Complete Echocardiography Research Articles

Clinical impact of right atrium function on tricuspid regurgitation

Abstract Background tricuspid regurgitation (TR) is frequent, and its related systemic venous congestion is associated with mortality. Purpose This study aims to evaluate the role of right atrial (RA) function, measured using the strain technique, on the medium- to long-term clinical effects of tricuspid regurgitation (TR). Our primary objective was to analyze the impact of RA function, measured at baseline, on a composite endpoint consisting of death and/or hospitalization for predominantly right-sided heart failure. The secondary endpoints are hospitalizations, worsening of renal function, and an increase in diuretic dosage (DD). Methods We performed a single center, prospective, observational study regarding adult patients with tricuspid regurgitation and measurable effective regurgitant orifice area (EROA) and a state of hemodynamic stability that underwent a complete echocardiography and full cardiologic evaluation in our Institution, from January 2020 to February 2023. Those patients with acute HF, poor quality imaging, previous repair or prosthetic replacement of the tricuspid valve, and severe renal or hepatic insufficiency were excluded. Patients were assessed clinically at each follow up. Results 134 patients were included (females 62%, mean age 73 ± 13 years old). Median follow up was 23,5 months (12 - 34 months). TR was functional in 87% of cases and was more than moderate in 52% of cases. Mean RA strain was 18,7 ± 11,2%, and divided patients in low strain (LS) and high strain (HS). HS was associated with lower increase and frequently a decrease in DD (-5,5 ± 44,7 mg vs 20,8 ± 63,2 mg, p = 0,009) but no echocardiographic variable independently predicted an increase in DD. Patients with worsening renal function had significantly lower RA (16.7 ± 10.6% vs 20.7 ± 10.9%, p 0.042). LS independently predicted a worsening renal function (OR 3,07; 95% CI 1,026-9,2). RA strain was significantly lower in hospitalized patients (13.1 ± 8 vs 20.3 ± 11.4, p<0.001). Cox regression analysis showed a LS to be an independent predictor of the composite endpoint (adjusted HR 3.1, 95% CI 1.101 – 8.74) correcting for other clinical and echocardiographic variables. ROC curve analysis showed an RA strain cut-off of 18.5% to have a sensitivity of 79% and specificity of 56% in predicting the combined endpoint. Conclusions RA strain is associated with DD and LS patients have higher DD at follow up. RA strain is an independent predictor of worsening renal function. RA function measured by strain is an independent predictor of the composite endpoint of death and/or hospitalization.

Right heart morphology and function in patients with severe aortic stenosis and cardiac amyloidosis

Abstract Background Additional cardiac amyloidosis (CA) in severe aortic stenosis (AS) is prevalent in around 8% of AS patients and leads to increased morbidity and mortality. Since both conditions cause comparable symptoms and echocardiographic characteristics of the left ventricle, such as apical sparing and left ventricular wall thickening, diagnosis of CA is challenging in clinical practice. Purpose The present substudy of the SAVER trial aims to compare right heart morphology and function in AS patients with and without additional CA. Methods From 2020 to 2023, AS patients planned for surgical (SAVR) or transcatheter aortic valve replacement (TAVR) with complete echocardiography of the right heart were enrolled in the SAVER study. Transthoracic echocardiography was performed during AS evaluation prior to SAVR or TAVR and, in case of suspected CA, patients underwent further diagnostics including bone scan or MRI. In the present subanalysis, we compared right heart morphology and function of AS patients with and without additional CA as confirmed by bone scan or MRI. Results A total of 28 AS patients were analyzed, including 13 patients with additional CA. The median age was 81±6 years, 75% of patients were male, and 96% were treated with TAVR. Left ventricular wall thickness was comparable between AS patients with and without CA. Regarding right heart morphology and function, AS patients with CA presented a tendency to larger right atrial and ventricular dimension (right atrial area: AS with CA 22 [12-32] mm² vs. AS 17 [8-26] mm²; right ventricular diameter basal: AS with CA 42 [32-52] mm vs. AS 38 [29-47] mm) and a reduced right ventricular function measured by right ventricular fractional area change (AS with CA 37±10% vs. AS 46±11%), right ventricular global (AS with CA -15±6% vs. AS -22±6%) and free wall strain (AS with CA -18±7% vs. AS -19±5%). Right ventricular wall thickness was comparable between both groups and reached 5±1mm. Further echocardiographic parameters are listed in Table 1. Conclusion AS patients with additional CA presented a tendency towards reduced right ventricular function and a more dilated right heart compared to AS patients without CA. These parameters may help to differentiate between both conditions in clinical practice.

Myocardial mechanics and outcomes after transcatheter aortic valve replacement. Does strain rate have added prognostic value?

Abstract Introduction Transcatheter aortic valve implantation (TAVI) has firmly become treatment option for elderly and/or high-risk patients with severe symptomatic aortic stenosis. Studies have shown that TAVI induces improvement in left ventricular (LV) systolic function, quantified using global longitudinal strain (GLS). Purpose To test if improvement in longitudinal deformation post TAVI is associated with changes in strain rate – the only non-invasive echo parameter associated with myocardial contractility. We wanted to assess impact of changes in longitudinal deformation and strain rate (SR) on clinical outcomes. Methods We studied retrospectively all consecutive patients who underwent TAVI in our Valve specialist center from 1st April 2023 to 31st March 2024. All participants underwent a transthoracic echocardiogram before and within 3 months following TAVI. We have re-measured mean trans-valvar pressure gradients and performed offline speckle tracking analysis using dedicated software (TomTec and GE EchoPAC) before and after TAVI. Data on all-cause mortality and cardiac hospitalizations were obtained from electronic medical records. Results Overall, 305 patients (mean age of 81±7.7 years) with severe aortic stenosis underwent TAVI. 255/305 patients (83%) had a successful and uncomplicated TAVI procedure, 26 (8.5%) developed complete heart block requiring permanent pacemaker insertion during the index admission, 15 (4.9%) experienced vascular access complications (pseudoaneurysm, haematoma), 5 (1.6%) developed haemopericardium requiring drainage and 5 (1.6%) had TAVI-related stroke, all patients were discharged with routine F/U in place. 247 (81%) who had complete echocardiography data were included into analysis, 45% were female. Significant reduction in trans-valvar gradient was accompanied by significant improvement in LV myocardial and endocardial GLS and average LV strain rate post-TAVI. The mean follow-up period was 246±107 days. There were 8 cases contributing to all-cause mortality and 12 cardiac hospitalizations. There was a significant difference in SR between alive and deceased patients (0.94±0.3 vs. 0.70±0.2, P=0.026). Post TAVI strain rate (HR 45.6; 95% CI 1.67 to 124.6, P<0.05) was the only independent predictor of all-cause mortality. Conclusion TAVI produces significant early improvement in LV mechanics. LV strain rate is an important independent predictor of all-cause mortality post TAVI. The addition of LV SR during echocardiographic assessment may be of value for the early identification of TAVI patients who are at greatest risk and who may benefit from early intensified risk factor management. KM CURVE: SR & ALL CAUSE MORTALITY

Hypertension and cardiac damage in pheochromocytoma and paraganglioma patients: a large-scale single-center cohort study

BackgroundHypertension (HT) is one of the most common manifestations in patients with catecholamine-secreting neuroendocrine tumors. Although the cardiovascular manifestations of these tumors have been described, there have been no large-scale investigations of the profile of HT and changes in cardiac structure and function that occur in patients with pheochromocytomas and paragangliomas (PPGL).Materials and methodsIn this study, we investigated the prevalence of HT and left ventricular remodeling (LVR) in a cohort of 598 patients who underwent surgery for PPGL at our center between January 2001 and April 2022. Information on demographics, reason for hospitalization, medical history, biochemical parameters, findings on echocardiography, and tumor characteristics were recorded. The LVR index was compared according to whether or not there was a history of HT.ResultsThe average age was 47.07 ± 15.07 years, and 277 (46.32%) of the patients were male. A history of HT was found in 423 (70.74%) of the 598 patients. Paraganglioma was significantly more common in the group with HT (26.00% vs. 17.71%, P = 0.030) and significantly less likely to be found incidentally during a health check-up in this group (22.93% vs. 59.43%, P < 0.001). Among 365 patients with complete echocardiography data, left ventricular mass index (86.58 ± 26.70 vs. 75.80 ± 17.26, P < 0.001) and relative wall thickness (0.43 ± 0. 08 vs. 0.41 ± 0.06, P = 0.012) were significantly higher in patients with PPGL and a history of HT. The proportions with left ventricular hypertrophy (LVH) (19.40% vs. 8.25%, P = 0.011) and LVR (53.73% vs. 39.18%, P = 0.014) were also higher when there was a history of HT. After adjusting for age, gender, body mass index, alcohol consumption, smoking status, diabetes, stroke, creatinine level, tumor location, and tumor size, a history of HT was significantly correlated with LVH (odds ratio 2.71, 95% confidence interval 1.18–6.19; P = 0.018) and LVR (odds ratio 1.83, 95% confidence interval 1.11–3.03; P = 0.018).ConclusionHT is common in patients with PPGL (70.74% in this cohort). PPGL without a history of HT is more likely to be found incidentally (59.43% in our cohort). HT is associated with LVR in PPGL patients with complete echocardiography data. These patients should be observed carefully for cardiac damage, especially those with a history of HT.

The vertebral right heart index: A new radiographic method to assess right heart enlargement in dogs.

In veterinary medicine, the radiographic assessment of right heart enlargement (RHE) is essentially subjective. The aim of this study was to evaluate the vertebral right heart index (VRHi) as a new quantitative radiographic method to detect RHE in dogs. This was a multicenter, retrospective, observational study, including dogs with RHE and control dogs. All dogs had to have a thoracic radiographic study and a complete echocardiography on the same day. Right heart enlargement was defined as the presence of right atrial enlargement, right ventricular enlargement, and/or hypertrophy based on echocardiography. For the radiographic study, all the radiographic views available for each case were considered for measurement: right lateral (RL), left lateral (LL), ventrodorsal (VD), and dorsoventral (DV). The VRHi was measured using LL, RL, VD, and DV views. A total of 204 dogs were included: 91 dogs with RHE and 113 control dogs. The VRHi (RL), the VRHi (LL), and the VRHi (VD) were significantly greater in dogs with RHE compared with controls (P<.0001). The best diagnostic accuracy was observed for VRHi (LL) (area under the curve [AUC] 0.86, P<.0001; cutoff≥3.5 vertebrae, sensitivity [Se] 71%, specificity [Sp] 89%), followed by VRHi (RL) (AUC 0.85, P<.0001; cutoff≥3.5 vertebrae, Se 68%, Sp 86%) and VRHi (VD) (AUC 0.80, P=.0004; cutoff≥3.0 vertebrae, Se 57%, Sp 95%). In conclusion, the lateral VRHi in LL and RL and the VD VRHi could represent useful radiological tools for the detection of RHE in dogs.

Noninvasive pressure-strain loop quantitative assessment of left ventricular function in anemic preterm infants with different modes of respiratory support

To investigate noninvasive pressure-strain loop (PSL) combined with two-dimensional speck tracking imaging and left ventricular pressure measurement in the evaluation of cardiac function changes in anemia of prematurity (AOP) with different modes of respiratory support, and to explore its value in detecting subclinical myocardial injury in preterm infants. This retrospective study included 79 preterm infants with anemia, according to different modes of respiratory support, who were divided into invasive respiratory support group (39 cases) and noninvasive respiratory support group (40 cases). A control group of 40 nonanemic preterm infants with matched age, sex, and gestational age were also included. Complete echocardiography was performed for each included infant. There are PSL parameters that used to evaluate cardiac function, including global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) among the three groups were compared. Compared with the control group, the value of GWI, GCW, and GWE were significantly lower and GWW was higher in the AOP groups (P < 0.05), and GWI, GCW and GWE were much significantly lower in the invasive respiratory support group than in the noninvasive respiratory support group (P < 0.05). There was no significant difference in GLS among the three groups (P > 0.05). Noninvasive PSL analysis can quantitatively assess myocardial work in AOP with different respiratory support, which is more sensitive than other conventional echocardiographic indices. This technique may provide a new method for monitoring subclinical myocardial injury with AOP.

Positive additive interaction effects of age, sex, obesity, and metabolic syndrome on left ventricular dysfunction.

This study aims to explore the association between metabolic syndrome (MetS) and left ventricular diastolic dysfunction (LVDD) and systolic dysfunction (LVSD), defined by impaired global longitudinal strain (GLS), and assess additive and multiplicative interactions among age, sex, obesity, and MetS regarding LVDD and LVSD. We prospectively recruited 5503 participants from the China PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons Project with complete echocardiography exam. Multivariable logistic models were used to calculate adjusted odds ratios to evaluate both additive and multiplicative interactions. The mean age was 56.59 years; 59.4% were women, 46.7% had MetS, 26.6% had left ventricular hypertrophy, 46.3% had LVDD, and 12.50% had impaired GLS. Compared to the non-MetS, the odds ratio (OR) of LVDD and impaired GLS in MetS were 1.40 (1.20-1.64) and 1.26 (1.03-1.54), respectively. For LVDD, relative excess risk due to additive interaction (RERI) for women and MetS, elderly and MetS, obesity and MetS were 0.76 (0.02-1.50), 35.65 (17.51-53.79), and 2.14 (0.66-3.62), respectively, thus suggesting additive interactions. For impaired GLS, RERI for obesity and MetS was 3.37 (0.50-6.24), thus suggesting additive interactions. The MetS is independently associated with LVDD and impaired GLS. From the public health implications, prevention of MetS in women, elderly, and obese individuals might result in a greater reduction of LVDD and LVSD risk in cardiovascular high-risk population.

Left atrial strain significance in prediction of early atrial fibrillation recurrence after cardioversion and ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The fibrosis of the LA, which is characteristic of AF, causes mechanical dysfunction of the LA and may also be present in patients without LA enlargement. LA strain represents a surrogate marker of this mechanical dysfunction. Early detection of LA dysfunction may be crucial in identifying patients who are more likely to experience AF recurrence following cardioversion and ablation. Before cardioversion and ablation, the probability of AF recurrence might be predicted, which could lead to better patient selection, an individualized therapeutic strategy with reduced risk and focused follow-up. Purpose The aim of this study was to evaluate the additional predictive value of LA function assessed by using strain echocardiography for early AF recurrence after cardioversion and ablation. Methods 94 patients diagnosed with symptomatic persistent atrial fibrillation (EHRA symptom score ≥3 (mean age 59.4 ± 12.2 years, 58% male, 42%female), preserved LV ejection fraction were prospectively analyzed. In 39 (41,5%) patients pharmacological cardioversion was done after saturation with antiarhythmic drugs,in 27 (28,7%) patients planed electrical cardioversion was done after medical saturation with antiarrhythmic drugs and failure of pharmacological cardioversion, and in 28 (29,8%) patients planed RF ablation was performed. Complete echocardiography evaluation including strain and volume index LA was performed before cardioversion and ablation. The rhythm evaluation was done in the first month after cardioversion and RF ablation (35±5 days). The primary endpoint was persistent AF recurrence. Results 29 (30,8%) patients had AF recurrence in the overall study population, independently of duration of AF or method of rhythm control. Peak atrial longitudinal strain (PALS) ≤15% had the highest incremental predictive value for AF recurrence (HR =8.42, 95% CI: 3.17–25.12, p &amp;lt; 0.001). In patients with non-dilated LA, PALS≤15% remained an independent predictor of AF recurrence (HR = 5.32, 95% CI: 1.77–17.42, p = 0.005). Conclusion This study shown that, in addition to LA dilatation, LA function as determined by PALS can provide a prognostic value for early AF recurrence after cardioversion or ablation. PALS also predicted AF recurrence in patients with nondilated LA. These findings highlight the additional prognostic usefulness of LA strain and recommend its implementation in the systematic assessment of AF patients prior to the choice of rhythm/rate control.

New generation of LCPM and left atrial strain: a promising predictor of atrio-ventricular synchrony in leadless pacemaker pacing

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Leadless cardiac pacemakers (LCPMs) are a new alternative to traditional transvenous pacemaker. They recently have evolved from a single chamber VVI-R pacemaker to devices that can provide atrio-ventricular synchrony (AVS) in patient with sinus rhythm through an 3-axis accelerometer, detecting atrial contractions. To date, Micra AV Transcatheter Pacing System (Medtronic) is the only LCPM on the market that provides AVS. Purpose Many efforts have been made to identify clinical predictors of a good A4 signal amplitude, that determines the ability of the Micra-AV to pace while maintaining AVS (1). Our exploratory study investigates the utility of Left Atrial strain (LAs) for this purpose. Methods Data was extracted from the Cardiac Interventional Registry implemented at our hospital and approved by local ethic committee. Six patients, implanted with Micra-AV (72±13 years), underwent to a complete echocardiography focused on left atrium (LA). Morphological (LA diameters, 2d LA volume and 2d LA area) and functional (EA ratio and LAs study) parameters were assessed. An echocardiography core laboratory studied LAs (Figure A), using a dedicated software (Philips, Epiq 7-Auto Strain Tomtec Application): LA Reservoir Strain (LAsr), LA Conduit Strain (LAscd) and LA Contraction Strain (LAsct) were measured (2). All patients after implantation had a complete electronic control of leadless pacemaker to assess A4 wave amplitude. Results We found that A4 wave amplitude was inversely correlated to 2D-LA volume (Spearman's coefficient rho=-0.96; p=0.003), while it was positively related to LAsr (rho=0.81; p=0.05) and LAsct absolute value (Figure B). In the last years, in addition to the traditional echocardiographic parameters, LA was studied with a new functional parameter, LAs (3). The MARVEL2 study showed that A4 amplitude is fundamental to ensure a high AVS percentage; it was directly related to a parameter defined generically "atrial strain" (4). It is known that LAs is a complex parameter that indicates how the left atrium works overall. Today, thanks to the technological developments of the new echocardiographic software, it can be evaluated more precisely in its components. According to our preliminary data the components that predict A4 amplitude are specifically LAsr and LAsct: we found higher value of A4 in patients that have grater absolute value of these LAs parameters. LAsr is related to the atrial filling and depends on atrial stiffness and fibrosis, LAsct is an indicator of LA ability to empty, thus contributing to the final stage of ventricular diastolic filling. These are simple measurable parameters of LA functional capacity and they seem capable of predicting the possibility of a good AVS in LCPM pacing. Conclusion Patient selection is crucial to obtain good clinical outcomes. In this context, echocardiographic parameters and particularly the LAs study look promising to make a correct choice.

P176 GLOBAL LONGITUDINAL STRAIN AS A PREDICTOR OF RESPONSE TO CARDIAC CONTRACTILITY MODULATION IN PATIENTS WITH HEART FAILURE: A CASE SERIES

Abstract Background Cardiac contractility modulation (CCM) in heart failure (HF) patients with reduced ejection fraction (HFrEF) is an innovative therapy which may contribute to increased exercise capacity and quality of life and reduced hospitalizations. With speckle–tracking echocardiography and global longitudinal strain (GLS), changes in myocardial function can be detected with greater sensitivity than conventional approaches for measuring diastolic and systolic function, including left ventricular ejection fraction. We aim to analyze the usefulness of GLS in detecting improvement in systolic function and response to CCM treatment. Methods We studied 5 patients with CCM referred to our outpatient cardiology clinic. All patients underwent complete echocardiography with evaluation of GLS and ejection fraction. Follow–ups were performed at 1, 3, and 6 months. Results All patients were men (mean age 65.3±15.7 yrs). Mean baseline ejection fraction was 37.1±9.3%, mean GLS was 7.7±3.1%, and patients had mild–to–moderate left ventricular enlargement (mean indexed telediastolic volumes 101.4±8.7 ml/m2). Follow–up performed at the first month showed values similar to baseline values. Between the third and sixth months, a non–significant improvement in ejection fraction and GLS was recorded (EF 40.75±9.6% p=0.51; GLS 8.9±4.2 p=0.62). Indexed telediastolic volumes were reduced (101.4±9.3 ml/m2 vs 89.5±7.4 ml/m2 p=0.05). Conclusions CCM therapy seems to be useful in achieving volumetric remodeling in patients with HFrEF. GLS assessment may be useful in detecting improvement in systolic function. Further studies with larger samples and longer follow–up are needed to confirm these results.

Incidence and risk factors of late right heart failure in chronic mechanical circulatory support.

Late right heart failure (LRHF) is a common complication during long-term left ventricular assist device (LVAD) support. We aimed to identify risk factors for LRHF after LVAD implantation. Patients undergoing primary LVAD implantation between 2006 and 2019 and surviving the perioperative period were included for this study (n = 261). Univariate Cox proportional hazards analysis was used to assess the association of clinical covariates and LRHF, stratified for device type. Variables with p < 0.10 entered the multivariable model. In a subset of patients with complete echocardiography or right catheterization data, this multivariable model was extended. Postoperative cardiopulmonary exercise test data were compared in patients with and without LRHF. Nineteen percentage of patients suffered from LRHF after a median of 12 months, of which 67% required hospitalization. A history of atrial fibrillation (AF) (HR: 2.06 [1.08-3.93], p = 0.029), a higher preoperative body mass index (BMI) (HR: 1.07 [1.01-1.13], p = 0.023), and intensive care unit (ICU) duration (HR: 1.03 [1.00-1.06], p = 0.025) were independent predictors of LHRF in the multivariable model. A significant relation between the severity of tricuspid regurgitation (TR) and LRHF (HR: 1.91 [1.13-3.21], p = 0.016) was found in patients with echocardiographic data. Patients with LRHF demonstrated a lower maximal workload and peak VO2 at 6 months postoperatively. A history of AF, BMI, and longer ICU stay may help identify patients at high risk for LRHF. Severity of TR was significantly related to LRHF in a subset of patients.

Association of Plasma Myeloperoxidase with Inflammation and Diabetic status in HFpEF.

Inflammation and oxidative stress are thought to play an important role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF) through the development of endothelial dysfunction. Myeloperoxidase (MPO) functions as a link between oxidative stress and inflammation and is an interesting therapeutic target. The objective of this observational cohort study was to compare MPO levels between HFpEF and old controls, to define clinical characteristics associated with high levels of MPO and to assess the relation between MPO levels and vascular function. Patients with HFpEF (N = 55) and controls 60 years (N = 18) were prospectively included. All subjects underwent complete echocardiography and blood sampling. MPO levels were dosed by ELISA assay. Effective arterial elastance (Ea) and peripheral arterial tonometry (EndoPAT reactive hyperemia index RHI and augmentation index AIx) were used to assess vascular function. Characteristics between groups defined by the median of MPO were compared using independent samples t-test or chi square test. Patients with HFpEF (80 8.7 years, 65% female) had higher levels of MPO compared to controls (75 5.0 years, 72% female) (34.7 ng/mL [22.7; 44.0] vs 22.6 [18.2; 32.0], p = 0.026). MPO levels were correlated with markers of inflammation; C-reactive protein (Pearson's R = 0.46, p = 0.001) and neutrophile to lymphocyte ratio (R = 0.36, p = 0.031) and with signs of left ventricular (LV) remodelling and elevated filling pressures, namely NT-proBNP levels (R = 0.32, p = 0.019), decreased LV ejection fraction (LVEF, R = -0.36, p = 0.008) and E/e' ratio (R = 0.35, p = 0.011). HFpEF patients with levels of MPO above the median were more often men (48% vs 21%, p = 0.037) and suffered more often from diabetes (48% vs 18%, p = 0.017). Intriguingly, they had lower indices of vascular stiffness (augmentation index 11.1 [0.1; 30.7] vs 19.9 [10.5; 33.4], p = 0.018 and arterial elastance Ea 2.06 0.676 vs 2.43 0.721, p = 0.065) and there was no difference in endothelial function (1.82 [1.34; 2.30] vs 1.66 [1.32; 1.95], p = 0.55). HFpEF patients have higher levels of MPO than controls, reflecting leukocyte activation and oxidative stress. Among patients, high levels of MPO are associated with male sex, diabetic status, subtle left ventricular dysfunction and pronounced diastolic dysfunction. The association between oxidative stress and vascular stiffness, on the other hand could not be demonstrated. Clinical trial NCT03197350.

Impact of pulmonary arterial systolic pressure on patients with mitral valve disease combined with atrial fibrillation.

To determine whether different changes of pulmonary artery systolic pressure (PASP) after surgeries have an impact on the long-term outcomes in patients with rheumatic and degenerative mitral valve (MV) disease and atrial fibrillation. Between 2004 and 2016, 1,188 patients with rheumatic and degenerative MV disease undergoing MV and Cox-Maze procedure were identified. Clinic outcomes, as well as rhythm state and echocardiography indices in long-term follow-up were recorded. Patients were grouped by the changes of PASP (persistently normal, persistently increased, increased, and decreased) from preoperative estimation to follow-up. A complete echocardiography was performed at baseline and after 5 years. During follow-up, free of death and atrial fibrillation (AF) off antiarrhythmic drugs was 90 and 61%, 78 and 41% at 5 and 10 years, respectively. Survival rate was higher in patients with persistently normal and became worse in patients with persistently increased and increased PASP (log-rank 166.0, P < 0.0001). Moreover, the patients with persistently normal PASP had a lowest risk of recurrent AF (SHR: 0817; CI: 0.765-0.872; P < 0.0001) after considering death as a competing risk. A persistently normal PASP at follow-up and degenerative MV disease were associated with improved survival and sinus rhythm (SR) maintenance at multivariable Cox regression analysis (P < 0.05). Patients with degenerative MV disease or have persistently normal PASP during follow-up have better survival and SR maintenance rate than patients with either rheumatic MV disease or persistently abnormal PASP.

Strain Longitudinal Global como Preditor de Cardiotoxicidade Induzida por Quimioterapia

Background: Chemotherapy-induced cardiotoxicity (ChC) is an important complication among patients receiving anthracyclines. Biomarkers and imaging parameters have been studied for their ability to identify patients at risk of developing ChC. Left ventricular global longitudinal strain (LV-GLS) is a sensitive parameter for detecting systolic dysfunction despite the presence of preserved left ventricular ejection fraction (LVEF). Objective: To evaluate the role of the LV-GLS as a predictor of ChC. Methods: This was a post-hoc analysis of the Carvedilol for Prevention of Chemotherapy-Related Cardiotoxicity trial, which evaluated the primary prevention of cardiotoxicity with carvedilol during doxorubicin chemotherapy in a population of patients with breast cancer. Cardiotoxicity was defined as a reduction ≥10% in LVEF. LV-GLS was determined before chemotherapy in patients with no prior cardiovascular disease or echocardiogram abnormalities. Results: Thirty-one patients for whom a complete echocardiography study including measurement of LV-GLS was performed before chemotherapy were included in this analysis. An absolute LV-GLS&lt;16.9% before chemotherapy showed 100% sensitivity and 73% specificity for predicting cardiotoxicity (area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.680–0.959; p&lt;0.001). In this population, LVEF values before chemotherapy did not predict ChC (95% CI, 0.478 to -0.842; p=0.17). The association of low LV-GLS (&lt;17%) and brain-type natriuretic peptide serum levels (&gt;17 pg/mL) at 2 months after chemotherapy increased the accuracy for detecting early-onset ChC (100% sensitivity, 88% specificity; AUC, 0.94; 95% CI, 0.781–0.995; p&lt;0.0001). Conclusions: Our data suggest that LV-GLS is a potential predictor of ChC. Larger studies are needed to confirm its clinical relevance in this clinical setting.

608 PEAK ATRIAL SYSTOLIC LONGITUDINAL STRAIN (PALS) AS AN EARLY PARAMETER OF CANCER THERAPY-RELATED CARDIAC DYSFUNCTION

Abstract Background Trastuzumab (TZ) is widely used for his key role in HER2 positive breast cancer. However, the most concerning cardiovascular complication is cardiotoxicity. Many studies have highlighted the importance of screening for subclinical myocardial dysfunction using left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, there are only few studies investigating a possible atrial damage. Purpose Aim of this study was to analyze the modification peak atrial systolic longitudinal strain (PALS) in patients undergoing therapy with TZ in a follow-up period of 12 months. The fluctuation of left atrial function parameters under chemotherapy was evaluated focusing the attention on those patients who developed cancer therapy–related cardiac dysfunction (CTRCD). Methods 116 women affected by breast cancer treated with TZ were enrolled. Each patient underwent a complete echocardiography at baseline and every 3 months. Exclusion criteria were poor quality imaging and lack of a complete follow up with consequent missing data. CTRCD was defined as a decrease in the left ventricular ejection fraction of &amp;gt;10 percentage points to a value &amp;lt;53% at any time of follow-up. 2D-Speckle tracking analysis was performed at baseline and at each examination using Tomtec software to analyze both atrial and left ventricular function. Trends of GLS, and PALS during 12 months-follow up periods were analyzed. Additionally, we explored if diabetes and renal impairment were associated with more prevalent atrial subclinical disfunction as demonstrated in previous studies. Results A total of 10 patients (9%) developed cancer therapy–related cardiac dysfunction. A significant reduction in GLS compared to the baseline was observed during the whole follow-up (p=0.05), starting in the first six months of treatment (-21 ± 2% vs -17 ± 2%, p= 0.021). Interestingly, PALS showed a similar trend with a significant decrease during the whole 12 months-follow up (p=0.012), starting in the first 3 months (45 ± 9% vs 35 ± 8%, p=0.001). 6 patients presented a diagnosis of diabetes at baseline, and presented lower PALS compared to the non-diabetic counterpart (38± 10% vs 49 ± 12% p=0.03). 2 patients presented a significant renal impairment (eGFR ≤30 ml/min). Similarly, these patients presented a lower PALS at baseline (32 ± 7% and 48 ± 7%; p=0.055). Conclusions In patients treated with Trastuzumab the development of left atrial impairment is frequent and PALS modifications seem to precede GLS variations in patients with CTRCD, suggesting a possible cardiotoxic effect of such therapy on both atrial and left ventricular myocardium and physiology.

Right Ventricle Involvement by Glycogen Storage Cardiomyopathy (PRKAG2): Standard and Advanced Echocardiography Analyses.

PRKAG2 syndrome is a rare, early-onset autosomal dominant inherited disease. We aimed to describe the right ventricle (RV) echocardiographic findings using two and three-dimensional (2D and 3D) modalities including myocardial deformation indices in this cardiomyopathy. We also aimed to demonstrate whether this technique could identify changes in RV function that could distinguish any particular findings. Thirty patients with genetically proven PRKAG2 (R302Q and H401Q), 16 (53.3%) males, mean age 39.1 ± 15.4 years, underwent complete echocardiography examination. RV-focused, 4-chamber view was acquired for 2D and 3D measurements. Student's t or Wilcoxon-Mann-Whitney tests were used to compare numerical variables between 2 groups, and p < 0.05 was considered significant. Twelve patients (40%) had a pacemaker implanted for 12.4 ± 9.9 years. RV free wall mean diastolic thickness was 7.9 ± 2.9 mm. RV 4-chamber longitudinal strain (RV4LS), including the free wall and interventricular septum, was -17.3% ± 6.7%, and RV free wall longitudinal strain (RVFWLS) was -19.1% ± 8.5%. The RVFWLS apical ratio measured 0.63 ± 0.15. Mean RV 3D ejection fraction (EF) was 42.6% ± 10.9% and below normal limits in 56.7% of patients. Positive correlation occurred between RV 3DEF, RV4LS, and RVFWLS, especially for patients without a pacemaker (p = 0.006). RV involvement in PRKAG2 syndrome is frequent, occurring in different degrees. Echocardiography is a valuable tool in detecting RV myocardial abnormalities in this condition. The use of 2D RV4LS, RVFWLS, and 3DEF offers reliable indicators of RV systolic dysfunction in this rare, challenging cardiomyopathy.

Abstract 14605: Deleterious Effects of Type 2 Diabetes on the Myocardium of Patients With Aortic Stenosis

Introduction: Type 2 diabetes (T2D) may induce myocardial alterations and is associated with an increased risk of heart failure. T2D is often associated to LV pressure overload, as encountered in aortic stenosis (AS). Hypothesis: We hypothesized that T2D has deleterious effects on LV remodelling and function in patients with severe AS and we explored some underlying mechanisms. Methods: Non diabetic and T2D patients with severe AS, referred for aortic valve replacement, were included. Patients with atrial fibrillation, LV ejection fraction (LVEF) &lt;50%, significant coronaropathy or other valvulopathy were excluded. Before surgery, patients underwent blood tests and a complete echocardiography. During surgery, a LV myocardium biopsy was obtained for histological analysis. Results: We included 82 patients, including 33 T2D. Hypertension and dyslipidaemia were more frequent in T2D patients. Severity of the AS was similar between the two groups. Echocardiography revealed that T2D was associated with a more pronounced LV hypertrophy (mass LV 3D/hight 2.7 ; p=0.03) and systolic dysfunction (Global Longitudinal Strain (GLS) 15±3 vs 18±2 %; p&lt;0.01). In addition, LV ventricular filling pressure was more often increased in T2D patients (50% of T2D vs 26% of non-diabetics; p=0.03). Circulating levels of leptin and endothelin 1 were significantly higher in T2D. Interestingly leptin level correlates with diastolic function (left atrial strain; r=-0.25, p=0.01) and Endothelin 1 with LV mass (r=0.27, p&lt;0.001) and GLS. Histologic analysis revealed an enhanced cardiomyocyte hypertrophy in T2D biopsies but similar degrees of fibrosis. Proximity ligation assay displayed a significant decreased proximity between the IP3-receptor and the mitochondrial porin VDAC in T2D hearts suggesting a reduced reticulum-mitochondria Ca 2+ transfer. Conclusions: T2D is associated with an increased LV remodelling and dysfunction in patients with a severe AS as well as an increased circulating level of leptin and endothelin-1. Our results also suggest a potential role of reticulum-mitochondria Ca 2+ uncoupling.

The impact of complete versus partial preservation of the sub-valvular apparatus on left ventricular function in mitral valve replacement.

In mitral valve replacement (MVR), sudden increases in afterload and disruption of the annular-chordal-papillary-left-ventricular wall causes left ventricular(LV) dysfunction in the early postoperative period. Preservation of the posterior mitral leaflet apparatus (MVR-P) has a favorable outcome on LV function. However, there is paucity of data on the impact of complete preservation of the sub-valvular apparatus (MVR-C). We investigated the impact of MVR-P and MVR-C on baseline and 3-months postoperative LV ejection fraction (EF) and global longitudinal strain (GLS). We retrospectively analyzed a cohort of 29 MVR-P and 19 MVR-C patients with complete echocardiography data at our unit, who were operated between 2008 and 2017. Between-group changes in LVEF and GLS were compared using independent sample T-test. Median age was 59 years (IQR 50-69 years). Baseline LVEF was 58% (51%- 60%). Baseline GLS was -18.4 (-21.2 to -15.5). There were no significant between-group differences between all baseline demographics and echocardiographic markers. There was significantly higher absolute postoperative LVEF in MVR-C patients (p = 0.029). There was also significant worsening in LVEF (p = 0.0121) and GLS (p < 0.0001) after MVR-P and not MVR-C, suggesting no reduction in LV function post-MVR-C but a reduction post-MVR-P. There was significantly less postoperative worsening of GLS per patient in MVR-C group as compared to the MVR-P group (p = 0.023), indicating better preservation of LV function. There was also a smaller decline in LVEF per patient in the MVR-C as compared to the MVR-P group, although not statistically significant (p = 0.23). MVR with complete preservation of the sub-valvular apparatus shows a favorable impact on the longitudinal function of the heart at 3 months. Further studies with larger patient numbers are indicated to investigate the long-term results of this surgical approach.

A 2D-speckle tracking analysis in patients undergoing trastuzumab in non-metastatic breast cancer

Abstract Background Trastuzumab (TZ) is widely used for his key role in HER2 positive breast cancer. However, the most concerning cardiovascular complication is cardiotoxicity. Many studies have highlighted the importance of screening for subclinical myocardial dysfunction using left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, there are only few studies investigating a possible atrial damage. Purpose Aim of this study is to analyze the modification of GLS and peak atrial systolic longitudinal strain (PALS) in patients undergoing therapy with TZ in a follow-up period of 12 months. The eventual fluctuation of left atrial function under chemotherapy was evaluated and the correlation between subclinical atrial disfunction and early left ventricular impairment was investigated. Methods 105 women affected by breast cancer treated with TZ were enrolled. Each patient underwent a complete echocardiography at baseline and every 3 months. 37 patients (35%) were excluded from the left atrial function analysis while LV function evaluation was performed in 83 patients (21%). Exclusion criteria were poor quality imaging and lack of a complete follow up with consequent missing data. 2D-Speckle tracking analysis was performed at baseline and at each examination using Tomtec software in order to analyze both atrial and left ventricular function. Subclinical LV disfunction was defined as a GLS reduction of ≥15% compared to the baseline value. Left atrial impairment was arbitrary defined as a PALS reduction of ≥25% compared to the initial value. Finally, trends of GLS and PALS during 12 months-follow up periods were analyzed. Additionally, we explored if diabetes and renal impairment were associated with more prevalent atrial subclinical disfunction as demonstrated in previous studies. Results A total of 49% patients developed subclinical LV dysfunction. Similarly, 48% patients showed a left atrial impairment. Interestingly a significant (p=0.0001) reduction in GLS was observed during the follow-up, particularly in the first six months of treatment. PALS showed a similar trend with a significant decrease during the whole 12 months-follow up (p=0.0001) and mostly in the first 6 months. 6 patients presented a diagnosis of diabetes at baseline, and presented lower PALS compared to the non-diabetic counterpart (37.6±9.9% vs 48.7±12.2%, p=0.03). 2 patients presented a significant renal impairment (eGFR ≤30 ml/min). Similarly, these patients presented a lower PALS at baseline (32±7 and 48±7; p=0.05). Conclusions In patients treated with Trastuzumab development of left atrial impairment is frequent and PALS modifications follow a similar pattern to GLS variations during the treatment, suggesting a possible cardiotoxic effect of such therapy on both atrial and left ventricular myocardium and physiology. Funding Acknowledgement Type of funding sources: None.

Myeloperoxidase as therapeutic target in HFpEF

Abstract Background Inflammation and oxidative stress are thought to play an important role in the pathophysiology of HFpEF through the development of endothelial dysfunction. Myeloperoxidase (MPO), a leukocyte-derived enzyme, functions as a link between oxidative stress and inflammation and is an interesting therapeutic target. Purpose To compare MPO levels between HFpEF and old controls and to define clinical characteristics associated with high levels of MPO. Methods Patients with HFpEF (N=55) and controls &amp;gt;60 years (N=18) were prospectively included. All subjects underwent complete echocardiography and standard biology. MPO levels were dosed by ELISA assay. Endothelial function was assessed by peripheral arterial tonometry through the reactive hyperemia index (RHI). Characteristics were compared using independent samples t-test or chi square test. Results Patients with HFpEF (80±8.5 years, 65% female) had higher levels of myeloperoxidase compared to controls (74±6.2 years, 72% female) (34.7 ng/mL [22.7; 43.9] versus 22.5 [18.1; 31.9], p=0.026) (Figure 1). HFpEF patients with levels of MPO above the median were more often men and diabetic and had higher levels of NTproBNP and CRP. However, MPO levels were not associated with endothelial function measured by RHI (Table 1). Conclusion(s) HFpEF patients have higher levels of myeloperoxidase than control subjects, reflecting leukocyte activation and oxidative stress. Myeloperoxidase levels are associated with inflammation and disease severity. Myeloperoxidase inhibitors could be useful for the treatment of HFpEF patients, especially in the subgroup of patients with diabetes. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Fondation Damman