Contractile Reserve In Patients Research Articles

Feasibility of Right Ventricular Free Wall Longitudinal Strain Assessment of Contractile Reserve in Patients Undergoing Lung Resection

Feasibility of Right Ventricular Free Wall Longitudinal Strain Assessment of Contractile Reserve in Patients Undergoing Lung Resection

P44 IMPROVEMENT OF THE LEFT VENTRICULAR CONTRACTILE RESERVE IN PATIENTS UNDERGOING MITRAL VALVE PLASTIC CARDIAC SURGERY

Abstract Mitral Regurgitation (MR) is a clinical condition characterized by a high morbidity and mortality in severe or moderate forms complicated by hemodynamic instability, that often finds a solution only in the reparative surgical treatment. MR is often caused the presence of myxomatous degeneration that affects one or more structures of the valve apparatus, causing the prolapse of one or both leaflets. Surgical treatment can improve the hemodynamic parameters and consequently the prognosis of the patients, even though there is not still data concerning the myocardial contractile reserve. The aim of the study was to evaluate the effect of MR reparative surgery on the left ventricular contractile reserve during physical stress echocardiography. We enrolled 12 patients, 8 females and 4 males, affected by MR candidate to cardiac surgery. We performed a physical stress–echo test by using the ABCDE protocol suggested by the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI), before and after approximately 12 weeks from cardiac surgery. After each test, the prognostic score deriving from the sum of the ABCDE criteria was calculated; in addition, we measured the left ventricular contractile reserve (C parameter of the score) that represents a parameter of the force deriving from the hemodynamic changes during the test. In all patients we observed a significant improvement in the ABCDE prognostic score after cardiac surgery (3.89 + 0.43 vs 3.18 + 0.37; p = 0.002). There were no significant changes in ejection fraction, indexed left atrial volume, wall motion score index–WMSI (A parameter), coronary reserve (D parameter), and heart rate reserve (E parameter). The most relevant data concerns the increase in the left ventricular contractile reserve at 3 months after cardiac surgery (1.77 mmHg/ml vs 2.44 mmHg/ml, p<0.0001). Furthermore, a significant reduction in pulmonary congestion during stress was observed (B parameter). These data demonstrate for the first time that mitral valve plastic surgery is able to improve the left ventricular contractile reserve in patients with severe MR. Furthermore, the surgical procedure determined both a reduction in the degree of pulmonary congestion and an improvement in the ABCDE prognostic score during physical stress echocardiography.

Feasibility of right ventricular free wall longitudinal strain assessment of contractile reserve in patients undergoing lung resection

Lung cancer is the second most common cancer in the UK; though lung resection is potentially curative, it results in a burden of postoperative dyspnoea and functional limitation. Previous work by our group demonstrated right ventricular (RV) function impairment at day 2 and 2 months after lung resection.1 During exercise, the normal physiological response is an increase in RV function termed RV contractile reserve (CR). Previous studies have suggested that RV-CR is impaired postoperatively and additionally associated with increased cardiopulmonary complications postoperatively2 (although their methodologies have since been challenged). RV free-wall longitudinal strain (RVFWLS) can identify subtle RV dysfunction and may therefore be a superior method of RV assessment. We examined the feasibility of RVFWLS assessment of RV-CR in patients before and after lung resection.

PS-C14-2: QUANTITATIVE METHODS FOR ASSESSING CONTRACTILE RESERVE IN PATIENTS WITH DIASTOLIC HEART FAILURE

Aim: The effectiveness of isometric handgrip exercise on changes of cardiovascular hemodynamical parameter in patients with diastolic heart failure is unknown. We assessed the effect of several hemodynamic parameters and it changes during handgrip maneuvers in patients with different stages of diastolic heart failure during chemotherapy and their improvements after 4 months follow up (4mFU) treatment with single pill combination of ACE inhibitor ACE) and beta blocker(BB). Methods: The study population included 65 patients female / mean age of 45 ± 12 years/ 55 with breast cancer and undergoing chemotherapy / 30 pts with HFpEF and 25 pts with HFmrEF / and 10 pts with HFnEF and without chemotherapy. The effect of handgrip maneuver on hemodynamic parameters were studied by speckle tracking echocardiography. Following maximal squeeze by 100%, during the next 3 minutes patients were instructed to apply pressure at 50%. The global longitudinal strain were extracted by 3, 4 and 2 chamber apical view images on 70 fr/s and MAP and HR were performed at basal level, 1st, 2nd and 3rd minutes during handgrip stress test. The contractility /force/ of LV were also calculate as ratio SBP / ESV. Patients with HFmrEF and HFpEF received for 4 months treatment with single pill combination ACE (perindorpril)/ BB (bisoprolol) 5/5 mg. Results: Heart rate(HR) and mean arterial pressure(MAP) increased significantly after handgrip maneuver / from 75 ± 6 beats /min to 101 ± 12 beats/ min, 109 ± 15 mmHg to 118 ± 19mmHg, p < 0,05 /. Pulmonary artery systolic(s) and diastolic (d) pressure(PAP),pulmonary capillary wedge pressure (PCWP), cardiac index(CI), LVEF did not change significantly(p > 0,5) after handgrip maneuvers. On the other hand, LV force (SBP/ ESV ratio),MAP and HR decreases significantly (p < 0,01) in group with HFmrEF. In same group were found significantly decreased GLVLS at 2nd and 3rd minutes during stress- test comparable with other 2 groups with HFpEF and HFnEF. After 4mFU and treatment with 5/5 mg doses combination of ACE / BB were found improvement in parameters: HR /p < 0,001/, MAP /p < 0.01/ and contractile reserve as well as LV force /p < 0, 01/ and GLVLS /p < 0,001/. Conclusion: Cardiovascular response to handgrip maneuver may be a marker of failure to respond to compensatory mechanisms. Patients with good LV reserve had a rise in stroke work with little or no change in LVEDP. Patients with poor contractile reserve had a fall in stroke work reserve together with a substantial rise in LVEDP. It is concluded that the stress imposed by sustained handgrip provides a simple test for evaluation of LV contractile reserve in patients, who will develop cardiotoxicity during chemotherapy treatment. The treatment with combination with small doses ACE/BB is a big challenge in patients with HFmrEF and HFpEF to improve the contractile reserve.

Impaired Left Ventricular Contractile Reserve in Patients With Hypertrophic Cardiomyopathy and Abnormal Blood Pressure Response: A Stress Echocardiographic Study.

Abnormal blood pressure response (ABPR) has been reported to be a risk factor for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). We aimed to elucidate the relationship between ABPR during exercise stress echocardiography (ESE) and impaired left ventricular (LV) contractile reserve based on two-dimensional strain in patients with HCM. Patients with HCM underwent ESE with treadmill exercise. Patients whose blood pressure elevation at maximum workload was lower than 20 mmHg from baseline were classified as having ABPR. Echocardiographic parameters were compared between patients with and without ABPR. Results: Of 26 patients with HCM, nine patients were diagnosed with ABPR. Significant LV outflow tract obstruction (>50 mmHg) was provoked only in one patient with ABPR (baseline to the conclusion of the exercise, 15.2 mmHg to 63.0 mmHg). Change in cardiac output (CO) and the ratio of early diastolic velocity to early annular velocity (E/e') from baseline to just after the conclusion of exercise did not differ between patients with and without ABPR (CO, 102±40% vs. 122±45%, P = 0.19; E/e', 4±22% vs. 2±20%, P = 0.86). Change in systemic vascular resistance change was not significant (patients with vs. without ABPR, -52±10% vs. -46±13%, P = 0.24). Percent change in LV global longitudinal strain was lower in patients with ABPR than patients without ABPR (12±17% vs. 27±15%, P = 0.02). In conclusion, impaired LV contractile reserve during exercise might contribute to ABPR in patients with HCM.

Peak oxygen consumption is associated with the inotropic reserve in patients with heart failure with reduced ejection fraction undergoing cardiopulmonary testing

Abstract Background The role of cardiopulmonary exercise testing (CPET) in the prognostic evaluation of heart failure with reduced ejection fraction (HFrEF) is powerful and well-established. Nevertheless, the value of CPET in predicting left ventricular inotropic reserve in HFrEF remains unknown. Purpose The investigation of possible associations between CPET variables and left ventricular contractile reserve in patients with HFrEF. Methods Consecutive patients aged ≥18 years old with a diagnosis of heart failure and a left ventricular ejection fraction ≤40%, as assessed by echocardiography, were prospectively enrolled. Demographic and clinical data were recorded. All subject underwent CPET with either a Bruce or a modified Bruce protocol. Peak oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation to carbon dioxide production (VE/VCO2) slope, minute ventilation (VE), and VO2/heart rate (HR) values were calculated, while hemodynamic parameters during the test were also measured. Results In total, 191 patients with HFrEF were included in the analysis. The mean age was 58.8±11.8 years and 30 (15.7%) patients were women. Ischemic heart disease was the etiology of HFrEF in 101 (52.9%) patients, whereas 90 (47.1%) patients had a history of dilated cardiomyopathy. The mean exercise time was 7.6±.3 minutes. Mean peak VO2 and VE/VCO2 slope values were calculated at 19.1±6.1 ml kg–1 min–1 and 43.7±10.1, respectively. According to peak VO2 values, 70 patients (37.2%) were in Weber class A, 57 (29.8%) in class B, 48 (25.1%) in class C and 15 (7.9%) in class D. In univariate analysis, the change between rest and peak systolic blood pressure (ΔSBP), which is considered to reflect the left ventricular inotropic reserve, was positively correlated to the peak VO2 (p<0.001), the total pulmonary ventilation (VE) (p<0.001) and the peak heart rate during exercise (p=0.02). In multivariable analysis, peak VO2 was independently, linearly associated with the ΔSBP during CPET (Figure 1) (β=0.661, p=0.022). In Roc analysis, it was found that a cut-off value for peak VO2 of 16 ml kg–1 min–1 exhibits 64% sensitivity and 60% specificity in predicting a ΔSBP>40mmHg during exercise (area under the curve: 0.657, p<0.001 – Figure 2). Conclusion The peak oxygen consumption during cardiopulmonary testing represents an acceptable predictor of inotropic reserve in patients with HFrEF. Funding Acknowledgement Type of funding sources: None.

The effect of empagliflozin on contractile reserve in heart failure: Prespecified sub-study of a randomized, double-blind, and placebo-controlled trial

Sodium-glucose co-transporter-2 inhibitors improve cardiac structure but most studies suggest no change in left ventricular (LV) systolic function at rest. Whether sodium-glucose co-transporter-2 inhibitors improve LV contractile reserve is unknown. We investigated the effect of empagliflozin on LV contractile reserve in patients with heart failure (HF) and reduced ejection fraction. Prespecified sub-study of the Empire HF trial, a double-blind, placebo-controlled, and randomized trial. Patients with LV ejection fraction (LVEF) ≤ 40% on guideline-directed HF therapy were randomized (1:1) to empagliflozin 10 mg or placebo for 12 weeks. The treatment effect on contractile reserve was assessed by low dose dobutamine stress echocardiography. In total, 120 patients were included. The mean age was 68 (SD 10) years, 83% were male, and the mean LVEF was 38 (SD 10) %. Respectively 60 (100%) and 59 (98%) patients in the empagliflozin and placebo groups completed stress echocardiography. No statistically significant effect of empagliflozin was observed for the contractile reserve assessed by LV-GLS (adjusted mean absolute change, empagliflozin vs placebo, 0.7% [95% confidence interval {CI} -0.5 to 2.0, P=.25]) or LVEF (adjusted mean absolute change, empagliflozin vs placebo, 2.2% [95% CI -1.4 to 5.8, P=.22]) from baseline to 12 weeks. LV-GLS contractile reserve was associated with accelerometer-measured daily activity level (coefficient -24 accelerometer counts [95% CI -46 to -1.8, P=.03]). Empagliflozin for 12 weeks added to guideline-directed HF therapy did not improve LV contractile reserve in patients with HF and reduced ejection fraction.

Impaired biventricular contractile reserve in patients with diastolic dysfunction: insights from exercise stress echocardiography.

Cardiac output limitation is a fundamental feature of heart failure with preserved ejection fraction (HFpEF) but the relative contribution of its determinants in symptomatic vs. asymptomatic stages are not well characterized. We aimed to gain insight into disease mechanisms by performing comprehensive comparative non-invasive exercise imaging in patients across the disease spectrum. We performed bicycle stress echocardiography in 10 healthy controls, 13 patients with hypertensive left ventricular (LV) concentric remodelling and asymptomatic diastolic dysfunction (HTDD), 15 HFpEF patients, and 15 subjects with isolated right ventricular (RV) dysfunction secondary to chronic thromboembolic pulmonary hypertension (CTEPH). During exercise, ventricular performance differed across the groups (all P ≤ 0.01 for interaction). Notably in controls, LV and RV function significantly increased (all P < 0.05) while both LV systolic and diastolic reserve were significantly reduced in HFpEF patients. Likewise, RV systolic reserve was also impaired in HFpEF but not to the extent of CTEPH patients (P < 0.001 between groups). HTDD patients behaved as an intermediary group with borderline LV systolic and diastolic reserve and reduced RV systolic reserve. The increased pulmonary vascular (PV) load in HFpEF and CTEPH patients in combination with impaired RV reserve resulted in RV-pulmonary artery uncoupling during exercise. The multifaceted decline of cardiac and PV function accompanying disease progression in HFpEF is unmasked by exercise and already emerges in preclinical disease. The revelation of these subtle abnormalities during exercise illustrates the benefit of exercise imaging and creates new prospects for early diagnosis and management.

Low-dose dobutamine stress gated blood pool SPECT assessment of left ventricular contractile reserve in ischemic cardiomyopathy: a feasibility study.

The purpose of the present study was to evaluate the feasibility of gated blood pool single-photon emission computed tomography (GBPS) with low-dose dobutamine (LDD) stress test, performed on a single-photon emission computed tomography (SPECT) camera equipped with cadmium-zinc-telluride (CZT) solid-state detectors, in assessing of left ventricle (LV) contractile reserve in patients with ischemic cardiomyopathy (ICM). A total of 52 patients (age 59 ± 7.2years, 47 men and 5 women) with ICM and a control group of 10 patients without obstructive coronary artery lesion underwent GBPS and transthoracic echocardiography (TTE) at rest and during LDD stress test (5, 10, 15µg/kg/min). The duration of each GBPS step was 5min. Stress-induced changes in LV ejection fraction (ΔLVEF), peak ejection rate, LV volumes, and mechanical dyssynchrony (phase histogram standard deviation, phase histogram bandwidth and entropy) obtained with GBPS were estimated. All GBPS indices except end-diastolic volume showed significant dynamics during stress test in both groups. The majority of parameters in ICM patients showed significant changes at a dobutamine dose of 10µg/kg/min as compared to the rest study. Seventeen percent of ICM patients, but none from the control group, showed a decrease in LVEF during stress, accompanied by a significant increase in entropy. The intra- and inter-observer reproducibility was excellent for both rest and stress studies. There was a moderate correlation (r = 0.5, p = 0.01) between GBPS and TTE, with a mean difference value of - 1.7 (95% confidence interval - 9.8; 6.4; p = 0.06) in ΔLVEF. Low-dose dobutamine stress GBPS performed with high-efficiency CZT-SPECT cameras can be performed for evaluating stress-induced changes in LV contractility and dyssynchrony with lower acquisition time. A dobutamine dose of 10µg/kg/min can potentially suffice to detect stress-induced changes in patients with ICM during GBPS. ClinicalTrials.gov identifier: NCT04508608 (August 7, 2020).

Abstract 13062: The Effect of Empagliflozin on Contractile Reserve in Heart Failure: Prespecified Sub-Study of a Randomized, Double-Blind, and Placebo-Controlled Trial

Introduction: Sodium-glucose co-transporter-2 (SGLT2) inhibitors improve cardiac structure but most studies suggest no change in left ventricular (LV) systolic function at rest. Whether SGLT2 inhibitors improve LV contractile reserve is unknown. We investigated the effect of empagliflozin on LV contractile reserve in patients with heart failure (HF) and reduced ejection fraction (HFrEF). Methods: Prespecified sub-study of the Empire HF trial, a double-blind, placebo-controlled, and randomized trial. Patients with LV ejection fraction (LVEF) ≤40% on guideline-directed HF therapy were randomized (1:1) to empagliflozin 10 mg or placebo for 12 weeks. The treatment effect on contractile reserve was assessed by low dose dobutamine stress echocardiography. Results: In total, 120 patients were included. The mean age was 68 (SD 10) years, 83% were male, and the mean LVEF was 38 (SD 10) %. Respectively 60 (100%) and 59 (98%) patients in the empagliflozin and placebo groups completed stress echocardiography. No statistically significant effect of empagliflozin was observed for the contractile reserve assessed by LV-GLS [adjusted mean absolute change, empagliflozin versus placebo, 0.7% (95% CI -0.5 to 2.0, P=0.25)] or LVEF [adjusted mean absolute change, empagliflozin versus placebo, 2.2% (95% CI -1.4 to 5.8, P=0.22)] from baseline to 12 weeks. LV-GLS contractile reserve was associated with accelerometer-measured daily activity level [coefficient, -24 accelerometer counts (95% CI -46 to -1.8, P=0.03)] as opposed to LVEF contractile reserve [coefficient, -2.9 accelerometer counts (95% CI -10 to 4.5, P=0.43)]. Conclusions: Empagliflozin for 12 weeks added to guideline-directed HF therapy did not improve LV contractile reserve in patients with HFrEF. Registration: NCT03198585. https://www.clinicaltrials.gov/ct2/show/NCT03198585?term=Empire+HF&amp;draw=2&amp;rank=1

Feasibility and Role of Right Ventricular Stress Echocardiography in Adult Patients.

Background:The great technological advancements in the field of echocardiography have led to applications of stress echocardiography (SE) in almost all diagnostic fields of cardiology, from ischemic heart disease to valvular heart disease and diastolic function. However, the assessment of the right ventricle (RV) in general, and in particular in regard to the contractile reserve of the RV, is an area that has not been previously explored. We, therefore, propose a study to investigate the potential use of SE for the assessment of RV function in adult patients.Aims and objectives:The primary aim is to evaluate the feasibility of right ventricular SE. The secondary aim is to assess right ventricular contractile reserve.Matherials and Methods:Eighty-one patients undergoing a physical or dobutamine stress echocardiogram for cardiovascular risk stratification or chest pain were the subject of the study. An exercise leg cycle using a standard WHO protocol was used to simultaneously assess the right and left ventricular global and regional function as well as acquiring Doppler data. Whereas the patient had limitations in mobility, a dobutamine SE was be performed. We evaluated the average values of tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), S-wave, systolic pulmonary artery pressure (sPAP), and right ventricle global longitudinal (free wall) strain (RVGLS) during baseline and at the peak of the effort. RV contractile reserve was defined as the change in RVGLS from rest to peak exercise. We also assessed the reproducibility of these measurements between two different expert operators (blind analysis).Results:At least 3 over 5 RV function parameters were measurable both during baseline and at the peak of the effort in 95% of patients, while all 5 parameters in 65% of our population, demonstrating an excellent feasibility. All RV-studied variables showed a statistically significant increase (P < 0.001) at peak compared to the baseline. The average percentage increases at peak were 31.1% for TAPSE, 24.8% for FAC, 50.6% for S-wave, 55.2% for PAPS, and 39.8% for RV strain. The reproducibility between operators at baseline and peak was excellent. Our study demonstrates that TAPSE, FAC, and S-wave are highly feasible at rest and at peak, while TAPSE, S-wave, and sPAP are the most reliable measurements during RV stress echo.Conclusion:RVGLS is useful in the assessment of RV contractile reserve in patients with good acoustic window. Further studies are needed to evaluate the impact of contrast echocardiography in improving RV contractile reserve assessment during SE.

Application of a novel straight leg raise test during high-resolution manometry can predict esophageal contractile reserve in patients with gastroesophageal reflux disease.

Increased intra-abdominal pressure from abdominal compression augments esophageal peristalsis during high-resolution manometry (HRM), and straight leg raise (SLR) while supine increases intra-abdominal pressure. We determined if water swallows performed during SLR can mimic contraction reserve seen with multiple rapid swallows (MRS). Consecutive patients evaluated for GERD symptoms completed validated GERD questionnaires, esophageal HRM, and upper endoscopy. Distal contractile integral (DCI) was analyzed during single water swallows (10×5mL), MRS (5×2mL), and during SLR (5x5mL). Peristaltic breaks were measured using software tools with a 20mmHg isobaric contour. Univariate correlational analyses were performed to compare esophageal motor patterns and DCI values during single water swallows, MRS, and SLR. Of 103 study patients (mean age: 46.7±12.3years, 56.3% female), 50 (48.5%) had ineffective esophageal motility (IEM). Contraction reserve was observed on MRS in 62% with IEM, and 35.8% with normal motility (p=0.008). DCI was significantly higher during SLR compared to mean single swallow DCI in both IEM and normal motility patients (p<0.001 for each comparison). In IEM patients, SLR significantly reduced swallows with peristaltic breaks (6.1±3.7 vs 3.6±3.6; p<0.001) and shortened the length of the largest break (4.8±3.4 vs 3.0±3.0cm; p<0.001). DCI response following MRS correlated with DCI with swallows during SLR, with a correlational coefficient (Pearson's r) of 0.70 (p<0.001). Swallowing against the resistance of increased intra-abdominal pressure from SLR improves esophageal body peristaltic performance and predicts esophageal body contraction reserve.

P972 Quantitative methods for assessing contractile reserve in patients with diastolic heart failure

Abstract Aim The effectiveness of isometric handgrip exercise on changes of cardiovascular hemodynamics parameter in patients with diastolic heart failure is unknown. We assessed the effect of several hemodynamic parameters and it changes during handgrip maneuvers in patients with different stages of diastolic heart failure during chemotherapy and their improvements after 4 months follow up (4mFU) treatment with single pill combination of ACE inhibitor ACE) and beta –blocker(BB) .Methods: The study population included 65 patients- female / mean age of 45 ± 12 years/ 55 with breast cancer and undergoing chemotherapy / 30 pts with HFpEF and 25 pts with HFmrEF / and 10 pts with HFnEF and without chemotherapy.The effect of handgrip maneuver on hemodynamic parameters were studied by speckle tracking echocardiography. Following maximal squeeze by 100%, during the next 3 minutes patients were instructed to apply pressure at 50%. The global longitudinal strain were extracted by 3, 4 and 2 chamber apical view images on 70-85 fr/s and MAP and HR were performed at basal level, 1st, 2nd and 3rd minutes during handgrip stress test. The contractility /force/ of LV were also calculate as ratio SBP / ESV . Patients with HFmrEF and HFpEF received for 4 months treatment with single pill combination ACE (perindorpril)/ BB (bisoprolol) 5/5 mg.Results:Heart rate(HR) and mean arterial pressure(MAP) increased significantly after handgrip maneuver / from 75 ±6 beats /min to 101 ±12 beats/ min, 109 ± 15 mmHg to 118 ± 19mmHg, p &amp;lt; 0,05 / .Pulmonary artery systolic(s) and diastolic (d) pressure(PAP),pulmonary capillary wedge pressure (PCWP) , cardiac index(CI) , LVEF did not change significantly(p &amp;gt; 0,5) after handgrip maneuvers . On the other hand, LV force (SBP/ ESV ratio) ,MAP and HR decreases significantly (p &amp;lt; 0,01) in group with HFmrEF. In same group were found significantly decreased GLVLS at 2nd and 3rd minutes during stress- test comparable with other 2 groups with HFpEF and HFnEF. After 4mFU and treatment with 5/5 mg doses combination of ACE / BB were found improvement in parameters: HR /p &amp;lt; 0,001/, MAP /p &amp;lt; 0.01/ and contractile reserve as well as LV force /p &amp;lt; 0, 01/ and GLVLS /p &amp;lt; 0,001/.Conclusion: Cardiovascular response to handgrip maneuver may be a marker of failure to respond to compensatory mechanisms. Patients with good LV reserve had a rise in stroke –work with little or no change in LVEDP. Patients with poor contractile reserve had a fall in stroke- work reserve together with a substantial rise in LVEDP. It is concluded that the stress imposed by sustained handgrip provides a simple test for evaluation of LV contractile reserve in patients, who will develop cardiotoxicity during chemotherapy treatment. The treatment with combination with small doses ACE/BB is a big challenge in patients with HFmrEF and HFpEF to improve the contractile reserve.

Assessment of Left Ventricular Function and Contractile Reserve in Patients with Hypertension

Background: Hypertension is a prevalent and well-recognized cardiovascular risk factor, which may lead to left ventricular (LV) systolic impairment through chronic pressure overload. Aim of the work: An impaired contractile reserve (CR) may be an early manifestation of left ventricular (LV) systolic dysfunction in hypertensive patients. Using normotensive patients as controls, we examined LV CR and its correlates in hypertensive patients. Material and methods: The study was conducted prospectively on fifty cases. 30 cases (24 males and 6 females aged 55.57 ± 10.07) had hypertension. All patients were subjected to complete history taking including comorbidities, risk factors and full clinical examination. Patients with significant coronary or valvular disease, previous myocardial infarction or revascularization and diabetes were excluded. LV ejection fraction (LVEF) & global longitudinal strain (GLS) were measured at rest and at low-dose dobutamine. Results: Hypertensive patients, compared to control had significantly impaired GLS at rest (-19.00 ± 2.34% vs. -20.50 ± 1.52%, P <0.015) and at low dobutamine dose (-19.90 ± 2.33% vs. -22.60 ± 1.88 %, P <0.001). Absolute and relative GLS CR were significantly lower in hypertensive patients (-0.88 ± 0.45% vs.-2.12 ± 0.77% and 4.70 ± 2.76% vs. 10.33 ± 3.78 %, respectively, both P < 0.001). Absolute and relative LVEF CR were significantly lower in hypertensive patients (3.31 ± 0.97 % vs. 7.09 ± 1.67% and 5.37 ± 1.64% vs. 11.61 ± 3.19%, respectively, both P < 0.001). Conclusion: Compared to control, hypertensive patients with no other co-morbidities had impaired LV GLS at rest and impaired CR despite normal LVEF.

Correlation of the coronary flow reserve, the angiographic TIMI flow and the contractile reserve in patients with cardiac syndrome x

Correlation of the coronary flow reserve, the angiographic TIMI flow and the contractile reserve in patients with cardiac syndrome x

P4534Reduced right ventricular contractile reserve in patients with systemic sclerosis and borderline pulmonary arterial pressures

P4534Reduced right ventricular contractile reserve in patients with systemic sclerosis and borderline pulmonary arterial pressures

Left atrial function: Correlation with left ventricular function and contractile reserve in patients with hypertension.

Alterations in left atrial (LA) and left ventricular (LV) function have been documented in hypertensive patients. However, the correlation of LA with LV functional changes has not been established. Using normotensive controls, we examined LA functional changes in hypertensive patients by strain deformation analysis, and their relationship to LV functional changes including contractile reserve (CR). One hundred and sixteen patients (61 men, aged 57.6±9.1years, 67 with hypertension) underwent dobutamine echocardiography. Patients with significant coronary or valvular disease, previous myocardial infarction or coronary revascularization, and diabetes were excluded. LA reservoir (Ɛs), conduit (Ɛe), and atrial contractile (Ɛa) strain were measured at rest. LV global longitudinal strain (GLS) and ejection fraction (LVEF) were measured at rest and at low-dose dobutamine. LV CR was calculated as the difference in GLS and LVEF between the low dose and their corresponding resting values. Hypertensive patients, compared with controls, had significantly impaired LA Ɛs (30.7±3.9% vs 42.4±4.9%), Ɛe (16.2±4.1% vs 22.5±5.5%), and Ɛa (14.5±4.1% vs 19.9±5.0%, all P<.001) strain. All LA phasic strain correlated with LV GLS at rest, at low-dose dobutamine, and LV CR. There was no correlation between LA strain and LVEF or LV CR assessed by LVEF. LV GLS and LAVImax were the strongest independent determinants for LA Ɛs/Ɛe and LA Ɛa, respectively. Compared to controls, hypertensive patients had impaired LA strain, which correlated with LV GLS and CR. LV GLS and LAVImax were the strongest independent determinants for LA Ɛs/Ɛe and LA Ɛa, respectively, independent of BP and LVMi.

Contractile reserve as a predictor of prognosis in patients with non-ischaemic systolic heart failure and dilated cardiomyopathy: a systematic review and meta-analysis

Objective: Patients with non-ischaemic systolic heart failure (HF) and idiopathic dilated cardiomyopathy (DCM) are a heterogenous group with varied morbidity and mortality. Prognostication in this group is challenging. We performed a systematic review and meta-analysis to examine the significance of the presence of contractile reserve as assessed via stress imaging on mortality and hospitalisation.Methods: A search for studies that non-invasively assessed contractile reserve in patients with DCM or non-ischaemic HF with reduced ejection fraction, stress imaging with follow-up data comparing outcomes. A range of imaging modalities and stressors were included. We examined primary endpoints of mortality and secondary endpoints of combined cardiovascular events including HF progression or hospitalisation. Our analysis compared endpoints in patients with contractile reserve and those without it.Results: Nine prospective cohort studies were identified describing a total of 787 patients. These studies are methodologically but not statistically heterogenous (I2 = 31%). Using a random effect model, the presence of contractile reserve was associated with a significantly lower risk of mortality and cardiovascular events odds ratios of 0.20 (CI 0.11, 0.39) (P < 0.00001) and 0.13 (CI 0.04, 0.40) (P = 0.0004), respectively.Conclusion: Regardless of stressor and imaging modality and despite the significant methodological heterogeneity within the current data (imaging techniques and parameters), patients with non-ischaemic cardiomyopathy and reduced EF who demonstrate contractile reserve have a lower mortality, and lower events/hospitalisations. The presence of contractile reserve therefore offers a potential positive prognostic indicator when managing these patients.

Left ventricular function and contractile reserve in patients with hypertension.

An impaired contractile reserve (CR) may be an early manifestation of left ventricular (LV) systolic dysfunction in hypertensive patients. Using normotensive patients as controls, we examined LV CR and its correlates in hypertensive patients. One hundred and twenty-nine (68 men, aged 58.6 ± 9.5 years, 73 had hypertension) patients underwent dobutamine echocardiography. Patients with significant coronary or valvular disease, previous myocardial infarction or revascularization, and diabetes were excluded. LV ejection fraction (LVEF), global longitudinal strain (GLS), circumferential, and radial strain were measured at rest and at low-dose dobutamine. Absolute CR was calculated as the difference in LVEF and multi-directional strain between low-dose dobutamine and their corresponding resting values. Relative CR is the ratio of absolute CR to their corresponding resting values. Hypertensive patients, compared with controls, have significantly impaired GLS at rest (-16.8 ± 2.2% vs. -19.6 ± 1.5%, P < 0.0001) and at low-dose dobutamine (-17.9 ± 2.7% vs. -22.8 ± 2.6%, P < 0.0001). Absolute and relative GLS CR were significantly lower in hypertensive patients (-1.1 ± 2.1% vs. -3.2 ± 2.2% and 7.4 ± 13.9% vs. 16.4 ± 11.7%, respectively, both P < 0.001). Circumferential strain was preserved at rest but impaired at low-dose dobutamine in hypertensive patients (-23.0 ± 4.1% vs. -25.2 ± 3.4%, P = 0.002). There were no differences in LVEF or radial strain between the groups. LV wall thickness and systolic blood pressure correlated significantly with GLS at rest and at low-dose dobutamine. LV wall thickness is the only independent correlates of absolute CR. Compared with controls, hypertensive patients have impaired LV GLS at rest and impaired CR despite normal LVEF. Impaired CR correlated with LV wall thickness but independent of prevailing blood pressure.

Value of mitral annular plane systolic excursion in the assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization

BackgroundMitral annular plane systolic excursion (MAPSE) is an M-mode derived echocardiographic marker of left ventricular longitudinal function, the aim of this study is to evaluate the value of MAPSE in assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization. MethodsThe study included 50 patients with ischemic cardiomyopathy with ejection fraction (EF) ≤35%, the patients presented to echocardiography laboratory for dobutamine stress echocardiography (DSE) to assess viability and contractile reserve before revascularization, patients with primary valvular disease, and those with significant mitral annular calcifications were excluded from the study. A low dose DSE was done to all patients using standardized incremental infusions of 5, 10, and 20 μg/kg/min and the following parameters were measured at both baseline and peak dose, (EF, wall motion score index(WMSI) and MAPSE). Contractile reserve was measured as the difference between the low dose and baseline values of the EF and WMSI. ResultsThe study included 50 patients aged 55.08±7.15 years, 94% were males, the DSE protocol was complete in all patients without serious side effects. A total of eight hundred segments were analyzed, at baseline 65% were dysfunctional including 31.2% hypokinetic, 28.8% were akinetic, and 5% were dyskinetic. At low dose study 70% of the dysfunctional myocardium showed viability, EF increased significantly from 30.84±4.56 to 42.24±8.15%, p <0.001, the WMSI reduced significantly from 1.92±0.33 to 1.47±0.39, and MAPSE increased significantly from 1.02±0.23 to 1.30±0.30mm. MAPSE showed a significant positive correlation with EF at both baseline and low dose study (r=0.283, p=0.046 & r=0.348, p=0.013) respectively and a significant negative correlation with WMSI at both baseline and low dose study (r=−0.3, p=0.034 & r=−0.409, p=0.003), respectively. By ROC curve analysis we found that Δ MAPSE ≥2mm can predict contractile reserve at Δ EF >10% (AUC=0.6, sensitivity 67.86, specificity 59.09), and Δ MAPSE ≥1.8mm can predict contractile reserve at ΔWMSI ≤0.20 (AUC=0.61, sensitivity 65.5, specificity 75.6). ConclusionsMAPSE is a rapid simple quantitative echocardiographic method that can asses contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.