Decrease In Left Ventricular Ejection Fraction Research Articles

Reversal of Acute Pacing-induced Cardiomyopathy by Cardiac Resynchronization Therapy in Setting of Post-tavr Heart Block

Introduction Transcatheter aortic valve implantation (TAVR) has emerged as a viable alternative to surgical aortic valve replacement. Due to the anatomical relationship to atrial-ventricular (AV) node and valve implantation site, high grade AV block may happen necessitating pacemaker implantation. Pacing-induced cardiomyopathy may result from sustained, chronic right ventricular (RV) pacing causing electrical dyssynchrony and redistribution of myocardial strain, with subsequent development of left ventricular (LV) systolic dysfunction. Time to onset of heart failure is typically months to years, with rare instances in a matter of days. Case Illustration A 70-year-old woman with a past medical history of severe symptomatic aortic stenosis, pulmonary hypertension, essential hypertension, type 2 diabetes mellitus presented for elective TAVR. Baseline left ventricular ejection fraction (LVEF) was 60-64%. Pre-operative QRS duration was 170 ms (Figure 1a). The procedure was complicated by complete atrial-ventricular block for which a dual chamber pacemaker was implanted emergently. A transthoracic echocardiogram (TTE) performed post-operatively day 1 showed dramatic interval decrease in LVEF from 60-64% to 25-29% with significantly increased end diastolic volume (EDV) and end systolic volume (ESV) suggesting LV dilation (Figure 2). Investigations for potential causes were unrevealing for obvious culprits, including absence of prosthesis dysfunction, unchanged patent coronary anatomy on repeat invasive coronary angiogram. After exclusion of reversible causes, the patient underwent cardiac resynchronization therapy (CRT) with a bi-ventricular implantable cardioverter-defibrillator (ICD) on post-operative day 10. Her symptoms improved and patient was discharged. At one-month follow up, updated TTE showed recovered LVEF of 55-60% with reversal of LV dilation (Figure 2). Electrocardiography (ECG) showed appropriate biventricular pacing (Figure 1b). Device interrogation showed 97% bi-ventricular paced. Conclusion Early recognition of cardiomyopathy induced by pacemaker implantation after TAVR allows prompt appropriate therapy that can reverse the cardiomyopathy process.

Association between clinical risk factors and left ventricular function in patients with breast cancer following chemotherapy.

The sequential or concurrent use of two different types of agents such as anthracyclines and trastuzumab may increase myocardial injury and cancer therapeutics-related cardiac dysfunction (CTRCD), which is often the result of the combined detrimental effect of the two therapies for breast cancer patients. However, the association between clinical risk factors and left ventricular (LV) function in such patients is currently unclear. We studied 86 breast cancer patients with preserved LV ejection fraction (LVEF) and treated with anthracyclines, trastuzumab, or both. Echocardiography was performed before and 16days after chemotherapy. In accordance with the current position paper, clinical risk factors for CTRCD were defined as: cumulative dose of doxorubicin > 240mg/m2, age > 65-year-old, body mass index > 30kg/m2, previous radiation therapy, B-type natriuretic peptide > 100pg/mL, previous history of cardiovascular disease, atrial fibrillation, hypertension, diabetes, and smoking. The relative decrease in LVEF after chemotherapy for patients with more than four risk factors was significantly greater than that for patients without (- 9.3 ± 10.8% vs. - 2.2 ± 10.2%; p = 0.02). However, this finding did not apply to patients with more than one, two or three risk factors. Patients with more than four risk factors also tended to show a higher prevalence of CTRCD than those without (14.3% vs. 2.8%; p = 0.12). Moreover, the relative decrease in LVEF became greater as the number of risk factors increased. This study found multiple risk factors were associated with LV dysfunction following chemotherapy. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy.

Occupational Exposures and Cardiac Structure and Function: ECHO-SOL (Echocardiographic Study of Latinos).

BackgroundOur objective was to determine associations of occupational exposures with cardiac structure and function in Hispanic/Latino adults.Methods and ResultsEmployed participants were included (n=782; 52% women, mean age 52.9 years). Occupational exposures to burning wood, vehicle exhaust, solvents, pesticides, and metals at the current and longest‐held job were assessed by questionnaire. Survey multivariable linear regression analyses were used to model the relationship of each self‐reported exposure with echocardiographic measures of cardiac structure and function. Exposure to burning wood at the current job was associated with decreased left ventricular (LV) ejection fraction (−3.1%; standard error [SE], 1.0 [P=0.002]). When the analysis was restricted to exposure at the longest‐held job, occupational exposure to burning wood was associated with increased LV diastolic volume (6.7 mL; SE, 1.6 [P<0.0001]), decreased LV ejection fraction (−2.7%; SE, 0.6 [P<0.0001]), worse LV global longitudinal strain (1.0%; SE, 0.3 [P=0.0009]), and decreased right ventricular fractional area change (−0.02; SE, 0.004 [P<0.001]). Exposure to pesticides was associated with worse average global longitudinal strain (0.8%; SE, 0.2 [P<0.0001]). Exposure to metals was associated with worse global longitudinal strain in the 2‐chamber view (1.0%; SE, 0.5 [P=0.04]), increased stroke volume (3.6 mL; SE, 1.6 [P=0.03]), and increased LV mass indexed to BSA (9.2 g/m2; SE, 3.8 [P=0.01]) or height (4.4 g/m2.7; SE, 1.9 [P=0.02]).ConclusionsOccupational exposures to burning wood, vehicle exhaust, pesticides, and metals were associated with abnormal parameters of LV and right ventricular systolic function. Reducing exposures to toxic chemicals and particulates in the workplace is a potential opportunity to prevent cardiovascular disease in populations at risk.

Impact of hypertension on left ventricular function in patients after anthracycline chemotherapy for malignant lymphoma

BackgroundHypertension is considered an important risk factors for cancer therapeutics-related cardiac dysfunction (CTRCD) as well as heart failure. However, the impact of hypertension and left ventricular (LV) hypertrophy (LVH), which is associated with hypertension, on LV function in patients treated with anthracycline chemotherapy for malignant lymphoma remains uncertain. MethodWe studied 92 patients with malignant lymphoma and with preserved LV ejection fraction (LVEF). Echocardiography was performed before and two-month after anthracycline chemotherapy. CTRCD was defined as the presence of an absolute decrease in LVEF ≥10% to a final value <53%. LVH was defined as concentric hypertrophy, which was determined as relative wall thickness ≥ 0.42 and LV mass index >95 g/m2 for females and > 115 g/m2 for males. ResultsRelative decrease in LVEF after anthracycline chemotherapy in patients with hypertension (n = 23) was significantly higher than that in patients without hypertension (n = 69) (−5.8% [−9.4, −1.3]) vs. (−1.1% [−4.1, 2.5]); P = .005). Moreover, the prevalence of CTRCD in patients with hypertension tended to be higher than in those without hypertension (17% vs. 5%, p = .09). A sequential logistic model for predicting CTRCD, based on baseline clinical variables including major clinical risk factors, was improved by the addition of the complication of hypertension (P = .049), and further improved by the addition of the presence of LVH (P = .023). ConclusionsHypertension, especially when complicated by LVH, was found to be associated with LV dysfunction after anthracycline chemotherapy in patients with malignant lymphoma and preserved LVEF. Watchful observation or early therapeutic intervention may thus be needed for such patients by the addition of the presence of LVH.

Improvement in Left Ventricular Ejection Fraction in Outpatients With Heart Failure With Reduced Ejection Fraction: Data From CHAMP-HF.

Among patients with heart failure (HF) with reduced ejection fraction (EF), improvements in left ventricular EF (LVEF) are associated with better outcomes and remain an important treatment goal. Patient factors associated with LVEF improvement in routine clinical practice have not been clearly defined. CHAMP-HF (Change the Management of Patients with Heart Failure) is a prospective registry of outpatients with HF with reduced EF. Assessments of LVEF are recorded when performed for routine care. We analyzed patients with both baseline and ≥1 follow-up LVEF assessments to describe factors associated with LVEF improvement. In CHAMP-HF, 2623 patients had a baseline and follow-up LVEF assessment. The median age was 67 (interquartile range, 58-75) years, 40% had an ischemic cardiomyopathy, and median HF duration was 2.8 years (0.7-6.8). Median LVEF was 30% (23-35), and median change on follow-up was 4% (-2 to -13); 19% of patients had a decrease in LVEF, 31% had no change, 49% had a ≥5% increase, and 34% had a ≥10% increase. In a multivariable model, the following factors were associated with ≥5% LVEF increase: shorter HF duration (odds ratio [OR], 1.21 [95% CI, 1.17-1.25]), no implantable cardioverter defibrillator (OR, 1.46 [95% CI, 1.34-1.55]), lower LVEF (OR, 1.15 [95% CI, 1.10-1.19]), nonischemic cardiomyopathy (OR, 1.24 [95% CI, 1.09-1.36]), and no coronary disease (OR, 1.20 [95% CI, 1.03-1.35]). In a large cohort of outpatients with chronic HF with reduced EF, improvements in LVEF were common. Common baseline cardiac characteristics identified a population that was more likely to respond over time. These data may inform clinical decision making and should be the basis for future research on myocardial recovery.

Assessment of Cardiac Function by Advanced Echocardiography in Breast Cancer Patients (HER2 Positive vs HER2 Negative)

Background: Human epidermal growth factor receptor 2(HER2) is a gene that makes proteins in the breast cell. The HER2 gene is present in about 25% - 30% of patients with breast cancers. The most common side effect of drugs is left ventricular dysfunction. Evaluation of left ventricular ejection fraction (LVEF) by 2D echocardiography cannot detect subtle changes in LV systolic function. Objectives: We want to draw a comparison between two groups of breast cancer patients (HER2 positive and negative) by advanced echocardiography. Methods: We have conducted a single center prospective study at Rajaie Cardiovascular Medical and Research Center in 2018 - 2019. Results: This analysis included 58 patients with breast cancer. 15 cases (34%) were HER2 positive. Mean left ventricular ejection fraction (2D LVEF) in HER2 positive patients was 55 % at baseline and in HER2 negative patients was 55 %. In HER2 positive patients we had 10 percent decrease in LVEF during follow-up and the final LVEF was about 45% (P value &lt; 0.05). Mean left ventricular ejection fraction by 3D echocardiography (3D LVEF) in HER positive patients was 57 % and in HER2 negative patients was 55 % at baseline. In HER2 positive patients we had about 20% decrease in 3D LVEF and the final LVEF was 40 % (P value &lt; 0.05). Mean circumferential strain (GCS) in HER2 positive patients was -21 and in HER2 negative patients was -21 at baseline which decreased to -18 in HER positive patients and -17 in HER2 negative patients, showing clinical significance ( P value = 0.008). Conclusions: In our study HER2 positive breast cancers showed about 10% drop in 2DEF, about 20% drop in 3DLVEF and about 5% drop in HMLVEF, which all were significant (P value &lt; 0.05). We found that GCS is more sensitive than GLS in detecting subclinical involvement, and early changes in GCS is a good predictor of subsequent development of drugs (anthracycline-transtuzumab) induced cardiotoxicity.

Efficacy and safety of sodium-glucose co-transporter 2 inhibition according to left ventricular ejection fraction in DAPA-HF.

The aim of this study was to examine whether left ventricular ejection fraction (LVEF) modified efficacy and safety of dapagliflozin 10 mg compared with placebo in the 4744 patients with LVEF ≤40% randomized in the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF). We examined whether LVEF, analysed categorically or continuously, modified the effect of dapagliflozin. The primary efficacy outcome was the composite of a worsening heart failure (HF) event (unplanned HF hospitalization/an urgent HF visit requiring intravenous therapy) or cardiovascular death. Mean LVEF was 31.1% and LVEF categories analysed were: <26% (n=1143), 26-30% (n=1018), 31-35% (n=1187), and >35%(n=1396). Each 5% decrease in LVEF was associated with a higher risk of the primary outcome [hazard ratio (HR) 1.18; 95% confidence interval (CI) 1.13-1.24]. The benefit of dapagliflozin was consistent across the spectrum of LVEF: the dapagliflozin vs. placebo HR was 0.75 (95% CI 0.59-0.95) for LVEF <26%, 0.75 (0.57-0.98) for LVEF 26-30%, 0.67 (0.51-0.89) for LVEF 31-35%, and 0.83 (0.63-1.09) for LVEF >35% (P for interaction=0.762). Similarly, the effect of dapagliflozin on the components of the primary endpoint was not modified by baseline LVEF (P for interaction for cardiovascular death=0.974, and for worsening HF=0.161). Safety of dapagliflozin was also consistent across the range of LVEF and neither efficacy nor safety were modified by diabetes status. Left ventricular ejection fraction was a significant predictor of hospitalization and mortality in patients with HF with reduced ejection fraction but did not modify the beneficial effect of dapagliflozin, overall or separately, in patients with and without diabetes. ClinicalTrials.gov Identifier NCT03036124.

P552Predictors of pacing induced left ventricular dysfunction and cardiomyopathy assessed by three-dimensional echocardiography and speckle tracking strain

Abstract OnBehalf Alexandria EPS Unit Background During recent years there was a focus on the negative effects associated with long term right ventricular (RV) pacing. It was shown in both experimental and clinical studies that RV pacing leads to ventricular dyssynchrony, similar to that of left bundle branch block (LBBB) with subsequent electrical, mechanical and anatomical changes leading to detrimental effects on left ventricular structure and function. During the last two decades, 3D echocardiography developed from a time-consuming method to a routine clinical approach. At present, evidence suggested that 3D echocardiography provided improved accuracy and reproducibility over 2D methods for LV volume and function calculation. There is a growing number of literature signifying that speckle tracking strain is able to identify left ventricular (LV) dysfunction even before any reduction in LV ejection fraction (LVEF). Methods This was an observational study of fifty consecutive patients without structural heart disease and preserved ejection fraction (LVEF &amp;gt; 50%) presented with high grade atrioventricular block for permanent pacing. Complete 2D and a full volume 3D echocardiography was done before implantation, one-week and 6-months after implantation together with global longitudinal strains analysis (GLS). Patients were followed for 6 months to detect the incidence of PIVD (defined as a reduction in LVEF &amp;gt;10 percentage points but still above 50%) and PICMP (defined as a decrease in LVEF by 10 percentage points from baseline in the absence of other known causes of cardiomyopathy resulting in EF &amp;lt; 50%). PIVD and PICMP predictors and risk factors were analyzed over a 6-month period. Results At six months, 25 (50%) patients developed PIVD; of these, 6 (12%) developed PICMP. Pre-implantation, GLS was significantly lower in the 6 patients who subsequently developed PICMP, compared to those who developed PIVD and the preserved EF group (mean GLS -15.50 vs. -21.0, -20.0 respectively; p = 0.005, 0.033 respectively). At one week, GLS was significantly lower in the 25 patients who subsequently developed PIVD, compared to those who did not (GLS -13.0 vs. -18.0 respectively; p = 0.002). A reduction of baseline GLS by 15% or more at one week was associated with the development of PIVD and PICMP (p = &amp;lt;0.001). A wider native QRS complex was associated with the development of PIVD and PICMP (p = 0.008, 0.018 respectively). The other predictors (Age, Sex, HTN, D.M, Post-pacing QRS width and axis, presence of native BBB, Pacemaker type and lead site) were found non-significant. Conclusion PICMP may be more common than previously reported and it may occur shortly after implantation. This rise in its incidence is due to the application of new sensitive tools like 3D echocardiography and speckle tracking strain. Pre-implantation GLS is a sensitive parameter for the development of PICMP. One-week GLS is an early predictor for the development of PICMP and PIVD before any reduction in EF develops.

P1296CARDIAC COMPLICATIONS OF ARTERIOVENOUS FISTULAS IN PATIENTS WITH END-STAGE RENAL DISEASE

Abstract Background and Aims Current literature suggests the arteriovenous fistula (AVF) to be the preferred type of vascular access for hemodialysis. However, AVFs have significant and potentially deleterious effects on cardiac functions particularly in the setting of preexisting heart disease. The aim of this study is to compare the clinical and echocardiographic evolution after creation of a proximal AVF and a radial AVF. Method We conducted a retrospective descriptive study including all chronic hemodialysis patients through AVF. Group 1 (G1) included patients with proximal AVF and group 2 (G2) patients with radial AVF. Results Twenty-four patients were collected in G1 and the average age was 55 years. G2 included 13 patients with a mean age of 44 years. Systolic blood pressure decreased after AVF creation in both groups (G1: 62.5%, G2: 45%, NS). A dyspnea was noted in 70% of cases of G1 and 38.4% of cases of G2 (NS). The interventricular septum was thickened in 20.8% of cases of G1 and 38.4% of G2 (NS). Left ventricular (LV) dilatation was observed in both groups with LV diastolic telegram diameter increase of 58% in G1 versus 10% in G2 (p = 0.04). A decrease in LV ejection fraction was found in 62.5% in G1 and 46.1% in G2 (p = 0.066). The major cardiac complications in G1 were acute coronary syndrome in 5 patients and atrial fibrillation in 4 cases after an average of 60 months and 35 months, respectively. No cardiac complications were noted in G2. Conclusion AVFs remain the preferred type of vascular access for chronic hemodialysis therapy because they are associated with better long-term patency and fewer complications compared with synthetic grafts. Its seat will depend on the vascular state and the cardiac status of the dialysis patient.

Four-year follow-up of a phase III study comparing SB3 (trastuzumab biosimilar) and reference trastuzumab in HER2-positive early or locally advanced breast cancer in neoadjuvant setting.

578 Background: SB3 was approved in the US and EU as a biosimilar of reference trastuzumab (TRZ). Here, we report 4-year cardiac safety and survival outcomes. Methods: After completing neoadjuvant-adjuvant therapy in patients with HER2 positive early breast cancer, patients from selected countries participated in a 5-year follow-up study of a phase III trial (Pivot et al. Eur J Cancer 2019). The aim was to observe long-term cardiac safety and survival. EFS and OS were analyzed in subgroups by ADCC status within TRZ in ad-hoc analyses. Results: Of 875 patients randomized in the phase III trial, 367 patients (SB3, N=186; TRZ, N=181) were enrolled in the follow-up study. The median follow-up was 53 months. During the follow-up, the incidence of asymptomatic significant left ventricular ejection fraction (LVEF) decrease was low (SB3, n=1; TRZ, n=2), with all patients recovering with LVEF ≥ 50%. No cases of symptomatic congestive heart failure, cardiac death, or other significant cardiac condition were reported. 4-year EFS rates were 83.4% for SB3 and 80.7% for TRZ with a HR of 0.77 [95% CI 0.47, 1.27]. 4-year OS rates were 94.3% for SB3 and 89.6% for TRZ with a HR of 0.53 [95% CI 0.24, 1.16]. From ad-hoc analysis, a difference in EFS and OS was seen between Non-drifted TRZ and Drifted TRZ; Difference between SB3 and Non-drifted TRZ was not statistically significant. Conclusions: In a subset of patients from the phase III trial, comparable long-term cardiac safety and survival at 4-year supports biosimilarity between SB3 and TRZ. Ad-hoc analysis results by ADCC status suggest a possible correlation between ADCC and clinical efficacy. Further follow-up is needed. Clinical trial information: NCT02771795 . [Table: see text]

Neo-aortic Root Dilatation, Aortic Stiffness, and Ventricular interactions in Long-Term Follow-Up After the Ross Procedure in Childhood.

Patients after the Ross procedure are at risk for right (RV) and left ventricular (LV) dysfunction due to neo-aortic and pulmonary dysfunction. While neo-aortic root dilatation has been related to LV dysfunction, the potential contributions of aortic stiffness and ventricular interactions have not been evaluated. Patients status post Ross procedure up to age 18years with cardiac magnetic resonance (CMR) exam from 2007 to 2018 were retrospectively reviewed. Aortic pulse wave velocity (PWV) was calculated from phase contrast and angiogram images. RV and LV peak global longitudinal (GLS) and circumferential strain (GCS) were measured using tissue tracking software. Multivariable regression was performed for variables associated with parameters of LV function. In 58 patients (median age 20.5years at CMR exam), male gender, longer time since Ross procedure, aortic root dilatation, and lower RV ejection fraction (EF) were associated with decreased LV EF. There was no association with LV late gadolinium enhancement or neo-aortic or conduit regurgitation. LV GCS and GLS also correlated with RV GCS, RV GLS and PWV. In multivariable analysis, the relation of RV and LV systolic function, but not aortic measurements, remained significant. In conclusion, in long-term follow-up after pediatric Ross procedure, RV function rather than aortic root size or aortic stiffness most closely relates to LV function. Ventricular interactions may impact decision-making on timing of conduit intervention, which could differ from established criteria in populations with only aortic or pulmonary valve disease. Further study is warranted to evaluate possible association with clinical outcome.

MANAGEMENT OF HEART FAILURE PATIENTS (UPDATE 2019) – PHARMACOLOGICAL THERAPY

The up-date of ESC Guidelines on the management of patients with heart failure was published last year. The beneficial effect of a new group of drugs (flozins, sacubitril/valsartan - ARNI) in patients with heart failure was pointed out. These drugs not only prevent the onset of heart failure but also reduce HF hospitalization rate and in patients with reduced left ventricular ejection fraction decrease risk of cardiovascular death and in case of empagliflozin, dapagliflozin or sacubitril/valsartan also total mortality. These latter medicines reduce also the likelihood of sudden cardiac death. ARNI reduce the number of appropriate ICD shocks, the incidence of non-sustained VT, premature ventricular contractions, and increase percentage of biventricular pacing in car­diac resynchronization recipients.

Electroacupuncture at "Neiguan"(PC6) decreased cardiac sympathetic hyperactivity and improved cardiac function in chronic myocardial ischemia model rats

To investigate the autonomic nervous mechanism of acupuncture therapy in the treatment of ischemic cardiomyopathy by observing the influence of electroacupuncture (EA) at "Neiguan"(PC6) on the superior cervical cardiac nerve activity and cardiac function in chronic myocardial ischemia (CMI) rats. Male SD rats were randomly divided into control, model and EA groups (n＝8 in each group). The CMI model was established by ligating the anterior descending branch of the left coronary artery. EA (15 Hz, 1.5 mA) was applied to bilateral PC6 for 20 min, once a day for 28 consecutive days. Cardiac sympathetic nerve electrical activities (CSNEA), electrocardiogram (ECG) of the standard limb lead Ⅱ and ultrasonic cardiogram (UCG) were recorded for observing changes of ST segment height, left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS)．. The CSNEA was significantly increased(P<0.001), and the hight of ECG-STⅡ， LVEF and LVFS were considerably decreased in the model group relevant to the control group (P<0.01, P<0.001), while after the intervention, modeling induced increase of CSNEA and decrease of ECG-STⅡ， LVEF and LVFS were obviously suppressed in the EA group in comparison with the model group (P<0.01, P<0.05, P<0.001). EA of PC6 can improve cardiac function and myocardial ischemia in CMI rats, which is possibly related to its effect in decreasing cardiac sympathetic hyperactivity.

Real world study of pertuzumab-trastuzumabchemotherapy versus trastuzumab-chemotherapy in neoadjuvant treatment of breast cancer.

The primary objective of the study is to compare the effectivenessof trastuzumab-chemotherapy with and without pertuzumab. Asa secondary objective, we seek to evaluate the cardiac safety of thetreatment. Retrospective observational study including all patients treatedwith either pertuzumab-trastuzumab-chemotherapy (n = 10) or trastuzumab-chemotherapy (n = 13) (January 2015-December 2018) in a specialtyhospital, which met the criteria established by the Commission Centralfor the Optimization and Harmonization of the pharmacotherapy of theAndalusian Health Service for the use of pertuzumab in neoadjuvance:HER2 positive tumor, negative hormonal receptors, with high risk of relapse(tumor &gt; 2 cm or lymph node involvement). To assess effectiveness,the complete pathological response was used. For cardiac safety, the decreasein left ventricular ejection fraction greater than 10% was employed. Complete pathological response was superior in the pertuzumabgroup (70.0% vs. 30.8%). Cardiac safety was similar in both. For patients with HER2 positive tumors and negativehormonal receptors with high risk criteria that receive pertuzumab, thecomplete pathological response is superior, with no increase in cardiactoxicity.

Diffusely Increased Myocardial Extracellular Volume With or Without Focal Late Gadolinium Enhancement: Prevalence and Associations With Left Ventricular Size and Function.

Myocardial extracellular volume fraction (ECV) using cardiovascular magnetic resonance (CMR) can identify diffuse lesions not detected by late gadolinium enhancement (LGE). We aimed to determine the prevalence of increased ECV and its relation to other CMR findings. Consecutive patients (n=609, age median [interquartile range] 53 [39 to 66] y, 62% male) underwent CMR at 1.5 T. Focal lesions on LGE images were noted. ECV in regions without focal LGE findings defined diffuse changes. Pronounced increases in left ventricular (LV) end-diastolic volume index and LV mass index, and pronounced decreases in LV ejection fraction were defined as >3 SD from the sex-specific mean in healthy volunteers. Of 609 patients without amyloidosis or hypertrophic cardiomyopathy, 8% had diffusely increased ECV and 5% of all patients had diffusely increased ECV without any focal LGE findings. Multivariate analysis showed that a pronounced increase in the LV end-diastolic volume index was associated with increased ECV (P=0.001), but not LGE (P=0.52). A pronounced decrease in LV ejection fraction was associated with the presence of LGE (P<0.001), but not with increased ECV (P=0.41). Eight percent of patients in this clinical cohort with known or suspected heart disease had diffusely increased ECV and 60% of these lacked focal LGE findings. LV size is independently associated with increased ECV, whereas systolic dysfunction is independently associated with LGE. This image-based clinical study demonstrates that ECV-CMR provides additional information negligibly related to the results of LGE imaging, and thereby increases the diagnostic yield of CMR.

Outcomes of myocardial fibrosis in patients undergoing transcatheter aortic valve replacement

We sought to investigate the relevance of myocardial fibrosis, assessed by mid-wall fibrosis risk (MFR) score, with respect to left ventricular (LV) reverse remodelling following transcatheter aortic valve replacement (TAVR). Between January 2010 and March 2015, we enrolled 207 patients in whom baseline MFR, which includes age, sex, high-sensitivity cardiac troponin I, presence of strain pattern on electrocardiography, and peak aortic valve velocity, as well as one-year follow-up echocardiography was available. LV reverse remodelling was defined as a >10% reduction in LV end-diastolic volume index (LVEDVi). A higher MFR score (≥52) was associated with increased LVEDVi and with decreased LV ejection fraction as well as higher baseline NT-proBNP levels (p<0.05 for all). One year after the TAVR procedure, a higher MFR score was associated with a decreased probability of LV reverse remodelling (OR 0.33, 95% CI: 0.23-0.87; p=0.03), which was independent of baseline echocardiographic parameters and comorbidities. In contrast, there was no significant difference in five-year mortality between patients with lower and higher MFR scores (57.9% vs 60.5%, p=0.66). A higher MFR score is associated with reduced LV reverse remodelling at one-year follow-up, whereas the MFR score does not appear to correlate with long-term mortality after TAVR.

Design and rationale of the Impact of MultiPoint pacing in CRT patients with reduced RV-to-LV delay (IMAGE-CRT) study.

Cardiac resynchronization therapy (CRT) is an established treatment in patients with heart failure and prolonged QRS duration. A biventricular device is implanted to achieve faster activation and more synchronous contraction of the ventricles. Despite the convincing effect of CRT, 30-40% of patients do not respond. We decided to investigate the role of multipoint pacing (MPP) in a selected group of patients with right ventricle (RV)-to-left ventricle (LV) intervals less than 80 ms that do not respond to traditional CRT. We will enrol 248 patients in this patient-blinded, observational, clinical study aiming to investigate if MPP could decrease LV end-systolic volume (ESV) in patients with RV-to-LV interval less than 80 ms. MPP will be activated ON at implant in patients with RV-to-LV delay less than 80 ms and OFF in RV-to-LV at least 80 ms. At follow-up the activation of MPP will be related to CRT response. The primary study endpoint will be the responder rate at 6 months, defined as a decrease in LV ejection fraction, LV end-diastolic volume, LV end-systolic volume (LVESV) at least 15% from baseline. Secondary outcomes include 12 months relative percentage reduction in LVESV and a combined clinical outcome measure of response to CRT defined as the patient being alive, no hospitalization due to heart failure, and experiencing an improvement in New York Heart Association functional class (Composite-Score). Reducing the nonresponder rate continues to be an important goal for CRT.If an increase in reverse remodelling can be achieved by MPP, this study supports the conduct of larger trials investigating the role of MPP on clinical outcomes in selected patients treated, right now, only with traditional CRT. ClinicalTrials.gov, NCT02713308. Registered on 18 March 2016.

Anti-HER2 therapy-associated cardiotoxicity in breast cancer patients: analysis of real-world data from a UK cancer centre

Cardiac adverse events are a recognised toxicity for patients with breast cancer receiving anti-human epidermal growth factor receptor-2 (HER2) therapy.[1][1] Large phase III clinical trials have shown an incidence of left ventricular ejection fraction (LVEF) decrease >10% of 7.1–18.6% and overt

Prognostic Value of Cardiac Biomarkers Assessment in Combination with Myocardial 2D Strain Echocardiography for Early Detection of Anthracycline-Related Cardiac Toxicity.

Background: Anthracyclines, a widely used chemotherapy agent with a definite survival improvement, can result in cardiac toxicity presenting with HF (heart failure).Objective: We aim to assess the predictive value of cardiac biomarkers assessment in combination with myocardial two-dimensional strain echocardiography for early detection of cardiac toxicity in patients who underwent Anthracycline-based chemotherapy.Methods: Fifty-two consecutive adult patients scheduled to undergo the first course of Anthracycline-based chemotherapy were subjected to the study. All the patients underwent highly sensitive 2D echocardiographic evaluation before the treatment, 4 and 12 weeks after completion of first-course chemotherapy. Longitudinal and segmental strains were measured. Serum levels of High-sensitive cardiac troponin I (hscTn-I) and N-terminal-pro-BNP (NT-proBNP) were also assessed before the initiation and 3 weeks after completion of first-course chemotherapy.Results: Fifteen patients (28.8%) revealed a decrease in LVEF (Left Ventricular Ejection Fraction) throughout the evaluations, while just 5 patients met the criteria of cardiac toxicity (9.6%). AUC for Global Longitudinal Strain (GLS) ROC curve at 4 weeks of follow-up was calculated to be 0.968. Inferoseptal Systolic Longitudinal Strain (SLS) had the highest AUC value (AUC: 0.934) among different wall SLS. LVESD (Left Ventricular End-Systolic Diameter) at first and second evaluation could predict the risk of cardiac toxicity among LVESD, LVEDD (Left Ventricular End Diastolic Diameter) and LVEDV (Left Ventricular End-Diastolic Volume). Among cardiac biomarkers, hs-cTnI had higher sensitivity, while NT-proBNP had higher specificity for cardiac toxicity.Conclusion: This study has shown that hs-cTnI with good sensitivity can predict cardiac toxicity in Anthracycline-based chemotherapy receiver. The use of strain with speckle echocardiography method has a prognostic value; however, both longitudinal and segmental strain should be assessed. Lateral and inferoseptal SLS (Segmental Longitudinal Strain) are specific markers of cardiac toxicity in the course of anthracycline-related cardiac toxicity.

Temporal changes in left ventricular ejection fraction and their prognostic impacts in patients with Stage B heart failure

BackgroundWe have recently demonstrated that left ventricular ejection fraction (LVEF) dynamically changes over time with prognostic impacts in Stage C/D patients, namely, those who have a current or past history of heart failure (HF). However, it is unknown whether this is also the case in asymptomatic Stage B patients, namely, those who have a risk of HF, but do not have a history of HF. MethodsIn our CHART-2 Study (N = 10,219), we enrolled 4005 Stage B patients and divided them into 3 groups by LVEF; preserved EF (pEF, LVEF ≥50%, N = 3526), mid-range EF (mrEF, LVEF 41–49%, N = 302), and reduced EF (rEF, LVEF ≤40%, N = 177). We examined the prognostic impacts of LVEF transitions among the 3 groups in comparison with 4477 patients with Stage C/D HF. ResultsStage B were characterized by less severe clinical status and better prognosis compared with Stage C/D. Stage B in mrEF and rEF at baseline dynamically transitioned to other groups at 1-year, whereas those in pEF unchanged; at 1-year, mrEF transitioned to pEF/rEF by 50/16%, and rEF transitioned to pEF/mrEF by 25/31%, respectively, whereas pEF transitioned to mrEF/rEF by only 3.6/0.7%, respectively, which were consistent with findings in findings with Stage C/D. Although LVEF decrease was directly associated with all-cause mortality in both the Stage B and Stage C/D with pEF, factors related to LVEF changes were different between the 2 groups. ConclusionsIn Stage B, LVEF dynamically changes with prognostic impacts as in Stage C/D, whereas different determination factors may be involved in the 2 stages.Clinical trial registration: Chronic Heart Failure Analysis and Registry in the Tohoku District (CHART)-2 (NCT00418041).