Development Of Left Ventricular Dysfunction Research Articles

Cardiac Toxicity: Using Angiotensin-Converting Enzyme Inhibitors to Prevent Anthracycline-Induced Left Ventricular Dysfunction and Cardiomyopathy

Anthracycline chemotherapies are effective in many different types of cancer. However, cumulative doses are associated with irreversible cardiac toxicity, most frequently manifested in the development of left ventricular dysfunction, cardiomyopathy, and congestive heart failure. The onset of cardiomyopathy and subsequent heart failure can result in the interruption or discontinuation of therapy. Cardioprotective agents, particularly angiotensin- converting enzyme inhibitors, have been shown to slow the progression of left ventricular dysfunction and prevent heart failure. This review assesses the efficacy of angiotensin-converting enzyme inhibitors in the prevention of anthracycline-induced left ventricular dysfunction. A literature search was performed using four electronic databases. Evidence from this review suggests that angiotensin-converting enzyme inhibitors may be effective in preventing or reducing anthracycline- induced left ventricular dysfunction and subsequent cardiomyopathy and heart failure.

Prognostic value of ejection fraction in patients admitted with acute coronary syndrome

Left ventricular (LV) systolic dysfunction after an acute coronary syndrome (ACS) is a frequent complication, which is influenced by several factors. Importantly, its presence increases the risk of death. The aim of this study was to examine the relationship between left ventricular ejection fraction (LVEF) with long-term prognosis in a cohort of patients with ACS. This is a prospective observational study of 404 patients consecutively admitted for ACS from January 2019 to November 2019. We studied 404 patients presented with ACS: seventy-nine of them (19.55%) had LVEF < 40% (first group) and 325 (80.45%) had LVEF ≥ 40% (second group). In the first group the prevalence of ST elevated myocardial infarction (STEMI) (73% vs. 49%; P < 0.001) was significantly more important than Non-ST elevated myocardial infarction (NSTEMI) (26% vs. 50%; P < 0.001). Anterior STEMI has a significant higher prevalence when EF was less than 40% (77% vs. 45%; P < 0.001) than the inferior one (22% vs. 57%; P < 0.001). Failure of thrombolysis was associated to LV dysfunction (82% vs. 46%; P = 0.007). Culprit artery in the first group was mostly the left anterior descending artery (LADA) (88% vs. 73%; P = 0.006). The first group patients had a significant longer hospital stay (4 days ± 2 vs. 3 days ± 1; P < 0.001). Kaplan–Meier curves showed that the mortality during the 12 months after the ACS was statistically higher if LVEF < 40% (Log rank = 0.04). Kaplan–Meier curves did not show that MACE was statistically different depending on LVEF (Log rank = 0.7) ( Fig. 1 ). In ACS, long-term prognosis is considerably worse in patients who develop LV dysfunction with an ejection fraction less than 40% than in patients with LVEF ≥ 40.

HIV, hepatitis C virus and risk of new-onset left ventricular dysfunction in women.

HIV and HCV have each been linked with cardiac dysfunction. Studies of HIV have often lacked appropriate controls and primarily involved men, whereas data for HCV are sparse. We performed repeat echocardiography over a median interval of 12 years in participants from the Women's Interagency HIV Study in order to evaluate the relationships of HIV and HCV with incident left ventricular (LV) dysfunction (systolic or diastolic). Of the 311 women included (age 39 ± 9), 70% were HIV-positive and 20% HCV-positive. Forty three participants (13.8%) developed LV dysfunction, of which 79.1% was diastolic. Compared with participants with neither infection, the group with HIV--HCV coinfection showed a significantly increased risk of incident LV dysfunction after adjustment for risk factors [RR = 2.96 (95% CI = 1.05-8.31)], but associations for the HCV monoinfected and HIV monoinfected groups were not statistically significant [RR = 2.54 (0.83-7.73) and RR = 1.66 (0.65-4.25), respectively]. Comparison of HCV-positive and HCV-negative women showed a significantly increased risk independent of covariates [RR = 1.96 (1.02-3.77)] but this was not the case for HIV-positive vs. HIV-negative women [RR = 1.43 (0.76-2.69)]. There was no evidence of HCV-by-HIV interaction. A more restrictive definition of LV diastolic dysfunction led to fewer incident cases, but a similar, though nonsignificant, risk estimate for HCV. Among mostly middle-aged women, HCV but not HIV infection was associated with a pronounced risk of incident LV dysfunction. Although the influence of residual confounding cannot be excluded, these findings bolster the potential benefits that could be realized by adopting recent recommendations for expanding HCV screening and treatment.

Refining the 10-Year Prediction of Left Ventricular Systolic Dysfunction in Long-Term Survivors of Childhood Cancer

BackgroundIn childhood cancer survivors (CCS) at risk for heart failure, echocardiographic surveillance recommendations are currently based on anthracyclines and chest-directed radiotherapy dose. Whether the ejection fraction (EF) measured at an initial surveillance echocardiogram can refine these recommendations is unknown. ObjectivesThe purpose of this study was to assess the added predictive value of EF at >5 years after cancer diagnosis to anthracyclines and chest-directed radiotherapy dose in CCS, for the development of left ventricular dysfunction with an ejection fraction <40% (LVD40). MethodsEchocardiographic surveillance was performed in 299 CCS from the Emma Children’s Hospital in the Netherlands. Cox regression models were built including cardiotoxic cancer treatment exposures with and without EF to estimate the probability of LVD40 at 10-year follow-up. Calibration, discrimination, and reclassification were assessed. Results were externally validated in 218 CCS. ResultsCumulative incidences of LVD40 at 10-year follow-up were 3.7% and 3.6% in the derivation and validation cohort, respectively. The addition of EF resulted in an integrated area under the curve increase from 0.74 to 0.87 in the derivation cohort and from 0.72 to 0.86 in the validation cohort (likelihood ratio p < 0.001). Reclassification of CCS without LVD40 improved significantly (noncase continuous net reclassification improvement 0.50; 95% confidence interval [CI]: 0.40 to 0.60). A predicted LVD40 probability ≤3%, representing 75% of the CCS, had a negative predictive value of 99% (95% CI: 98% to 100%) for LVD40 within 10 years. However, patients with midrange EF (40% to 49%) at initial screening had an incidence of LVD40 of 11% and a 7.81-fold (95% CI: 2.07- to 29.50-fold) increased risk of LV40 at follow-up. ConclusionsIn CCS, an initial surveillance EF, in addition to anthracyclines and chest-directed radiotherapy dose, improves the 10-year prediction for LVD40. Through this strategy, both the identification of low-risk survivors in whom the surveillance frequency may be reduced and a group of survivors at increased risk of LVD40 could be identified.

Reflected wave intensity increases based on aortic diameter after endovascular aortic therapy in a goat model

Reflected wave increases after endovascular aortic repair (EVAR) in patients with aortic aneurysm. This affects the left ventricular (LV) diastolic function and leads to a poor prognosis. This study aimed to evaluate the relationship between increased reflected wave amplitude and aortic diameter after EVAR. EVAR was performed in seven healthy goats. We assessed wave intensity (WI), aortic diameter, and stiffness parameter β. Moreover, we evaluated the relationship between negative reflected wave (NW, reflected waves toward the heart from the periphery by WI) and other parameters after EVAR. Results showed an increase in stiffness parameter β (3.5 ± 0.3 vs 15.9 ± 4.7, p = 0.018) and a decrease in the change of aortic diameter (6.9 ± 0.7 vs 2.7 ± 0.4%, p = 0.018) after EVAR. The NW was significantly amplified after EVAR from baseline (−589.8 ± 143.4 to − 1192.3 ± 303.7 mmHg-m/sec3, p = 0.043). The NW showed a significant correlation with maximum aortic diameter (R = 0.707, p = 0.038) and minimum aortic diameter (R = 0.724, p = 0.033). The reflected wave was enhanced after EVAR and was correlated to the aortic diameter at the stent-graft site. It is important to consider that patients with smaller aortic diameters in landing zone who undergo EVAR may develop LV dysfunction.

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

Abstract Funding Acknowledgements Type of funding sources: None. Background 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. For risk stratification to detect the development of CTRCD, the current position paper from the European Society of Cardiology (ESC) lists several factors associated with risk of cardiotoxicity. Purpose Our purpose was to investigate the impact of baseline risk factors on left ventricular (LV) function in patients with preserved LV ejection fraction (LVEF) who have undergone chemotherapy for breast cancer. Methods We studied 86 breast cancer patients treated with anthracyclines, trastuzumab, or both. Mean age was 59 ± 13 years and LVEF was 67 ± 5%. In accordance with the current definition, CTRCD was defined as a decline in LVEF of &amp;gt;10% to an absolute value of &amp;lt;53% after chemotherapy. Based on the 2016 ESC position paper, clinical risk factors for CTRCD were defined as: (1) a cumulative total doxorubicin dose of ≥ 240mg/m², (2) age ≥ 65-year-old, (3) body mass index ≥ 30kg/m², (4) a previous history of radiation therapy to chest or mediastinum, (5) B-type natriuretic peptide ≥ 100pg/mL, (6) a previous history of cardiovascular disease, (7) atrial fibrillation, (8) hypertension, (9) diabetes mellitus, (10) current or ex-smoker. Results 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, patients with more than four risk factors were more likely to have higher LV mass index (109.3 ± 29.0g/m² vs. 83.2 ± 21.0g/m², p &amp;lt; 0.001), lower global longitudinal strain (18.4 ± 2.8% vs. 20.0 ± 2.6%, p = 0.06) and higher E/e’ (10.4 (8.9-13.0) vs. 9.0 (7.4-10.9), p = 0.06) compared to those without. Furthermore, receiver-operator characteristics curve analysis showed that an optimal cut off value of a cumulative total doxorubicin dose for developing LV dysfunction in patients with more than any of four risk factors was lower than that in those without (180 mg/m² vs. 280 mg/m²). Conclusions Association between clinical risk factors and LV dysfunction following chemotherapy became stronger with an increase in the number of risk factors in breast cancer patients, and was especially strong for patients treated with chemotherapy who had more than four risk factors. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy. Abstract Figure.

Ketone Ester Treatment Improves Cardiac Function and Reduces Pathologic Remodeling in Preclinical Models of Heart Failure.

Accumulating evidence suggests that the failing heart reprograms fuel metabolism toward increased utilization of ketone bodies and that increasing cardiac ketone delivery ameliorates cardiac dysfunction. As an initial step toward development of ketone therapies, we investigated the effect of chronic oral ketone ester (KE) supplementation as a prevention or treatment strategy in rodent heart failure models. Two independent rodent heart failure models were used for the studies: transverse aortic constriction/myocardial infarction (MI) in mice and post-MI remodeling in rats. Seventy-five mice underwent a prevention treatment strategy with a KE comprised of hexanoyl-hexyl-3-hydroxybutyrate KE (KE-1) diet, and 77 rats were treated in either a prevention or treatment regimen using a commercially available β-hydroxybutyrate-(R)-1,3-butanediol monoester (DeltaG; KE-2) diet. The KE-1 diet in mice elevated β-hydroxybutyrate levels during nocturnal feeding, whereas the KE-2 diet in rats induced ketonemia throughout a 24-hour period. The KE-1 diet preventive strategy attenuated development of left ventricular dysfunction and remodeling post-transverse aortic constriction/MI (left ventricular ejection fraction±SD, 36±8 in vehicle versus 45±11 in KE-1; P=0.016). The KE-2 diet therapeutic approach also attenuated left ventricular dysfunction and remodeling post-MI (left ventricular ejection fraction, 41±11 in MI-vehicle versus 61±7 in MI-KE-2; P<0.001). In addition, ventricular weight, cardiomyocyte cross-sectional area, and the expression of ANP (atrial natriuretic peptide) were significantly attenuated in the KE-2-treated MI group. However, treatment with KE-2 did not influence cardiac fibrosis post-MI. The myocardial expression of the ketone transporter and 2 ketolytic enzymes was significantly increased in rats fed KE-2 diet along with normalization of myocardial ATP levels to sham values. Chronic oral supplementation with KE was effective in both prevention and treatment of heart failure in 2 preclinical animal models. In addition, our results indicate that treatment with KE reprogrammed the expression of genes involved in ketone body utilization and normalized myocardial ATP production following MI, consistent with provision of an auxiliary fuel. These findings provide rationale for the assessment of KEs as a treatment for patients with heart failure.

Incidence and Clinical Outcomes of Pacing Induced Cardiomyopathy in Patients With Normal Left Ventricular Systolic Function and Atrioventricular Block

Patients with preserved left ventricular (LV) ejection function (EF) and atrioventricular block (AVB) who are anticipated for high-burden of right ventricular (RV) pacing possess a risk to develop pacing-induced cardiomyopathy (PIC) and adverse clinical outcomes. Hence, the aim of the study is to evaluate the incidence, predictors, and clinical outcomes of RV PIC in patients with preserved LVEF, AVB, and high-burden of RV pacing. One thousand and thirteen patients with second or third-degree AVB underwent first time pacemaker implantation between January 2002 and August 2016. A total of 203 patients with a newly implanted pacemaker, normal baseline LVEF, and high burden of RV pacing were included in the present study. Follow-up echocardiography was examined for a new decrease in LVEF of 10% or higher. Alternative causes for cardiomyopathy were ruled out. Patient characteristics, echocardiographic measurements, device clinic data, mortality, and hospitalizations for heart failure were collected and compared between the PIC and the non-PIC groups. Fifty-one patients (25%) developed LV dysfunction with 22 patients (11%), showing LVEF < 40%. During a mean follow-up of 49.2 months, the risk of heart failure hospitalization or all-cause mortality was significantly higher in the PIC group versus non-PIC group (35.3% vs 19.1%, p = 0.009). In conclusion the incidence of PIC in patients with normal LVEF and AVB, who are anticipated for high-burden of RV pacing is high. PIC in patients with a previously normal LV function is associated with unfavorable long-term clinical outcomes, including higher rates of heart failure hospitalizations and all-cause mortality.

P1462 Additive value of global longitudinal strain measurement in patients with known or suspected ischaemic heart disease undergoing stress echo

Abstract BACKGROUND Speckle-tracking echocardiography (STE) can be applied in a large variety of clinical conditions. Global longitudinal strain (GLS) shows high diagnostic accuracy for the detection of myocardial ischemia as it reflects changes in subendocardial fibers deformation that are more exposed to ischemic damage, even before alterations in segmental kinetics are revealed. PURPOSE Aim of our study was to assess whether the measurement of global longitudinal strain during stress-echo can provide additional information compared to the assessment of conventional parameters such as left ventricular ejection fraction (LVEF) and wall motion abnormalities. We also evaluated the added value of strain in patients with complete (CRP) and incomplete revascularization (IRP). METHODS We enrolled 69 patients, 39 with known (IHD) and 30 with suspected ischaemic heart disease (SIHD) with indication to perform a stress echocardiogram. Inclusion criteria were: known or suspected CAD, age &amp;lt;85 and &amp;gt;18, adeguate acoustic window. Cardiological evaluation and stress echo were performed in all patients. Primary end point was evaluating whether in patients with negative stress test the presence of reduced GLS identifies patients with an adverse prognosis at follow up and to assess if in IRP and negative stress test there is evidence of left subclinical ventricular dysfunction identifiable by GLS analysis compared to CRP. RESULTS LVEF was significantly reduced in IHD patients compared to SIHD patients (54 ± 7vs 60 ± 4 at rest; 55 ± 8vs62 ± 3 at peak; p &amp;lt; 0.0001). We also observed a significant reduction of GLS in IHD patients compared to SIHD patients (-16.7 ± 4,3vs-19 ± 2.2 - p = 0.07 at rest, -18 ± 4.6vs22 ± 3.4-p = 0.004 at peak). In CRP patients GLS did not change significantly with a tendency to improve (-17.6 ± 4 at rest vs -19 ± 4.5 at peak - p = 0.4). Instead in IRP patients, significant reduction of GLS was observed at peak (17.5 ± 0.7 at rest vs 14.2 ± 0.3 at peak, p value 0,03). LVEF did not significantly differ in CRP (54 ± 5 at baseline vs 55 ± 7 at peak, p = 0.5) and IRP (52 ± 9 at baseline vs. 52 ± 9 at peak, p = 0.9) . CONCLUSIONS Our study shows that strain analysis during stress echocardiography can provide additional information in identifying a subclinical reduction of myocardial function at baseline and a reduction in contractile reserve under stress, secondary to coronary flow reduction. Being GLS a powerful prognostic marker probably patients with negative stress test and incomplete revascularization, reduced baseline GLS and reduction of GLS at peak exercise represent a population at higher risk of coronary artery disease progression and development of left ventricular dysfunction who need a closer follow up. To verify our hypothesis we plan to increase our sample size and to prospectively follow up our patients.

P2456Role of left atrial volume as simple and early predictor of cardiotoxicity

Abstract Background It is crucial to predict and early detect Trastuzumab (TZ)-related cardiotoxicity (CT) in patients with HER2-positive breast cancer (BC). Although baseline left atrial (LA) volume and its changes over time assessed by echocardiography have been used as prognostic tool in various clinical conditions, up to now there are no well-defined LA-based parameters predictive of chemotherapy-related dysfunction. Aim To define the role of increased baseline LA indexed volumes (LAVI) and its changes over time as early predictors of TZ-related CT in a larger and well characterized cohort of BC patients. Methods HER-2 positive BC patients receiving TZ were retrospectively recruited. Patients underwent consecutive transthoracic echocardiography at baseline and then every three months. CT was defined as decrease in left ventricular ejection fraction (LVEF) to a value &lt;50% or a decrease of &gt;10 percentage points from baseline, according to our oncology unit. Results Eligible patients were 280, mean age 56±12 years. Mean follow-up (FU) was 15±5 months and CT occurred in 64 patients (22,9%). Baseline LAVI showed to be associated with development of CT (p=0,003), and to predict its onset, Odds Ratio (OR) per 5 ml/mq LAVI increase 1,32 (95% CI 1,07: 1,62), p=0,006. After multivariate adjustment (age, systolic arterial pressure, anthracycline treatment) baseline LAVI remained an independent predictor of CT: OR 1,25 (95% CI 1,00- 1,56), p=0,04. LAVI showed an increasing trend that has been evident since the very beginning (at three months) and continued over time. LAVI dilation appeared to be small on average, but became significant in patients with subsequent CT (Figure 1). Early LAVI dilation (0–3 months) was able to predict CT OR 1.22 (CI 1.03–1.47) p=0.02 per 5 ml/mq increase, Even when adjusted for baseline LAVI, age, and systolic arterial pressure, OR 1.31 (CI 1.07–1.58), p=0.004. In patients who had mitral regurgitation at baseline, there was no significant worsening of regurgitation overtime. Conclusion Baseline LAVI, as assessed by routine practice, provides an incremental predictive value about CT risk over the other known clinical features. On top, LAVI dilation over time seems to begin before LVEF decreases, and hence could anticipate the development of left ventricular dysfunction. Even if LAVI is a simple and well known echocardiographic measurement, it could be used in this newborn context to stratify patients after validation with prospective studies.

Epicardial Fat Thickness in Children with Classic Congenital Adrenal Hyperplasia

Objective:Epicardial fat thickness (EFT) is an emerging cardio-metabolic risk factor and has been shown to be related to atherosclerosis. EFT has not been studied in the context of CAH. This study aimed to evaluate EFT in children with CAH and its relation to carotid artery intima-media thickness (CA-IMT) and left ventricular (LV) functions.Methods:Thirty-six children with classical CAH were compared with 36 healthy controls. All patients had confirmed CAH and were receiving steroid substitution therapy. Patients and controls underwent anthropometric evaluation, measurement of fasting lipids, glucose, insulin, homeostasis model assessment for insulin resistance (HOMA-IR). LV functions and EFT were assessed using conventional echocardiography. Duplex ultrasonography was used to measure CA-IMT.Results:Compared to controls, patients had greater EFT (p=0.001), CA-IMT (p=0.01), LV mass index (LVMI) (p=0.001) and prolonged mitral deceleration time (DcT) (p=0.01). CAH patients also had significantly worse HOMA-IR (p=0.001) than controls. Abnormalities were worse in uncontrolled CAH on treatment. Multivariate analysis in CAH subjects showed EFT correlated positively with waist circumference odds ratio (OR) [OR=1.9; 95% confidence interval (CI): 1.07-1.14; p=0.01], 17-hydroxyprogesterone [OR=1.6; 95% CI: 1.33-2.89; p=0.05], testosterone concentration (OR=1.7; 95% CI: 1.55-2.13; p=0.01), LVMI (OR=1.14; 95% Cl: 1.08-1.13; p=0.01), mitral DcT (OR=2.25; 95% CI: 1.15-2.05; p=0.01) and CA-IMT (OR=1.6; 95% CI: 1.15-2.05; p=0.01).Conclusion:EFT is elevated in children with classical CAH, particularly in those with poor control, and is correlated with CA-IMT, LV mass and mitral DcT. Measurement of EFT in CAH children may help to identify those at high risk of developing LV dysfunction and subclinical atherosclerosis.

Assessment of anthracycline-induced long-term cardiotoxicity in patients with hematological malignancies

BACKGROUND: Anthracyclines are antibiotic antineoplastic drugs used in the treatment of various hematological and solid malignancies. They are well-known for their cardiotoxic side effects which are related to their cumulative dosages. Many investigations are used to detect such cardiotoxicity, the gold standard of which is the endomyocardial biopsy that has a limited use because it is an invasive procedure. The aims of this study were to explore the cardiotoxicity induced by anthracyclines in patients with hematological malignancies by using electrocardiography (ECG) and echocardiography and to determine relationship between the detected changes in ECG and echocardiography, with some demographic and clinical variables. PATIENTS AND METHODS: A cross-sectional study of fifty patients was recruited at Al-Imamein Al-Kadhemein Medical City from March 2014 to January 2015. ECG and echocardiography were done to the patients to study several parameters such as ejection fraction (EF), diastolic dysfunction, QRS voltage, QRS duration, and corrected QT (QTc) both at baseline and reassessment. Reassessment was done after completing induction for leukemia patients and at mid-term reassessment for lymphoma patients. RESULTS: ECG showed reduction in QRS voltage, increase in QRS duration, and increase in QTc, all of which showed statistical significance and may reflect the effect on the depolarization and repolarization on the myocardium. The echo study showed the development of systolic left ventricular (LV) dysfunction (EF 30% from baseline) with the development of LV dysfunction was also found. CONCLUSIONS: Significant changes in QRS voltage, QRS duration, QTc, as well as the occurrence of LV systolic dysfunction and diastolic dysfunction were noted. The mean cumulative dose at which LV systolic dysfunction occurred was about 250 mg/m2.

Frequent premature ventricular beats in healthy children: when to ignore and when to treat?

Premature ventricular beats (PVCs) are frequently identified in healthy children with structurally normal hearts and generally have a benign clinical course often disappearing spontaneously. However, a small percentage of children may develop a cardiomyopathy. The purpose of this review is to understand which children may be at risk of development of left ventricular (LV) dysfunction with idiopathic PVCs. There is increasing evidence that a ventricular ectopic burden more than 24% in adults may lead to LV dysfunction. Most of the pediatric studies to date are retrospective, small case series from single institutions and have conflicting results regarding a direct correlation of the PVC burden to LV dysfunction. Development of a cardiomyopathy from frequent PVCs in children is likely multifactorial relating to the burden itself, presence of higher levels of ectopy (couplets and runs of ventricular tachycardia) as well as the duration of ventricular ectopy. Understanding the duration of ectopy is often unknown as patients are asymptomatic and the irregular heart beat was identified at a well-child examination. Asymptomatic children with normal ventricular function and a low ectopy burden can be followed without any intervention and generally reassured. Children with an ectopy burden more than 30% are at some risk of developing LV dysfunction and should be more closely followed with noninvasive imaging. Development of symptoms attributed to the ectopy or signs of increasing LV dimensions or LV dysfunction should be treated with medication or catheter ablation.

Revisiting Peripartum Cardiomyopathy: A Subsequent Pregnancy

Peripartum cardiomyopathy, or pregnancy-associated cardiomyopathy, is the development of left ventricular dysfunction usually occurring during the last trimester of pregnancy, shortly after delivery, or five months postpartum. As a result of the cardiovascular strain of pregnancy, patients who have developed peripartum cardiomyopathy, particularly those with persistent left ventricular dysfunction, are strongly advised against subsequent pregnancies. If a subsequent pregnancy should occur in the setting of a diminished left ventricular ejection fraction, the risk of fetal and maternal morbidity and mortality increases significantly. This case describes a 25-year-old Caucasian female patient who became pregnant eighteen months after developing peripartum cardiomyopathy. The association between barriers to adequate care and increased development of peripartum cardiomyopathy in both a rural and global setting has been recognized by several researchers. Literature has shown that expectant mothers from underserved areas, those of African descent and those who smoke, have hypertension, or use cocaine carry a greater risk of developing peripartum cardiomyopathy. Therefore, in addition to the related complications of peripartum cardiomyopathy, practitioners in underserved areas with high-risk populations should be aware of the risk factors and pathophysiologic manifestations inherent with the disease.

Characterization of Left Ventricular Dysfunction by Myocardial Strain in Critical Pulmonary Stenosis and Pulmonary Atresia After Neonatal Pulmonary Valve Balloon Dilation

Transient left ventricular (LV) dysfunction occurs in some infants born with critical pulmonary stenosis (PS) or membranous pulmonary atresia with intact ventricular septum (PAIVS) after pulmonary valve (PV) balloon dilation (BD). The cause for this is not well understood. We sought to characterize this LV dysfunction by investigating regional differences in this cohort using myocardial strain imaging. Patients who underwent neonatal (<2 weeks age) PV BD for critical PS or PAIVS from Jan, 2007 to March, 2014 with echocardiographic images suitable for strain analysis were identified; infants with ≥moderate post-BD LV dysfunction (ejection fraction <40%, n = 8) were matched 1:1 with controls who underwent PV BD but did not develop LV dysfunction. Longitudinal and circumferential global and segmental strain were analyzed before and after PV BD. For the 8 LV dysfunction cases, LV global longitudinal strain worsened after PV BD (-16% pre- vs -8% post-PV BD, p = 0.008) with similar impairment in global LV circumferential strain (-17% vs -8%, p = 0.008); there was no significant change in RV global or segmental longitudinal strain pre- vs post-PVBD. No significant pre/post-BD differences in global or circumferential strain were found in control pts. Segmental analysis of longitudinal and circumferential LV strain before and after balloon dilation in cases demonstrated decreased strain in all segments, but more pronounced and statistically significant in septal segments as compared with the free wall. In conclusion, transient LV dysfunction post-PV BD for critical PS/PAIVS is characterized by impaired global longitudinal and circumferential LV strain, with the most significant reductions in strain at the interventricular septum; longitudinal RV strain remains unchanged. These findings suggest that the mechanism of LV dysfunction post-PV BD is adverse ventricular-ventricular interactions specifically involving the interventricular septum.

Homocysteine Level in Children with Classic Congenital Adrenal Hyperplasia: Relationship to Carotid Intimal Wall Thickness and Left Ventricular Function

Background/Aims: Homocysteine is an important and independent risk factor for atherosclerotic diseases. The aim of this study was to evaluate serum levels of homocysteine in children with congenital adrenal hyperplasia (CAH) and their relation to carotid artery intima-media thickness (CA-IMT) and left ventricular (LV) function. Methods: This study included 36 children with classic CAH and 36 healthy children. All underwent anthropometric evaluation. Measurement of serum levels of total homocysteine was carried out. The LV mass (LVM) and function were assessed using conventional echocardiography. Duplex ultrasonography was used to measure CA-IMT. Results: Compared to the controls, the patients had higher homocysteine levels (p = 0.001), a thicker CA-IMT (p = 0.01), a higher LVM index (LVMI) (p = 0.001), and a prolonged mitral deceleration time (DcT) (p = 0.01). Abnormalities were marked in children who were uncontrolled on medical treatment. In multivariate analysis, homocysteine levels were significantly correlated with systolic (OR = 2.2; 95% CI: 1.10–1.18; p = 0.01) and diastolic blood pressures (OR = 2.9; 95% CI: 1.45–2.4; p = 0.01), atherogenic index (OR = 2.6; 95% CI: 1.33–2.89; p = 0.01), HOMA-IR (OR = 1.3; 95% CI: 1.04–1.34; p = 0.001), LVMI (OR = 2.6; 95% CI: 1.1–1.13; p = 0.001), mitral DcT (OR = 2.4; 95% CI: 1.15–2.05; p = 0.01), and CA-IMT (OR = 1.6; 95% CI: 1.16–1.57; p = 0.01). Conclusions: Serum total homocysteine was elevated in children with classic CAH, particularly in those with poor control on medical treatment, and it was correlated with CA-IMT, LVMI, and mitral DcT. Measurement of homocysteine in children with CAH may help to identify those at high risk of developing LV dysfunction and subclinical atherosclerosis.

Circulating miR-30a-5p as a prognostic biomarker of left ventricular dysfunction after acute myocardial infarction

Left ventricular (LV) dysfunction after acute myocardial infarction (AMI) is associated with an increased risk of heart failure (HF) development. Diverse microRNAs (miRNAs) have been shown to appear in the bloodstream following various cardiovascular events. The aim of this study was to identify prognostic miRNAs associated with LV dysfunction following AMI. Patients were divided into subgroups comprising patients who developed or not LV dysfunction within six months of the infarction. miRNA profiles were determined in plasma and serum samples of the patients on the first day of AMI. Levels of 14 plasma miRNAs and 16 serum miRNAs were significantly different in samples from AMI patients who later developed LV dysfunction compared to those who did not. Two miRNAs were up-regulated in both types of material. Validation in an independent group of patients, using droplet digital PCR (ddPCR) confirmed that miR-30a-5p was significantly elevated on admission in those patients who developed LV dysfunction and HF symptoms six months after AMI. A bioinformatics analysis indicated that miR-30a-5p may regulate genes involved in cardiovascular pathogenesis. This study demonstrates, for the first time, a prognostic value of circulating miR-30a-5p and its association with LV dysfunction and symptoms of HF after AMI.

Foci of chronic infection and vascular rigidity in persons of military age

The role of focal infection as a possible risk factor for development of atherosclerotic cardiovascular diseases is discussed quite intensively now. Estimated some parameters of vascular stiffness in young men of military age with the features of their infectious-inflammatory medical history by the type of foci of chronic infection. It is established that in young men with foci of chronic infection such indicators of vascular stiffness, as peripheral augmentation index, augmentation index, normalized to heart rate, and augmentation index of the aorta were significantly higher than in their peers with a positive history. The differences in the first two indicators have reached a reliable level. It should be emphasized the presence of more low blood pressure in the presence of foci of chronic infection , which eliminates the distortion parameters of vascular status, influenced by the tensile effect from the blood pressure in the time of the study. The obtained data clearly indicate the higher rigidity of the walls of the aorta and large arteries in young men under the influence of their foci of chronic infection. Some tendency to development of left ventricular dysfunction in young people with presence of chronic tonsillitis and other infectious and inflammatory diseases was also revealed. This dysfunction is expressed in reducing the maximum rate of growth of blood pressure and increasing the period of expulsion of the left ventricle. The presented results confirm the concept of lifelong formation of «infectious-inflammatory load» in terms of increasing vascular rigidity and subclinical changes in the functioning of the myocardium at young age, subject to the presence of a focal chronic infection. These data allow us to regard foci of chronic infection as another risk factor of atherosclerosis, which in turn requires consideration when carrying out the relevant preventive measures among young population in the process of health checkups.

PREDICTION OF LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC FUNCTIONS SIX MONTHS FOLLOWING MITRAL VALVE REPLACEMENT USING NEW ECHO DOPPLER INDICES

The development of left ventricular dysfunction is a major concern in the management of patients withsevere mitral regurgitation. In the initial stages, contractility impairment may be ‘‘invisible’’ by the traditional methodsto assess the ventricular function, because of different loading conditions. This fact can mask the presence of LVdysfunction. Sometimes, LV dysfunction may be ‘‘unmasked’’ only by change in loading conditions after surgicalcorrection, leading to the development of overt LV dysfunction and congestive heart failure. The identification ofcontractile dysfunction at an early stage and surgical correction may avoid the development of irreversible postoperativeLV dysfunction.

Left Ventricular Strain and Dyssynchrony in Young and Middle-Aged Peritoneal Dialysis Patients and Healthy Controls: A Case-Matched Study

Background: This study aimed to evaluate the role of two-dimensional speckle-tracking imaging (2D-STI) and myocardial layer-specific analysis in evaluating early left ventricular (LV) myocardial function and systolic dyssynchrony in young and middle-aged uremic patients undergoing peritoneal dialysis (PD). Methods: We enrolled 31 PD patients aged ≤65 years with preserved LV ejection fraction (LVEF, ≥54%) as the PD group and 49 age-matched healthy people as the control group. Echocardiography was used to assess the left atrial diameter index (LADI, LAD/BSA), LV mass index (LVMI), LVEF, peak early diastolic velocity/late diastolic velocity (E/A) (measured by pulsed Doppler), and peak early diastolic velocity (by pulsed Doppler)/peak velocity of the early diastolic wave (by pulsed-wave tissue Doppler) (E/e′). Next, we used 2D-STI and myocardial layer-specific analysis to obtain longitudinal strains (LS) of the endocardium (LSendo), the myocardium (LSmyo), the epicardium (LSepi), and the global myocardium (GLS). Then, we measured the postsystolic index (PSI) to evaluate LV myocardial function. Time to peak LS (TTP) and peak strain dispersion (PSD) from 17 consecutive segments were assessed to quantify LV dyssynchrony. Results: Compared with the controls, PD patients had significantly increased LADI (p = 0.041), LVMI (p = 0.000), and E/e′ (p = 0.009), but reduced LVEF (p = 0.000) and E/A (p = 0.000). The average values of GLS (GLS avg) (p = 0.01) and GLS of the apical 2-chamber view (p = 0.003), including the LSendo (p = 0.024), LSmyo (p = 0.024), and LSepi (p = 0.032), were significantly decreased in patients with PD compared with controls. In PSI, segments of LS were markedly delayed in the anterior septum (p = 0.047), anterior (p = 0.000) and septum wall (p = 0.024) from basal segments, anterior wall (p = 0.001) from middle segments, and anterior (p = 0.024) and inferior (p = 0.024) wall from apical segments. Moreover, PSD was significantly increased in PD patients (p = 0.015), while TTP was evidently delayed in the anterior septum (p = 0.004), anterior (p = 0.000) and posterior (p = 0.042) wall from basal segments, and inferior wall (p = 0.048) from apical segments. Conclusions: Despite preserved LVEF, young and middle-aged PD patients developed LV dysfunction and myocardial systolic dyssynchrony earlier compared with controls.