showed significant reductions in 3D area strain (AS) compared to resting values. The 33 patients without inducible ischaemia showed, however, a significant increase in this parameter. Results are shown in table 1. Conclusion 3D area strain SE could help to identify patients with inducible ischemia. However, further studies are need to confirm these data. Ischemia + (n = 11) Ischemia - (n = 33) P 2D LVEF rest 57.2; 5.5 61.4; 6.0 0.04 2D LVEF peak stress 56.9; 11.7 70.0; 9.0 <0.01 3D LVEF at rest 54.3; 6.9 64.3; 9.7 0.17 3D LVEF peak stress 51.9; 22.5 66.0; 8.6 0.17 AS rest 38.3; 5.1 40.4; 5.7 0.29 AS peak stress 37.2; 11.3 43.6; 7.2 0.03 LVEF: left ventricle ejection fracion; AS: area strain.

P933 Peak left atrial systolic strain as a marker of left ventricular diastolic dysfunction in patients with ischemic heart failure with depressed ejection fraction after STEMI: pilot study

Abstract Funding Acknowledgements 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 Background Echocardiographic assessment of diastolic dysfunction and left ventricular (LV) filling pressures is a complex and challenging process, requiring a multiparameter analysis. In recent years strain imaging has been emerging as a promising method for evaluation of left atrium (LA) function, being correlated with LV systolic dysfunction. Purpose We sought to evaluate LA mechanics in a cohort of patients with ischemic heart failure (HF) at one month after ST elevation myocardial infarction (STEMI) Material and methods 40 patients were enrolled in this study: 30 consecutive patients with ischemic HF after STEMI, with LVEF < 50% and 10 healthy age- and sex-matched controls. All patients had standard echocardiographic examination; also LA strain curves were obtained using speckle tracking with measurement of peak LA systolic strain. Categorization of diastolic dysfunction severity into 3 grades was realized according to 2016 guidelines. Results 2D and 3D LVEF (33% vs 55%, p = 0.00), LV global strain (-10 vs -19, p = 0.00) and peak LA systolic strain (16 vs 33, p = 0.00) were significantly reduced in HF patients compared to controls. In both groups LA strain correlated with the following parameters: 2D EF (p = 0.024), 3D EF (p = 0.02), LV global strain (p = 0.00), E/A (p = 0.05), septal e’ (p = 0.00), lateral e’ (p = 0.00), E/septal e’ (p = 0.006), E/lateral e’ (p = 0.003), E/mean e’ (p = 0.014), LA volume (p = 0.014) and LV filling pressures (p = 0.001). Peak LA systolic strain (PALS) values progressively decreased with worsening of diastolic function showing significant differences between all diastolic dysfunction grades. Using ROC analysis we identified 3 PALS thresholds to distinguish between normal diastolic function and the 3 diastolic dysfunction grades. The optimal cut off values were as follows: between normal diastolic function and grades 1-3 with PALS cut off value of 26.5 (Sb 90%, Sp 87%), AUC 0.963, CI 95%, p = 0.00; between grades 0-1 and grades 2-3 with peak LA strain cut off value of 17.2 (Sb 75%, Sp 93%) AUC = 0.828, CI 95%, p = 0.002; between grade 0-2 and grade 3 with peak LA strain cut off value of 11 (Sb 85%, Sp 93%), AUC 0.942, CI 95%, p = 0.00. Also, PALS value differed significantly between patients with normal vs high LV filling pressures. Using ROC analysis we determined a cut off value for LA of 15.1 to differentiate between the two subgroups with excellent discrimination power AUC 0.902, CI 95%, p = 0.00, Sb 88.9%, Sp 83% thus making LA strain an accurate surrogate estimate of LV filling pressures. Conclusions Global peak LA systolic strain is significantly correlated with LV systolic and diastolic function. PALS is a feasible option for detection and categorization of diastolic dysfunction in patients with HF and depressed LVEF after STEMI. Incorporating LA strain into noninvasive assessment of LV diastolic dysfunction may improve the detection of elevated LV filling pressures. Further large scale studies are needed to validate this data.

P1387 Correlations between left atrial strain parameters and left ventricular function in young patients presenting with acute ST elevation myocardial infarction

Abstract Funding Acknowledgements 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 Background Previous studies demonstrated the role of left atrial (LA) deformation parameters in characterisation of left ventricular (LV) diastolic dysfunction. It is a marker of the severity of diastolic dysfunction; LA remodelling also proved to be a predictor of clinical outcome, therefore a prognostic marker in acute coronary syndromes. Purpose In this study we aimed to investigate the correlations between left atrial strain and conventional systolic and diastolic dysfunction parameters in a cohort of young patients with acute ST elevation myocardial infarction (STEMI) treated by primary PCI. Material and methods We included 56 consecutive patients in this study: 46 patients under 50 years of age with STEMI and 10 healthy age and sex matched controls. We performed conventional transthoracic echocardiography for all included patients. In addition to conventional echocardiographic parameters, LA strain curves were obtained for each patient using two-dimensional speckle tracking imaging with measurement LA deformation parameters. Results LV ejection fraction, LV global strain and peak LA systolic strain (PALS) were significantly reduced in STEMI patients compared to controls. PALS had significant correlation with 2D LVEF (p = 0.00), LV global longitudinal strain (p = 0.03), E wave (p < 0.05), E/e’ (p < 0.05), left atrial volume and the type of diastolic dysfunction (p = 0.06). PALS also had inversre correlation with the presence of an occluded coronary artery at angiography. PALS was higher in control group than in STEMI group ( 34.6 vs 20.4, p < 0.05). PALS values progressively decreased with worsening of LV diastolic dysfunction showing significant differences between all diastolic dysfunction grades. Using ROC (Receiver operating Characteristics) analysis we identified a cut off value of 25.9 (Sensibility 88%, Specificity 74%, AUC 0.94, CI 95%, p < 0.05) to discriminate between diastolic dysfunction and normal diastolic function. Moreover, PALS was significantly different in patients with normal vs high LV filling pressures. Using ROC analysis we determined a cut off value of 14.5 for LA peak systolic strain to discriminate between the two subgroups, with excellent discrimination power, AUC 0.935, CI 95%, p = 0.045, Sensibility 100%, Specificity 91%. Therefore LA peak systolic strain could be considered a surrogate estimate of LV filling pressures. Conclusion LA peak systolic strain correlated significantly with LV systolic and diastolic function in young patients with acute myocardial infarction treated with primary PCI. Peak LA strain may be helpful as a complementary method to evaluate diastolic dysfunction in this patient population and may also improve the detection of elevated LV filling pressures.

P626 Peripartum cardiomyopathy with persistent ventricular dysfunction and intracavitary thrombosis despite treatment with dopamine receptors agonist. The role of the three-dimensional echocardiography

Abstract Introduction Peripartum cardiomyopathy (MPP) is a type of cardiomyopathy characterized by heart failure secondary to left ventricular systolic dysfunction during the last month of pregnancy or in the first 5 months of puerperium without other apparent etiology, being a diagnosis of exclusion. The left ventricle is not always dilated, but the fraction of left ventricular ejection is always less than 45%. The natural history and prognosis of the disease is diverse. Ventricular dysfunction is usually transient and normalizes at 3-6 months in up to 60% of cases. Mortality is variable, with reports ranging from 0 to 28%, affecting more certain ethnic groups, in patients with persistent ventricular dysfunction, evidence of the efficacy of a specific treatment beyond optimal medical therapy for heart failure is limited. Clinical case We present the clinical case of a 22-year-old woman, who was referred to the our institute with an acute heart failure syndrome two months after the end of her first pregnancy. On admission to the hospital, dilated cardiomyopathy and intracavitary thrombi were documented by transthoracic echocardiography (TTE) with dilatation and eccentric left ventricular hypertrophy, generalized hypokinesia and mobile thrombi inside, the largest of 34x16mm with severe left ventricular dysfunction 3D LVEF of 28% and global longitudinal strain (GLS) of -5.8%, pulmonary hypertension and right ventricular dysfunction with severe functional tricuspid regurgitation. Other specific etiologies of dilated cardiomyopathy were investigated and discarded, finally establishing the diagnosis of peripartum cardiomyopathy. The support management was carried with inotropic, diuretic, supplemental oxygen and parenteral anticoagulation was initiated, with gradual improvement. Subsequently, optimal medical treatment was started for heart failure, cabergoline and vitamin K antagonist. He was released to his home on II NYHA. Two months later she presented with progressive dyspnea, increased abdominal perimeter. On March 14, 2018, a TTE was performed, with absence of improvement in conventional and advanced ventricular function parameters. Apical thrombi of smaller size compared with previous study, severe left ventricular dysfunction, which worsened with respect to the previous echocardiogram, with 3D LVEF of 25% and GLS 3.7% Discussion We present the case of a woman with MPP, in whom persistent left ventricular dysfunction after 6 months of diagnosis, although cabergoline scheme in addition to optimal medical management for heart failure, with no improvement. In patients who dont present an adequate response to the management, it is necessary to consider enlisting for heart transplantation. Abstract P626 Figure. TTE, severe ventricular dysfunction

4300Strain parameters at rest and after exercise in symptomatically stable patients with improved heart failure - STRESS-HF

Abstract Background Optimal medical therapy (OMT) results in improvement in left ventricular (LV) ejection fraction (EF) and reduction in LV size in approximately 40% of patients of heart failure with reduced ejection fraction (HFrEF). Recent studies have proposed to continue treatment in all patients of this subgroup as improvement in LVEF does not indicate actual myocardial recovery. Global Longitudinal strain (GLS) is more sensitive marker of LV systolic function and better predictor of mortality than LVEF. GLS may identify probable patients in whom the therapy can be minimized or stopped. Aim To determine global longitudinal strain at rest and after exercise in patients with idiopathic dilated cardiomyopathy (DCM) who have improved LVEF ≥50% on guideline directed medical therapy (GDMT) and compare with resting & exercising LVEF on 3-dimesional (3D). Material and methods This Observational study was conducted in a tertiary care referral hospital, from February 2018 to October 2018. All patients with idiopathic DCM who had a documented LVEF of ≤40% in the past and improved LVEF (LVEF ≥50%) on GDMT were included in the study. Patients with secondary causes of HFrEF, poor echocardiographic window and inability to exercise were excluded from the study. Strain parameters were calculated at rest and after atleast 5 METS of exercise. GLS value of ≥ minus 12.6% was considered as mildly reduced strain, ≤ minus 8% as severely reduced strain and the values in between as moderately reduced strain. Post exercise, drop of >5% in absolute LVEF value or decrease in GLS >15% from baseline was considered as poor myocardial recovery. Results A total of 44 patients [mean age of 46.8±13.1 years and 24 males (54.5%)] constituted the study group. At the time of diagnosis, 31 (70.5%) patients were in NYHA class II and the remaining were in class III. Duration of GDMT ranged from 4 to 38 (median 12) months. Following improvement on GDMT, 25 (56.8%) were in class I and rest were in class II. Mean LVEF at diagnosis and after recovery was 33.6±4.9% and 55.1±4.5%, respectively with a mean absolute change in LVEF of 21.3±6.1%. At rest, mean 3D LVEF was 53±3.5% and GLS was −12.3±3.1. Mild, moderate and severely reduced strain was seen in 24 (54.5%), 13 (29.6%) and 7 (15.9%), respectively. After exercise, mean 3D LVEF was 51.5.±4.5% (mean decrease 1.5±2.1%) and mean GLS was −7±4.2% (mean decrease −5.3±4.6%). After exercise, none had a fall of LVEF >5% however 32 (72.7%) had a decrease of >15% in GLS. Seven (15.9%) patients had improvement in GLS, 4 (9.1%) had <15% decrease and 1 (2.3%) showed no change in GLS on exercise. The change in GLS on exercise was significant (p=0.001), but change in 3D LVEF was not significant (p=0.956). Conclusion Global longitudinal strain is a better marker for assessing myocardial recovery than LVEF in patients of heart failure with improved ejection fraction. Acknowledgement/Funding None

Real Time 3-D Echocardiography for Evaluation of Left Ventricular Systolic Function in Patients with Liver Cirrhosis Caused by Hepatitis C Virus

Background: Cardiovascular changes are associated with Liver cirrhosis so, it is important to assess its function in cirrhotic patients. Child-Pugh scoring system is the simplest clinical method used for classifying liver cirrhosis. 3D echo and 2D speckle tracking echocardiography (2D-STE) are the most recent imaging modalities able to evaluate LV systolic function accurately. Aim: To assess LV systolic function in patients with chronic liver cirrhosis caused by HCV by different echocardiographic modalities including 3D and STE and correlation of the results with the severity of cirrhosis based on Child-Pugh score. Material and methods: A prospective study was done in Cardiology Department, AlZahraa University Hospital including a total of 75 subjects; 45 cirrhotic patients and 30 subjects as a control. 2D, 3D LV volumes and EF and 2D-STE of the LV were measured. Then, the patients’ group was divided into 3 subgroups according to Child Pugh score then LV systolic function were assessed with different echo modalities (2D, 3D and MM, TDI (Sm) and, 2D STE). Results: The LVEF increased significantly in patient group by M-mode and 2D but decreased by TDI, 3D echo and STE. Increased systolic velocity (Sa) by TDI in group III of cirrhosis but lowered systolic function by using STE. Also, there was a significant correlation between severity of liver cirrhosis and LVEF by 2D STE, 3D and 2D. Conclusions: The recent noninvasive 3D echo and 2-D STE techniques are a promising methods for early detection of LV systolic dysfunction in asymptomatic patients with viral liver cirrhosis. Also, the LV systolic dysfunction is related to the extent of severity of liver cirrhosis.

Real Time 3-D Echocardiography for Evaluation of Left Ventricular Systolic Function in Patients with Liver Cirrhosis Caused by Hepatitis C Virus

Background: Cardiovascular changes are associated with Liver cirrhosis so, it is important to assess its function in cirrhotic patients. Child-Pugh scoring system is the simplest clinical method used for classifying liver cirrhosis. 3D echo and 2D speckle tracking echocardiography (2D-STE) are the most recent imaging modalities able to evaluate LV systolic function accurately. Aim: To assess LV systolic function in patients with chronic liver cirrhosis caused by HCV by different echocardiographic modalities including 3D and STE and correlation of the results with the severity of cirrhosis based on Child-Pugh score. Material and methods: A prospective study was done in Cardiology Department, AlZahraa University Hospital including a total of 75 subjects; 45 cirrhotic patients and 30 subjects as a control. 2D, 3D LV volumes and EF and 2D-STE of the LV were measured. Then, the patients’ group was divided into 3 subgroups according to Child Pugh score then LV systolic function were assessed with different echo modalities (2D, 3D and MM, TDI (Sm) and, 2D STE). Results: The LVEF increased significantly in patient group by M-mode and 2D but decreased by TDI, 3D echo and STE. Increased systolic velocity (Sa) by TDI in group III of cirrhosis but lowered systolic function by using STE. Also, there was a significant correlation between severity of liver cirrhosis and LVEF by 2D STE, 3D and 2D. Conclusions: The recent noninvasive 3D echo and 2-D STE techniques are a promising methods for early detection of LV systolic dysfunction in asymptomatic patients with viral liver cirrhosis. Also, the LV systolic dysfunction is related to the extent of severity of liver cirrhosis.

Role of Speckle Tracking Echocardiography in the Evaluation of Breast Cancer Patients Undergoing Chemotherapy: Review and Meta-analysis of the Literature.

Diagnosis and management of Cancer therapeutics-related cardiac dysfunction is of crucial importance in breast cancer (BC) patients. The role of advanced echocardiographic techniques, such as deformation imaging, in the diagnosis and characterization of patients receiving cancer therapy has so far involved relatively small studies in the research setting. Therefore, we conducted a meta-analysis and systematic review of observational studies evaluating myocardial changes during chemotherapy detected through conventional echocardiographic parameters, such as 2D left ventricular ejection fraction (2D LVEF), and 2D Speckle tracking echocardiography (STE). The literature search retrieved 487 research works, articles, of which 17 were found to be pertinent with this topic. After full article review, 16 studies were considered suitable for the present analysis. Two separate analyses, one for the anthracyclines-based therapeutic regimen and one for the trastuzumab based therapeutic regimen, were performed. A significant reduction in 2D LVEF and 2D STE parameters during cancer therapy was found in both the investigations. Peak systolic global longitudinal strain demonstrated to be the most consistent 2D STE parameter in detecting early myocardial changes among all the studies. Thus, we confirmed the role of 2D STE for the early detection of myocardial damage, suggesting its crucial role in monitoring BC patients and eventually driving the introduction of cardioprotective treatment.

3D echocardiographic global longitudinal strain can identify patients with mildly-to-moderately reduced ejection fraction at higher cardiovascular risk.

Severely reduced left ventricular (LV) ejection fraction (EF) derived from 2D echocardiographic (2DE) images is associated with increased mortality and used to guide therapeutic choices. Global longitudinal strain (GLS) is more sensitive than LVEF to detect abnormal LV function, and accordingly may help identify patients with mildly-to-moderately reduced LVEF who are at a similarly high cardiovascular (CV) risk. We hypothesized that 3D echocardiographic (3DE) measurements of EF and GLS, which are more reliable and reproducible, may have even better predictive value than the 2DE indices, and compared their ability to identify such patients. We retrospectively studied 104 inpatients with 2DE-derived LVEF of 30-50% who underwent transthoracic echocardiography during 2006-2010 period, had good quality images, and were followed-up through 2016. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Kaplan-Meier survival curves were generated for two subgroups defined by the median of each parameter as the cutoff. Of the 104 patients, 32 died of CV related causes. Cox regression revealed that 3D GLS was the only variable associated with CV mortality. Kaplan-Meier curves showed that 2D LVEF, 2D GLS and 3D EF were unable to differentiate patients at higher CV mortality risk, but 3D GLS was the only parameter to do so. Because 3D GLS is able to identify patients with mildly-to-moderately reduced LVEF who are at higher CV mortality risk, its incorporation into clinical decisions may improve survival of those who would benefit from therapeutic interventions not indicated according to the current guidelines.

Left ventricular global longitudinal strain following revascularization in acute ST elevation myocardial infarction – A comparison of primary angioplasty and Streptokinase-based pharmacoinvasive strategy

ObjectiveTenecteplase-based pharmacoinvasive percutaneous coronary intervention (PCI) has been shown to yield outcomes comparable to primary PCI in the setting of acute ST elevation myocardial infarction (STEMI). This study was designed to compare the efficacy of pharmacoinvasive PCI following successful thrombolysis with Streptokinase versus primary PCI in patients with STEMI. MethodologyWe conducted a prospective single center observational study in 120 patients with STEMI who underwent primary PCI (n=60) and Streptokinase-based pharmacoinvasive PCI (n=60). Patients with Killips class 3 or 4 at presentation, and those with evidence of failed fibrinolysis were excluded. The primary outcome was LV systolic function after angioplasty, as assessed by 2D global longitudinal strain (GLS) using speckle tracking echocardiography (STE), as well as 2D LVEF using Simpson's biplane method. ResultsLV systolic function after PCI was significantly lower in the pharmacoinvasive arm as compared to the primary PCI arm, both by 2D STE (GLS: −9% vs −11%; p=0.03) and 2D Simpson's biplane method (LVEF: 40.7% vs 45.1%; p=0.02). TIMI flow in the culprit vessel prior to angioplasty was better in the pharmacoinvasive arm indicating successful thrombolysis, whereas post angioplasty flow was not different. There was no in-hospital mortality in either group. There was a trend toward increased incidence of acute kidney injury in the pharmacoinvasive arm. ConclusionLV systolic function is significantly better after primary angioplasty as compared to pharmacoinvasive PCI following successful thrombolysis with Streptokinase.

Using three-dimensional echocardiography to guide left ventricle lead position in cardiac resynchronization therapy: does it make any difference.

Cardiac resynchronization therapy (CRT) is an effective treatment for patients with advanced heart failure. Nearly 30% of candidates are inadequate responders. Proper patient selection, left ventricle (LV) lead placement optimization, and optimization of the programming of the CRT device are important approaches to improve outcome of CRT. We examined the role of three-dimensional (3D) echocardiography in determining the optimal LV lead position as a method of optimizing CRT response. Forty-seven patients with a mean age of 60.2 ± 11.1years including five (10.6%) females, all having advanced CHF (EF <35%, LBBB >120mesc, or non-LBBB >150msec, with NYHA II-III or ambulatory class IV) were enrolled. Detailed history (NYHA class, Minnesota living with heart failure questionnaire), clinical examination, 6-min walk test, and standard 2D echocardiography were done in all cases. 3D echo detailed analysis of the LV 16 segments was done to determine the latest wall to reach the minimal systolic volume. Multisite pacing was done blind to the 3D echo data achieving a stable LV lead position in mid LV segment. This exact fluoroscopic site was determined (in two orthogonal views) and correlated with 3D most delayed area using a resized 16-segment schema. Patients were classified retrospectively into group A with concordance between the delayed LV area and LV lead position and group B with discordance between both. Patients were followed up after 3-6 (5.1 ± 1.8) months. Patients with reduction of 2D LV end-systolic volume of ≥10% at follow-up were termed volumetric responders. Poorly echogenic patients and those with decompensated NYHA class IV, sustained atrial arrhythmias, and rheumatic or congenital heart diseases were excluded. LV lead placement was concordant in 22 (46.8%) cases. After the follow-up period, 31 (65.9%) of the study population were considered volumetric responders with no significant difference among both groups (14 (63.3%) in group A vs 17 (68%) in group B, p > 0.05). CRT insertion resulted in significant improvement of NYHA class in 36 (76.5%) cases, 6-min walk test (447.2 ± 127.0 vs 369.6 ± 87.5m, p < 0.01), MLHFQ (58.1 ± 19.7 vs 69.6 ± 13.5, p < 0.01), QRS duration (131.2 ± 13.8 vs 149.4 ± 16msec, p < 0.01), 2D LV EF 33.0 ± 9.5 vs 25.3 ± 6.5, p < 0.001), LVESV (156.0 ± 82.9 vs177.6 ± 92.7ml, p < 0.05), and 3D LVEF (29.1 ± 9.0 vs 23.6 ± 5.9, p < 0.001) irrespective of the etiology of heart failure. However, there were no significant differences between both groups regarding the same parameters (6-min walk test 470.8 ± 128.7 vs 428.3 ± 126.8m, MLHFQ 56.8 ± 20.0 vs 58.11 ± 19.0, QRS duration 129.9 ± 12.4 vs 132.1 ± 15.1msec, 2D LVEF 30.9 ± 8.3 vs 34.58 ± 10.9, LVESV 173.0 ± 110.0 vs 143.0 ± 67.9, 3D LVEF 26 ± 8 vs 31 ± 9, for groups A and B, respectively, p < 0.05). Standard anatomical LV lead placement remains a simple, practical, and effective method in patients undergoing CRT. 3D echocardiography-guided LV lead placement added no clinical benefit compared to standard techniques.

Improving Quantitation of Left Ventricular Ejection Fraction in a Tertiary Echocardiography Lab- Merging Guidelines with Practice

Background: The American Society of Echocardiography strongly recommend quantitative assessment of LVEF on transthoracic echocardiographic (TTE) by 2DE; Modified Simpson's rule or 3D echocardiography (3DE) where available. Purpose: To assess whether education and implementation of the guidelines results can improve the performance and reporting of 2DE/3DE quantitative LVEF and quality improvement. To validate whether the use of automated 3D technology (Philips HeartModelA.I.(HM)) can produce accurate and reproducible online 3DE measurements of LVEF. Methods: Consecutive TTE studies performed over a month prior to and after education intervention and guideline implementation were included. Baseline TTE studies were assessed whether quantitative LVEF was performed by the sonographer and included in the final report by the cardiologist. HM was then utilised prospectively and correlated with conventional 3DE LVEF as the reference. Results: 1422 TTEs (664 before and 758 after intervention) were included. Pre-intervention, the quantitative LVEF was calculated in 27% and 33% were included in the final report. Following educational intervention, these increased to 45% and 52% respectively. 3DE LVEF (by HM) in 48 patients demonstrated good correlation and agreement with conventional 3D LVEF (intraclass correlation coefficient 0.89; p < 0.0001)and good test-retest reproducibility (intra-observer variability 0.2 + -1.0% and inter-observer variability 2.7 + - 2.8%). Conclusions: In a busy clinical echocardiography laboratory, over-reliance on visual estimation of LVEF remains common. Education and implementation of guidelines improves confidence, performance, and reporting of quantitative 2DE LVEF. Incorporation of new automated technology 3DE LVEF (using HM) is feasible, accurate and reproducible.

Consistencies of 3D TTE global longitudinal strain of both ventricles between assessors were worse for 2D, but better for 3D ventricular EF

PurposeWe evaluated the consistency of different-assessors in estimating three-dimensional (3D) global-longitudinal-strain (GLS) of left (LV) and right ventricle (RV) using transthoracic-echocardiography (TTE) for LV and RV systolic-function. We compared results from two-independent-specialists using this-approach for 3D LV and RV parameters in a population with 74% hypertrophic-cardiomyopathy (HCM) patients. Methods58 patients (43 HCM (32 male; 62±15years) and 15 controls (5 male; 53±22years)) underwent TTE (Vivid-E9) to measure 2D and 3D GLS of the LV and RV by two-independent-specialists. ResultsConsistencies of estimates of 3D LV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection-fraction (EF) between the two-assessors were 0.872 (3D LVEDV, P<0.001), 0.797 (3D LVESV, P<0.001), and 0.215 (3D LVEF, P=0.105). Consistencies of 2D and 3D LV GLS between two-assessors were 0.900 (2D LVGLS, P<0.001) and 0.874 (3D LVGLS, P<0.001). Consistencies of estimates of 3D RVEDV, RVESV, and RVEF between two assessors were 0.781 (3D RVEDV, P<0.001), 0.755 (3D RVESV, P<0.001), and 0.26 (3D RVEF, P=0.049). Consistencies of 2D and 3D GLS of whole RV and those of RV free wall only between two-assessors were 0.886 (2D GLS of whole RV, P<0.001), 0.687 (3D GLS of whole RV, P<0.001), 0.707 (2D GLS of RV free wall, P<0.001), and 0.630 (3D GLS of RV free wall, P<0.001). ConclusionsConsistencies of independent-estimates of 3D GLS of the LV and RV using TTE between two-assessors were worse than for 2D GLS of the LV and RV, but better than for 3D LVEF and RVEF in a population with 74% HCM patients.