Depressed Left Ventricular Ejection Fraction Research Articles

Myocardial Injury in Multiple Myeloma Patients With Preserved Left Ventricular Ejection Fraction: Noninvasive Left Ventricular Pressure-Strain Myocardial Work.

IntroductionOver one-half of patients with multiple myeloma (MM) die of heart failure or arrhythmia. Left ventricular ejection fraction (LVEF) is used to describe left ventricular systolic function. However, depressed LVEF means advanced stage of left ventricular dysfunction in patients with MM. Left ventricular pressure-strain-derived myocardial work (LVMW) is a novel and noninvasive method for evaluating LV function related to LV dynamic pressure load. MW is assessed by LV MW index (LVMWI), constructive work, wasted work, and LV MW efficiency (LVMWE). In this study, we aimed to investigate the value of LVMW in cardiac function assessment and clinical prognosis of MM patients with preserved LVEF.MethodsA total of 72 subjects, including 40 untreated MM patients with preserved EF (including the thick wall and normal wall groups) and 32 non-MM patients, were enrolled in this study. Laboratory data and clinical history of all the patients were collected. All the patients underwent comprehensive echocardiographic examinations and then LVMWI and LVMWE were calculated. Moreover, cardiac adverse events (CAEs) were observed in MM patients treated with bortezomib-based therapy after 6 months and the prognostic value of MW was assessed.Results(1) LV myocardial global work index (GWI), myocardial global work efficiency (GWE), and global longitudinal strain (GLS) were lower in the thick wall group of patients with MM compared with the normal wall group and controls. Cardiac segmental analysis of LVMWI in patients with MM showed an apical sparing pattern; (2) The area under the curve (AUC) of GWE for judging the disease severity based on the Revised International Staging System (R-ISS) was 0.835 (95% CI: 0.684–0.933, p < 0.05); (3) GWE, LgdFLC, and arrhythmia were independent risk factors of CAEs. The AUC of GWE for predicting CAEs in MM patients treated with bortezomib-based therapy for 6 months follow-up was 0.896 (95% CI: 0.758–0.970, p < 0.05).ConclusionMM Patients with preserved EF had subclinical LV systolic dysfunction, which was worse in the thick wall group. LVMWI was presented as “apical sparing” in patients with MM. A lower LVGWE may have a predictive value for CAEs in patients with MM after 6 months of follow-up.

Exhaustive review and triggering factors precipitating Takotsubo cardiomyopathy induced during dobutamine stress echocardiography

Our purpose was to make an exhaustive research of TTC-DSE reports and compared this cohort to a large retrospective sample of DSE exams, to identify factors which could possibly induced TTC-DSE. Between 2006 and 2019, we identify 30 observations of TTC-DSE, all of them with typical features of TTC. Over a three-year period (2013–2015), a sample of 578 consecutive patients, all exams were enrolled as reference and then compared to TTC-DSE cohort. TTC-DSE cohort showed a strong predominance of aged female population > 50 years (93.3%); depression and/or anxiety (26.7%); EKG: ST elevation (70%); normal coronary angiography; depressed angiographic left ventricular ejection fraction < 40% (14/18 pts); typical segmental LV impairment: apical (7.3%); mid-ventricular (13.6%); reverse (9%); low troponin peak: 2.65 ± 2.04 ng/mL; one death (acute heart failure), but rapid recovery of LVEF (29/30 pts). On a 3-year retrospective period (2013–2015), The 578 consecutive DSE patients were compared with TTC-DSE patients: mean age (70 vs. 64), peak dose dobutamine (30 vs. 40 μg/kg/min), maximum peak heart rate (94 vs. 81%), smoking (16 vs. 36.6%), all P < 0.01. In a multivariate analysis, female sex (OR = 9.6; 95% CI: 3–28), smoker (OR = 4.8; 95% CI: 2–11) and dobutamine posology (OR = 1.07; 95% CI: 1.02–1.12), all P < 0.01, were independent predictors of TTC-DSE. Using ROC curve analysis, dobutamine posology > 30 gammas/kg/min gives the best cut off (AUC 0.7 ± 0.04; P < 0.01). TTC-DSE is rare and superimposable to the usual TTC. By comparison with DSE, independent factors (female sex, smoker, dobutamine posology > 30 gammas/kg/min) are predictive of TTC-DSE. Nevertheless, the discrepancy between the large number of daily DSE examinations and the rarity of TTC-DSE remains unexplained.

107 Left ventricular intramural haematoma secondary to transcatheter aortic valve replacement

Abstract An 80-year-old woman was electively hospitalized at our institution to undergo transcatheter aortic valve replacement (TAVR) for severe aortic valve stenosis symptomatic for exertional dyspnoea (NYHA III). At the admission she presented a normal electrocardiogram (EKG), a creatinine clearance (CrCl) of 36 ml/min, a normal size and hypertrophic left ventricle with a preserved ejection fraction (EF 70%). A pre-procedure coronary angiography was performed and showed absence of significant epicardic stenoses. A balloon-expandable valve (Edwards Sapien 26 mm) was successfully implanted via the trans-femoral access without intra-procedural complication and the patient was transferred to cardiology ward for monitoring; in the post-procedure, the patient complained of nausea and a feeling of vomiting, without other cardiologic symptoms; she had low blood pressure (BP 95/70 mmHg) with normal heart rate and oxygen saturation (Killip 1). An EKG was performed and showed a ST-elevation in antero-lateral leads, so a bed-side echocardiogram was performed showing a good function of TAVR but an ipo-akinesia of the left ventricle’s lateral wall. The patient was transferred to the Cath lab and at the emergent coronary angiography no clear epicardic stenoses were seen, with a diffuse narrowing of an early obtuse marginal (OM) branch and of the distal branches of circumflex artery, suggestive for a spasm, that was refractory to repeated nitroglycerine infusions. A clear mismatch between coronary angiogram findings and EKG was detected. Considering the hemodynamic compromise and symptoms persistence a percutaneous transluminal coronary angioplasty of OM was performed with a partial ST resolution. The patient was transferred to the Coronary Unit Care where an echocardiogram was repeated confirming the good function of TAVR but outlining the presence of a voluminous intramural haematoma (&amp;gt;30 mm of maximum diameter) with anterior, lateral and posterior wall akinesia and depressed left ventricle ejection fraction (EF 35%). A conservative management of the haematoma was chosen. The hospital stay was complicated by an acute pulmonary oedema, requiring non-invasive ventilation, a cardiogenic shock, requiring inotropic (dobutamine) support, and an acute renal failure (creatinine peak 2.9 mg/dl with CrCl of 15 ml/min) with anuria, requiring continuous renal replacement therapy for two days; she developed a left branch block with no complete atrioventricular block. The pre-discharged echocardiogram showed a partially organized moderate pericardial effusion (1.3 cm) and moderate mitral regurgitation. After six months, she was asymptomatic, with a significant improvement of functional status (NYHA II) and a stable renal function (CrCl &amp;gt; 30 ml/min); no more echocardiographic signs of pericardial effusion were shown but the persistence of akinesia of the postero-lateral- and anterior-wall with depressed left ventricle ejection fraction (EF 37%) and moderate-severe mitral regurgitation. The persistence of good result of TAVR (aortic mean gradient 9 mmHg, absence of peri-valvular leak) was confirmed. Intramural dissecting haematoma (IDH) is a rare complication of myocardial infarction, chest trauma and percutaneous interventions; it consists of a cavity filled with blood, with the integrity of both the outer wall (myocardium and pericardium) and the inner wall (myocardium and endocardium) and it can develop in the left ventricle free wall, the right ventricle and the interventricular septum. IDH’s formation may result from intra-myocardial vessels’ rupture in the interstitial space. Never understimate nausea as symptom: think about heart is challenging but mandatory!

675 A rare case of tako-tsubo syndrome in a patient with hypertrophic cardiomyopathy

Abstract Aims We know that basal septal hypertrophy is a rare and unique anatomical finding associated with hypertrophic cardiomyopathy (HCM). Tako-Tsubo cardiomyopathy (TTC) is a transient left ventricular systolic dysfunction induced by high physical or emotional stress. Its occurrence with HCM is unusual. However, this presentation occurs more often with the classic asymmetrical septal hypertrophy compared with the apical variant. This case demonstrates that the coexistence of TTC with septal HCM in an elderly patient may lead to a severe haemodynamic instability picture. Methods and results A 81-year-old female presented to the emergency department (ED) complaining of dyspnoea and chest pain lasting for 1 day. She had hypertension and dyslipidemia associated with a familial history of sudden death. On physical exam, we found a severe hypotension (systolic blood pressure of 80 mmHg) associated with bilateral rales at chest auscultation. Cardiac auscultation revealed a harsh systolic murmur, best heard over the left sternal border. Heart rate was 60 b.p.m. in sinus rhythm. Labs were significant for HS-I troponin of 6.035 ng/L (NV: ≤ 12) and NT-proBNP of 7.640 pg/ml (NV: ≤1800). A 12-leads electrocardiogram (ECG) at admission revealed a STEMI-like ST segment elevation from V2 to V6 (Figure 1A). For this reason she was urgently taken to the cath-lab where she was found to have tortuous but normal coronary arteries. After coronary angiography, a trans-thoracic echocardiogram (TTE) revealed a pathological LV hypertrophy with a septal diastolic thickness of 19 mm, depressed LV ejection fraction (LVEF) due to a severe apical ballooning. At continuous wave (CW)-Doppler there was a dynamic obstruction across the LV outflow tract (LVOT), with a late peak velocity of 4.9 m/s and an estimated peak gradient of 98 mmHg. The gradient was increased by a systolic anterior motion (SAM) of anterior mitral leaflet causing a moderate mitral regurgitation (MR). All these findings were consistent with obstructive septal HCM associated with Takotsubo cardiomyopathy. After treatment with intravenous diuretics and metoprolol (5 + 5 mg i.v. bolus followed by oral dose of 100 mg daily), her clinical condition markedly improved. One week later, ECG demonstrated deeply inverted T waves on antero-lateral leads and QT prolongation (501 ms). Three weeks later, after a complete resolution of the LV apical dyskinesia, LVEF normalized. LVOT gradient decreased to 20 mmHg, with a dynamic increase to 70 mmHg during Valsalva manoeuvre. Conclusions It is well known that TTC may be complicated by a reversible LVOT obstruction by itself but the combination with obstructive HCM can lead to low cardiac output and acute heart failure. This combination has been found to be not common and the correct treatment of this unusual type of cardiogenic shock is still unclear. Careful initial evaluation and continuous monitoring must be warranted in such rare cases. Supportive care afterward with beta blockers, along with echocardiogram surveillance, are the mainstay of management. Cardiologists, intensivisits, and clinicians alike need to recognize and comprehend the pathophysiology behind this unique clinical manifestation so that they may adjust their management and treatment accordingly.

Variability in Reassessment of Left Ventricular Ejection Fraction After Myocardial Infarction in the Acute Myocardial Infarction Quality Assurance Canada Study

Persistently depressed left ventricular ejection fraction (LVEF) after myocardial infarction (MI) is associated with adverse prognosis and directs the use of evidence-based treatments to prevent sudden cardiac death and/or progressive heart failure. To assess adherence with guideline-recommended LVEF reassessment and to study the evolution of LVEF over 6 months of follow-up. This was a multicenter cohort study at Canadian academic and community hospitals with on-site cardiac catheterization services. Patients with type 1 acute MI and LVEF less than or equal to 45% during the index hospitalization were enrolled between January 2018 and August 2019 and were followed-up for 6 months. Data analysis was performed from May 2020 to September 2021. Baseline clinical factors, in-hospital care and LVEF, and site-specific features. The main outcomes were receipt of repeat LVEF assessment by 6 months and the presence of a persistent LVEF reduction at 2 thresholds: LVEF less than or equal to 40%, prompting consideration of additional medical therapy for heart failure, or LVEF less than or equal to 35%, prompting referral for implanted cardioverter defibrillator in addition to medical therapy. This study included 501 patients (mean [SD] age, 63.3 [13.0] years; 113 women [22.6%]). Overall, 370 patients (73.4%) presented with STEMI, and 454 (90.6%) had in-hospital revascularization. The median (IQR) baseline LVEF was 40% (34%-43%). Of 458 patients (91.4%) who completed the 6-month follow-up, 303 (66.2%; 95% CI, 61.7%-70.5%) had LVEF reassessment, with a range of 46.7% to 90.0% across sites (χ213 = 19.6; P = .11). Participants from community hospitals were more likely than those from academic hospitals to undergo LVEF reassessment (73.6% vs 63.2%; χ21 = 4.50; P = .03), as were those with worse LVEF at baseline. Follow-up LVEF improved by an absolute median (IQR) of 8% (3%-15%). However, 103 patients (34.1%) met the definitions of clinically relevant LVEF reduction, including 52 patients (17.2%) with LVEF less than or equal to 35% and 51 patients (16.9%) with LVEF of 35.1% to 40.0%. In this cohort study, approximately 1 in 3 patients with at least mild LVEF reduction after acute MI did not undergo indicated LVEF reassessment within 6 months, suggesting that programs to improve the quality of post-MI care should include measures to ensure that indicated repeat cardiac imaging is performed. In those with follow-up imaging, clinically relevant persistent LVEF reduction was identified in more than one-third of patients.

Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study.

Background:Latin America has limited information about the full spectrum cardiogenic shock (CS) and its hospital outcome. This study sought to examine the temporal trends, clinical features and outcomes of patients with CS in a coronary care unit of single Mexican institution.Methods:This was a retrospective study of consecutive patients hospitalized with CS in a Mexican teaching hospital between 2006–2019. Patients were classified according to the presence or absence of acute myocardial infarction (AMI).Results:Of 22,747 admissions, 833 (3.7%) exhibited CS. Among patients with AMI (n = 12,438), 5% had AMI–CS, and in patients without AMI (n = 10,309), 2.3% developed CS (non-AMI–CS). Their median age was 63 years and 70.5% were men. Cardiovascular risk factors were more frequent among the AMI–CS group, whereas a history of heart failure was greater in non-AMI–CS patients (70.1%). In AMI-CS patients, the median delay time was 17.2 hours from the onset of AMI symptoms to hospital admission. Overall, the median left ventricular ejection fraction (LVEF) was 30%. Patients with CS at admission showed end-organ dysfunction, evidenced by lactic acidosis, renal impairment, and elevated liver transaminases. Of the 620 AMI–CS patients, the main cause was left ventricular dysfunction in 71.3%, mechanical complications in 15.2% and right ventricular infarction in 13.5%. Among the 213 non-AMI–CS patients, valvular heart disease (49.3%) and cardiomyopathies (42.3%) were the most frequent etiologies. In-hospital all-cause mortality rates were 69.7% and 72.3% in the AMI–CS and non-AMI–CS groups, respectively. Among AMI–CS patients, renal dysfunction, diabetes, older age, depressed LVEF, absence of revascularization and the use of mechanical ventilation were independent predictors of in-hospital mortality. However, in the non-AMI–CS group, only low LVEF and high lactate levels proved significant.Conclusions:This study demonstrates differences in the epidemiology of CS compared to high-income countries; the high mortality reflects critically ill patients and the lack of contemporary effective therapies in the population studied.

Abstract 12898: Eosinophilic Myocarditis Following Osimertinib Treatment for Epidermal Growth Factor Receptor Mutated Lung Adenocarcinoma

A 60-year-old man with oligometastatic adenocarcinoma of the lung presented with symptoms of heart failure 6 weeks after initiation of treatment with osimertinib, an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor. A transthoracic echocardiography (TTE) showed a moderately sized pericardial effusion, mildly increased left ventricular (LV) wall thickness, and mildly depressed LV ejection fraction (45-50%), without tamponade physiology. His TTE prior to treatment initiation was normal. He endorsed chest pain across the entire chest that had started on the second day after initiation of osimertinib and was worse when laying down. His serum troponin I concentration was elevated to 10.6 ng/mL upon admission and ECG showed sinus tachycardia. He was carefully diuresed with some improvement in symptoms. A peripheral eosinophilia was noted, which raised suspicion for eosinophilic myocarditis. A cardiac magnetic resonance imaging confirmed a mildly reduced LVEF of 51% and mildly increased LV wall thickness. There was diffuse late gadolinium enhancement throughout the entire myocardium, with increased T1 and T2 signals and the extracellular volume was increased to 40%, supporting a diagnosis of perimyocarditis. A left and a right heart catheterization were subsequently undertaken. His coronary arteries were normal and the right heart cathetherization showed unremarkable hemodynamics, including a right atrium pressure of 6 mm Hg, right ventricular pressure of 34/6 mm Hg, pulmonary artery pressure of 33/9 mm Hg, and a pulmonary capillary wedge pressure of 10 mm Hg. A right heart biopsy revealed a dense eosinophilic infiltration of the myocardium, consistent with an eosinophilic hypersensitivity reaction, manifesting as myocarditis. High dose prednisone was initiated and after 2 months of treatment, repeat TTE showed resolution of his pericardial effusion and normalization of the LV wall thickness and LVEF (65%). This case illustrates the value of multi-modality imaging and endomyocardial biopsy to diagnose rare complications of novel, targeted cancer therapeutics.

Akut Anterior Miyokard İnfarktüsü Geçiren ve Primer Perkütan Koroner Girişim Uygulanan Hastalarda Sol Ventrikül Apikal Trombüs Oluşumunun Öngördürücüleri: SYNTAX Skorunun Önemi

Aim: Left ventricular (LV) apical thrombus development is one of the important advers event patients with anterior ST elevation myocardial infarction (STEMI) and accompanies with LV apical aneurysm and systolic dysfunction. SYNTAX score is an important determinant of cardiovascular morbidity and mortality in patients with coronary artery disease. We aimed that the relationship between LV apical thrombus and SYNTAX score and other clinical risk factors patients with anterior STEMI Methods: A total of 205 consecutive anterior STEMI patients undergoing primary PCI (35 female/ 170 male mean age: 55.8 ± 9.6 years) were included in our study. We assessed the severity and complexity of coronary artery disease by using SYNTAX score. The patients were divided into two groups; patients with apical thrombus (n=19) and patients without apical thrombus(n=186). Results: We found that systolic and diastolic blood pressure were lower patients with apical thrombus groups. (p&amp;lt;0.001 for both). Syntax score was higher and LV ejection fraction (LVEF) is lower in patients with apical thrombus (p&amp;lt;0.001 for both). We also showed that LV apical thrombus formation was independently associated with lower systolic blood pressure (p=0.006), SYNYAX score (p=0.003), and depressed LVEF (p=0.001). Conclusion: In this study, impaired LVEF, lower systolic blood pressure and SYNTAX score have been found to be predictors of LV thrombus generation. Patients presenting with anterior myocardial infarction who have high SYNTAX scores (&amp;gt; 18.25) at PPCI should be followed up closely.

Using a machine learning algorithm to detect depressed ejection fraction from a single-lead ECG

Abstract Background Multiple studies demonstrate the benefit of intervention for left ventricular ejection fraction (LVEF) below 40%, so the development of a low ejection fraction algorithm to detect LVEF below 40% can aid in early screening of initial asymptomatic Heart Failure with reduced Ejection Fraction (HFrEF). Objective To demonstrate the performance of a low ejection fraction algorithm using single-lead ECG data to detect LVEF below 40%. Methods We collected 1325 single-lead ECG recordings (15s duration) at various chest positions using an electronic stethoscope from 197 patients. We analyzed these ECG recordings using a deep neural network model trained on individual leads extracted from a 12-lead ECG to discriminate left ventricular ejection fractions (EFs) above or below different thresholds. We compared the model output to ejection fraction measured using echocardiograms. Results Across all recordings from all patients, we obtained an AUROC of 0.89, with a sensitivity of 88% and specificity of 74% using a model output threshold of 0.35 (Figure 1). The AUROC of recordings taken at different orientations and stances ranged from 0.85 to 0.92 (Table 1), with a sensitivity of at least 78% and specificity of at least 66% at any orientation. Conclusion Using a single lead ECG measured by an electronic stethoscope and a deep neural network model, we were able to detect depressed ejection fraction (≤40%) with a sensitivity of 88% and specificity of 74%. This work demonstrates the utility of a low-cost electronic stethoscope and machine learning for early screening and detection of depressed left ventricular ejection fraction. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Eko Health

Iron deficiency – a factor in left ventricular ejection fraction depression post-myocardial infarction

Abstract Introduction Iron deficiency was shown to affect functional capacity and ejection fraction in patients with heart failure and reduced ejection fraction. Myocardial infarction is an important cause of reduced left ventricular ejection fraction (LVEF). Moreover, there is some evidence of the iron deficiency as a factor to predict cardiovascular and non-cardiovascular mortality. Purpose Evaluate the presence of iron deficiency in patients with acute coronary syndromes (ACS) admitted to the intensive cardiac care unit and its eventual association with LVEF and mortality. Population and methods We performed a prospective study in which ACS patients were divided into groups according to the presence or absence of iron deficiency. We collected demographic data, comorbidities, as well as determination of troponin I, haemoglobin and criteria for absolute and functional iron deficiency (ID) and other data related to the use of mechanical ventilation, need for aminergic support, LVEF and death. Results From 148 patients we included 78 patients who met the criteria for being analysed. 49 patients had iron deficiency (51% had absolute iron deficiency and 49% had relative iron deficiency). There were no differences between groups in terms of myocardial infarction with or without ST segment elevation (p=0.609 and p=0.329, respectively), hypertension (p=0.926), diabetes (p=0.882), obesity (p=0.343), dyslipidaemia (p=0.482), smoking (p=0.876), valvular heart disease (p=0.888), acute and chronic renal failure (p=0.800 and p=0.888, respectively) and LVEF (p=0.886). There were no differences in need for aminergic support (p=0.984), ventilation (p=0.315) and death (p=0.704). We found that in the sub-population of patients without anaemia (Hb&amp;gt;12g/dL), the proportion of patients with depressed LVEF (inferior to 50%) and relative iron deficiency was significantly higher than those with preserved LVEF (48.1 vs 13.8%, p=0.005). Furthermore, we also found that in this sub-population, patients with myocardial infarction without ST segment elevation had higher proportion of absolute iron deficiency (45.0 vs 19.4%, p=0.043). Conclusion Our study showed that the prevalence of iron deficiency in ACS patients is 62.9% (n=49). Moreover, in patients without anaemia, this results seems to point out that the presence of iron deficiency may be related with LVEF, at least during the acute event. Further studies with a higher sample size are warranted to either establish or discard this association. Furthermore, a follow-up of this patients can further enlighten us as to the role of iron deficiency in long term LVEF and mortality. Funding Acknowledgement Type of funding sources: None.

Dobutamine stress echocardiography-induced Takotsubo cardiomyopathy. Which triggers?

Abstract Aims Takotsubo cardiomyopathy (TTC) is a rare complication of dobutamine stress echocardiography (DSE), a non-invasive modality widely used to detect myocardial ischemia. Purpose Identification of clinical reports of TTC induced during DSE (TTC-DSE), and comparison to a selected group DSE exams group, with the objective to identify factors which could induce TTC during DSE. Methods From an exhaustive search and review, using key words “apical ballooning, stress cardiomyopathy and DSE”, 30 observations of DSE-TTC (2006–2020), with typical features of TTC were identified: (a) occurrence of TTC during DSE, (b) “InterTAK diagnostic criteria”. Over a 3-year retrospective period (2013–2015), 578 consecutive DSE patients were selected and then compared to the TTC-DSE cohort. Results The TTC-DSE cohort showed typical characteristics of TTC: strong predominance of aged female population &amp;gt;50 years (93.3%); depression and/or anxiety (26.7%); EKG: ST elevation (70%); normal coronary angiography; depressed angiographic left ventricular ejection fraction &amp;lt;40% (14/18 pts); typical segmental LV impairment: apical (7.3%); mid-ventricular (13.6%); reverse (9%); low troponin peak: 2.65±2.04 ng/ml; one death (acute heart failure), but rapid recovery of LVEF (29/30 pts) in few days. On the other hand, the DSE group of 578 consecutive patients showed: mean age 70 years (62–77 interquartile range), 44% of women, and frequent cardiovascular factors, diabetes (43%), hypertensive (41.4%) and dyslipidemia (28%). Significant differences with the TTC-DSE cohort were: mean age (70 vs 64), smoking (16 vs 36.6%), peak heart rate (94 vs 81%) and peak dose dobutamine (30 vs 40 μg/kg/mn), all p&amp;lt;0.01. In a multivariate analysis, female sex (OR=9.6; 95% CI: 3–28: p&amp;lt;0.01), smoking habit (OR=4.8; 95% CI: 2–11; p&amp;lt;0.01) and dobutamine dosage &amp;gt;30 μg/kg/mn (OR=1.07; 95% CI: 1.02–1.12; p&amp;lt;0.01) were independent predictors of DSE-TTC. Using ROC curve analysis, dobutamine dosage &amp;gt;30 μg/kg/mn gives the best cut off (AUC 0.7±0.04; p&amp;lt;0.01). Conclusion TTC-DSE is a rare and severe situation, superimposable to the usual TTC. It gives the rare opportunity to observe TTC in its acute phase. By comparison to DSE patients, independent factors (female sex, smoking habit, dobutamine dosage &amp;gt;30 μg/kg/mn) are predictive of TTC-DSE. However, the discrepancy between the volume of daily DSE exams and the scarcity of TTC-DSE, remains poorly explained. Funding Acknowledgement Type of funding sources: None.

Incessant Atrial Tachycardia: Problem Solving With Minimally Invasive Surgery

A 35-year-old female with sarcoidosis sought medical attention due to palpitations. The ECG showed an atrial tachycardia (AT), apparently originating in the left atrium. A 24-hour Holter monitoring revealed AT to be present during the entire day. Cardiac magnetic resonance exhibited no cardiac involvement by sarcoidosis but registered a mildly depressed left ventricular ejection fraction (LVEF). Atrial electroanatomical mapping showed the earliest activation zone on the distal portion of the left atrial appendage (LAA). Considering the high risk for perforation with catheter ablation in this region, she was sent to thoracoscopic surgical LAA exclusion with a clip device; it was possible to witness the termination of the arrhythmia during the procedure. She was safely discharged two days after surgery and has completed a one-year follow-up without recurrence of AT or symptoms, and with normalization of LVEF.

Hyperdynamic Left Ventricular Ejection Fraction in ICU Patients With Sepsis.

To evaluate the cause and prognosis of hyperdynamic left ventricular ejection fraction in critically ill patients with sepsis. Retrospective, single-center cohort study. University Hospital ICU, Birmingham, United Kingdom. ICU patients who received a transthoracic echocardiogram within 7 days of sepsis between April 2016 and December 2019. None. The 90-day mortality rates of normal (55-70%), depressed (< 55%), and hyperdynamic left ventricular ejection fraction (> 70%) were compared. Multivariate logistic regression analysis was performed to determine the association of left ventricular ejection fraction phenotypes with mortality and the association of clinical variables with left ventricular ejection fraction phenotypes. One thousand fourteen patients met inclusion criteria and were 62 years old (interquartile range, 47-72), with mostly respiratory infections (n = 557; 54.9%). Ninety-day mortality was 32.1% (n = 325). Patients with hyperdynamic left ventricular ejection fraction had a higher mortality than depressed and normal left ventricular ejection fraction cohorts (58.9% [n = 103] vs 34.0% [n = 55] vs 24.7% [n = 167]; p < 0.0001, respectively). After multivariate logistic regression, hyperdynamic left ventricular ejection fraction was independently associated with mortality (odds ratio, 3.90 [2.09-7.40]), whereas depressed left ventricular ejection fraction did not (odds ratio, 0.62 [0.28-1.37]). Systemic vascular resistance was inversely associated with hyperdynamic left ventricular ejection fraction (odds ratio, 0.79 [0.58-0.95]), and age, frailty, and ischemic heart disease were associated with depressed left ventricular ejection fraction. Hyperdynamic left ventricular ejection fraction was associated with mortality in septic ICU patients and may reflect unmitigated vasoplegia from sepsis. Depressed left ventricular ejection fraction was not associated with mortality but was associated with cardiovascular disease.

EpCAM and microvascular obstruction in patients with STEMI: a cardiac magnetic resonance study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” Bachground. Microvascular obstruction (MVO) is negatively associated with cardiac structure and worse prognosis after ST-segment elevation myocardial infarction (STEMI). Epithelial cell adhesion molecule (EpCAM), involved in endothelium adhesion, is an understudied area in the MVO setting. Purpose. We aimed to evaluate whether EpCAM is associated with the appearance of cardiac magnetic resonance (CMR)-derived MVO and long-term systolic function in reperfused STEMI. Methods. We prospectively included 106 patients with a first STEMI treated with primary percutaneous coronary intervention, quantifying serum levels of EpCAM 24 hours post-reperfusion. All patients underwent CMR imaging 1 week and 6 months post-STEMI. The independent correlation of EpCAM with MVO, systolic volume indices, and left ventricular ejection fraction (LVEF) was evaluated. Results. The mean age of the sample was 59 ± 13 years and 76% were male. Patients were dichotomized according to EpCAM median (4.48 pg/mL). At 1-week CMR, lower EpCAM was related to extensive MVO (p-value = 0.02) and greater infarct size (p-value = 0.02). At presentation, only EpCAM values were significantly associated with the presence of MVO in univariate (Odds Ratio [95% confidence interval] (OR [95% CI]): 0.58 [0.38-0.88], p-value = 0.01) and multivariate logistic regression models (OR [95% CI]: 0.54 [0.34-0.85], p-value = 0.007). Although MVO tends to resolve at chronic phases, decreased EpCAM was associated with worse systolic function: depressed LVEF (p-value = 0.009) and higher left ventricular end-systolic volume (p-value = 0.04). Conclusions. EpCAM is associated with occurrence of CMR-derived MVO at acute phases and long-term adverse ventricular remodeling post-STEMI. Future studies are needed to confirm EpCAM as biomarker, and eventually biotarget in STEMI pathophysiology.

Takotsubo cardiomyopathy induced during Dobutamine Stress Echocardiography (TTC-DSE): A complex world

Dobutamine stress echocardiography (DSE) is widely used, TTC-DSE is extremely rare. Our purpose was to compare TTC-DSE reports with DSE exams, to identify triggers of TTC. Retrospective study: – systematic analysis of TTC-DSE observations from 2006 to 2020; – over a 3-year period (2013-2015), selection (data base) of consecutive DSE patients; – comparison of the two groups. An extensive search identified 30 TTC-DSE observations, mean age 64 years (52-74) and a high proportion of women (86.6%), all with TTC criteria: Predominance of female > 50 years (93.3%); Depression, or anxiety (26.7%); EKG ST elevation (70%); Normal coronary angiography and depressed angio left ventricular ejection fraction (LVEF)< 40% (14/18 pts); Typical segmental LV impairment: apical (77.3%); mid-ventricular (13.6%); reverse (9%); Low troponin peak; Rapid recovery of LVEF (29/30 pts), but one death (acute heart failure). The 2nd group of 578 consecutive DSE patients was characterized by older patients (70 vs. 64), and a smaller proportion of women (44 vs. 64%) all P < 0;01). The comparison between TTC-DSE vs. DSE showed a greater proportion of smoker (16 vs. 36.6%), the onset of TTC at a higher mean peak dose Dobutamine (40 vs. 30 g/kg/mn), but at a lower Maximum Peak Heart Rate (81% vs. 94%), all P < 0.01). In a multivariate analysis, female sex (OR = 9.6;95%CI: 3-28), smoking (OR = 4.8;95%CI: 2-11) and Dobutamine posology (OR = 1.07; 95%CI: 1.02-1.12) were independent predictors of TTC-DSE (all P < 0;01). Dobutamine posology > 30 gammas/kg/mn was the best cut-off (AUC 0.7 ± 0.04, P < 0.01) to predict TTC-DSE. By comparison with DSE patients, independent factors (female sex, smoker, Dobutamine posology > 30 gammas/kg/mn) are predictive of TTC-DSE. Superimposable to the usual TTC, TTC-DSE remains, however, poorly explained.

Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19: A Case Series Experience in a Tertiary Care Hospital of Southern Turkey.

ObjectiveAim of the study is to assess the clinical characteristics and treatment outcomes of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19.Study designThe study comprised 52 children with MIS-C admitted to University of Health Sciences Adana City Training and Research Hospital pediatric wards from September 2020 to April 2021. Demographic characteristics and clinical data were retrospectively collected from patient files.ResultsMedian age of patients was 9 (5-13) years. Fever (92.3%), abdominal pain (76.9%), rash (48.1%) and vomiting (48.1%) were the most common presenting symptoms. Fever duration was 8 (4.25-10) days in overall. Depressed left ventricular ejection fraction was found in 17.3% of patients. At admission, elevated levels of CRP, procalcitonine, ESR, D-dimer, ferritin were found in 98.1%, 96.2%, 75%, 84.6% and 69.2% of the patients, respectively. Lymphopenia, hyponatremia and hypoalbuminemia were found in 76.9%, 59.6%, 42.3% of the patients. Intravenous immunoglobulin was used in 96.2%, corticosteroids in 71.2% and anakinra in 3.8% of the patients. 28.8% of the patients were admitted to pediatric intensive care (PICU) and 17.3% received vasopressor support. Median duration of hospital length of stay was 12.5 days. Comorbidities were present in 19.2% of the patients. No mortality was recorded.ConclusionsWhile being rare and treatable, MIS-C is the ugly and mysterious face of the COVID-19 pandemic for children. The increasing number of MIS-C cases shows that this phenomenon is more common than thought. Comprehensive studies are required to understand the pathogenesis of the disease and determine the treatment regimens clearly.Lay SummaryWhile being rare and treatable, Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 is the ugly and mysterious face of the COVID-19 pandemic for children. MIS-C is now thought to be a post-infectious (SARS-CoV2) hyperinflammatory disease secondary to an abnormal immune response, rather than a complete obscurity. The increasing number of MIS-C cases and new case series reports from all over the world show that MIS-C is more common than thought. Despite our increasing experience, we may encounter a new finding every day in MIS-C patients. Therefore, we want to contribute to literature by presenting the MIS-C cases we treated in our clinic in detail. We have experienced that MIS-C patients can apply with similar but also different and unique characteristics. In case of delayed diagnosis or treatment, morbidity and mortality rates may increase. Therefore, the level of awareness and knowledge of all physicians, especially those dealing with pediatric patients, about MIS-C should be increased. Although the early effects of MIS-C are known, we don’t have enough information about the long-term consequences yet. Comprehensive studies are required to understand the pathogenesis of the disease and determine the treatment regimens clearly.

The Impella 5.5 as a Short Term Mechanical Circulatory Support Device in High Risk Cardiac Surgery

Purpose Post-cardiotomy cardiogenic shock (PCCS) is a life-threatening condition characterized by severe myocardial contractile impairment and reduced end organ perfusion. PCCS has been reported to occur in up to 9% of all cardiac surgery cases with a mortality approaching 40%. The Impella 5.5 micro-axial, full support, surgical pump has emerged as a useful support device in the setting of weaning from cardiopulmonary bypass (CPB) and for the mitigation of a low cardiac output syndrome. Methods From July 2020 to September 2020, 7 consecutive patients underwent urgent cardiac surgery supported by the Impella 5.5 device. In all cases, the Impella 5.5 was implanted during the index cardiac surgery via the ascending aorta using a 10mm woven Dacron graft and positioned using transesophageal echo guidance. In this retrospective study, we evaluated short-term outcomes of hospital mortality, acute kidney injury, cerebrovascular events, and device-related adverse events. Results The mean age was 61 years (range 46-71). Mean preoperative LVEF was 31% (range 25-50). Six patients underwent coronary artery bypass grafting and one patient underwent redo sternotomy and mitral valve replacement. The Impella 5.5 was implanted prior to weaning from cardiopulmonary bypass in six patients and for the onset of post-cardiotomy shock in one patient. In all patients, hemodynamics improved and stabilized immediately after the initiation of Impella support. The mean duration of Impella support was 3.8 days (1.9-6.6 days). There were no in-hospital deaths, no reoperation for bleeding, and no patients suffered a neurologic complication or renal failure requiring dialysis. There was no incidence of hemolysis requiring device explantation. All patients experienced native heart recovery. Four patients (57%) were discharged home, and three patients were discharged to a skilled nursing facility or rehabilitation center. Conclusion The peri-operative use of the Impella 5.5 heart pump facilitates surgery on high‐risk patients with depressed left ventricular ejection fraction and helps to prevent post-cardiotomy shock. Prospective studies looking at the preemptive use of the Impella 5.5 in these patients are needed.

Deferoxamine as a Treatment for Cardiac Siderosis Induced Cardiomyopathy Post Liver Transplantation

Introduction Iron overload cardiomyopathy (CM) occurring after liver transplantation in the absence of preexisting myocardial dysfunction or severe hepatic iron overload (ie hemochromatosis) has been described post-mortem. Cardiac siderosis without primary iron overload syndromes was found to be positively correlated to both higher pretransplant transferrin saturation (TSAT) and transfusion of red blood cells. We report an unusual case of a patient with alcohol-induced cirrhosis and heterozygous C282Y mutation who developed a dilated CM post-liver transplant with confirmed cardiac siderosis treated with IV deferoxamine leading to improvement in cardiac function. Case Report A 47-year-old woman with alcohol-induced cirrhosis underwent liver transplantation with a normal pre-operative cardiac evaluation including a transthoracic echocardiogram (TTE) with left ventricular ejection fraction (LVEF) 55-60%. Pre-operative iron studies showed an iron saturation of 91% with ferritin of 156. Her post-op course was uncomplicated, receiving minimal blood products (4 units of packed red blood cells). Two months later she was hospitalized for dyspnea and large pleural effusions. TTE showed depressed LVEF 17%. A cardiac MRI demonstrated a severely dilated LV indexed to BSA (1.5) with severe myocardial siderosis indicated by decreased T2* of 9-14 ms as well as significant mid-wall myocardial fibrosis. Right heart catheterization demonstrated a normal right atrial pressure, wedge pressure 18 mmHg, mean pulmonary pressure 26 mmHg and Fick cardiac index of 2.02 L/min/m2 for which milrinone was initiated. Endomyocardial biopsy confirmed intramyocardial iron deposition and native liver biopsy had grade 2-3 iron deposition. Etiology of her CM post-transplant was attributed to HFE gene heterozygosity in the setting of cirrhosis with post-transplant iron sensitivity (hepcidin depletion). She was initiated on IV chelation therapy with deferoxamine with follow up CMRI showing improved cardiac siderosis indicated by T2* of 13-17 ms with RV function 41% from 20% and LV function 25% from 17%. She was weaned off milrinone and continued on weekly deferoxamine chelation sessions. Summary This case highlights an unusual cause of cardiac siderosis related cardiomyopathy post-liver transplantation treated with IV iron chelation therapy leading to partial LV/RV recovery.

Validation of evaluating left ventricular diastolic function with estimated left atrial volume from anteroposterior diameter

BackgroundLeft atrial (LA) volume (LAV) is one of the recommended key variables for evaluating left ventricular (LV) diastolic function. However, only LA anteroposterior diameter (LAAP) is available in numerous large-scale existing databases. Therefore, this study aimed to validate whether LV diastolic function could be evaluated with estimated LAV from LAAP.MethodsA total of 552 inpatients with sinus rhythm were consecutively enrolled. LAV was measured by biplane Simpson’s disk summation method. LV diastolic function was evaluated according to the 2016 proposed recommendations. Best-fitting regression models of LAAP index (LAAPI)–LAV index (LAVI) were developed and equations with the highest F-value were chosen in the first 276 subjects (derivation set), and concordance for evaluating LV diastolic function between using estimated and observed LAVI was verified in the remaining 276 subjects (validation set).ResultsIn the derivation set, the linear model has the highest F-value in all subjects and in the subjects with normal or depressed LV ejection fraction. In the validation set, using the linear equation (LAVI = 2.05 × LAAPI − 13.86), the higher area under curve and narrower range of difference were shown between estimated LAVI and observed LAVI, respectively. Further, concordance for diagnosis (overall proportion of agreement, 88.4%; κ = 0.79) and grading (overall proportion of agreement, 84.8%; κ = 0.74) of LV diastolic dysfunction was substantial between using estimated and observed LAVI.ConclusionsLV diastolic function can be evaluated with estimated LAVI from LAAPI, which might provide a surrogate method when the direct measurement of LAV is not available.

Percutaneous pulmonary artery debanding

BackgroundThere is a paucity of data on palliative or total percutaneous pulmonary artery debanding (p-debanding), particularly with use of a stent. MethodsTwelve p-debandings in eight patients were included in this study. Age at pulmonary artery banding (PAB) ranged from 3 days to 1 year (median, 13 days), while p-debanding was performed at 2–157 (7) months. The body weight at the p-debanding ranged from 3.2 to 22.2 (7.3) kg. We chose the balloon diameter of 30–50% to the circumference of the band for palliative, and larger than 50% for total p-debanding, respectively. In either way, the balloon diameter did not exceed 1.5 times the reference vessel diameter. Stent was implanted for palliative p-debanding in 2 patients. Results1. The circumference of the band ranged from 16 to 23 (20) mm, while the balloon diameter ranged from 20–60 (40)% to that, where larger than 50% was used for 2 procedures intended total p-debanding. 2. PAB diameter increased from 2.5–4.7 (3.0) mm to 2.8–9.5 (4.5) mm (p<0.01), however, there was no significant change in the diameter in 2 procedures. In one patient, p-debanding was the definitive treatment associated with spontaneous near closure of muscular ventricular septal defect, in another patient of congenitally corrected transposition of the great arteries, severely depressed left ventricular ejection fraction was recovered following p-debanding. 3. Arterial oxygen saturation (SaO2) increased from 64–97 (80)% to 66–95 (90)% (p<0.01), while in 10 procedures of 6 patients where the indication of p-debanding was hypoxia, SaO2 increased in 8 procedures. There was no significant pulmonary hypertension following p-debanding. ConclusionPalliative or total p-debanding using balloon and/or stenting is generally feasible and effective. A balloon diameter 35–50% to the band circumference in palliative, and more than 50% in total p-debanding, while in either way less than 1.5 times the reference vessel diameter, is safe.