Diastolic Dysfunction Grade Research Articles

Diastology in the intensive care unit: Challenges for the assessment and future directions.

Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

Artificial intelligence-enabled ECG for left ventricular diastolic function and filling pressure

Assessment of left ventricular diastolic function plays a major role in the diagnosis and prognosis of cardiac diseases, including heart failure with preserved ejection fraction. We aimed to develop an artificial intelligence (AI)-enabled electrocardiogram (ECG) model to identify echocardiographically determined diastolic dysfunction and increased filling pressure. We trained, validated, and tested an AI-enabled ECG in 98,736, 21,963, and 98,763 patients, respectively, who had an ECG and echocardiographic diastolic function assessment within 14 days with no exclusion criteria. It was also tested in 55,248 patients with indeterminate diastolic function by echocardiography. The model was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, and its prognostic performance was compared to echocardiography. The AUC for detecting increased filling pressure was 0.911. The AUCs to identify diastolic dysfunction grades ≥1, ≥2, and 3 were 0.847, 0.911, and 0.943, respectively. During a median follow-up of 5.9 years, 20,223 (20.5%) died. Patients with increased filling pressure predicted by AI-ECG had higher mortality than those with normal filling pressure, after adjusting for age, sex, and comorbidities in the test group (hazard ratio (HR) 1.7, 95% CI 1.645–1.757) similar to echocardiography and in the indeterminate group (HR 1.34, 95% CI 1.298–1.383). An AI-enabled ECG identifies increased filling pressure and diastolic function grades with a good prognostic value similar to echocardiography. AI-ECG is a simple and promising tool to enhance the detection of diseases associated with diastolic dysfunction and increased diastolic filling pressure.

Multiparametric Monitoring of Disease Progression in Contemporary Patients with Wild-Type Transthyretin Amyloid Cardiomyopathy Initiating Tafamidis Treatment.

Recently, a disease modifying therapy has become available for transthyretin amyloid cardiomyopathy (ATTR-CM). A validated monitoring concept of treatment is lacking, but a current expert consensus recommends three clinical domains (clinical, biomarker and ECG/imaging) assessed by several measurable features to define disease progression. We retrospectively analyzed data of wild-type ATTR-CM patients initiating tafamidis therapy assessed within our local routine protocol at baseline and 6-months follow-up with respect to the frequency of values beyond the proposed thresholds defining disease progression. Additionally, associations of cardiac magnetic resonance (CMR) tomography with clinical domains were examined within a subgroup. Sixty-two ATTR-CM patients were included (88.7% male, mean age 79 years). In total, 16.1% of patients had progress in the clinical and functional domain, 33.9% in the biomarker domain and 43.5% in the imaging/electrocardiography (ECG) domain, with the latter driven by deterioration of the diastolic dysfunction grade and global longitudinal strain. In total, 35.5% of patients showed progress in none, 35.5% in one, 29.0% in two and no patient in three domains, the latter indicating overall disease progression. A subgroup analysis of twenty-two patients with available baseline and follow-up CMR data revealed an increase in CMR-based extracellular volume by more than 5% in 18.2% of patients, with no significant correlation with progress in one of the clinical domains. We provide first frequency estimates of the markers of disease progression according to a recent expert consensus statement, which might help refine the multiparametric monitoring concept in patients with ATTR-CM.

Incidence of heart failure with preserved ejection fraction (HFpEF) in COPD patients during acute exacerbation in Ain Shams University Hospitals

Abstract Background Cardiovascular comorbidities are frequent in chronic obstructive pulmonary disease (COPD) and are associated with a worse prognosis, and the presence of COPD has a negative impact on cardiovascular disease and heart failure The available estimates of the prevalence of diastolic dysfunction vary widely, probably due to different diagnostic approaches and small sample sizes. Aim Perspective analytical comparison of ECHO findings (done or will be done) within a 3-month interval of acute exacerbations. Outcomes Previous or prospective comparison of EF with current findings at the examination station or grade of diastolic dysfunction, Left atrial dimension, E/A, E/e′ ratios, and slope findings among the 3-month follow-up period perceptively (incidence) in the following two groups, namely Group A: the patient group with prior EHCO findings showing no heart failure with preserved ejection fraction (HFpEF) before enrollment but develop HFpEF during acute exacerbations. Group B: the patient group with ECHO findings of HFpEF following acute exacerbations within 3 months or thereafter. Patients and methods Patients with confirmed COPD by spirometry were evaluated by echocardiography initially as baseline and 3 months after for the assessment of diastolic dysfunction grades. Those patients are divided into two groups as inpatients and outpatients. Results An observational cross-sectional study including 36 COPD diagnosed patients: 33 males and 3 females with a mean age of (58.5 ± 7.7 years). The patients were divided into 17 inpatients and 19 outpatients. These patients were divided according to COPD severity into groups A, B, and C (outpatient group) and D (inpatient group) as 7, 9, 3, and 17 patients, respectively. Comparisons between baseline echocardiographic findings and after 3 months’ follow-up were processed. There were significant increases of tricuspid regurgitation (TR) and diastolic dysfunction in COPD group D compared with the other group at baseline and in the same group after a 3-month follow-up and significant correlation with COPD grade D cases and high-grade diastolic dysfunction. There were significant decrease of TR and decrease of diastolic dysfunction grades after a 3-month follow-up of acute exacerbations compared with baseline. It was found that spirometry parameters were nonstatistically different at baseline concerning the existing diverse diastolic dysfunction. However, only a significant negativecorrelation was found between baseline left atrial dimension and forced expiratory volume in first second/percentage of forced vital capacity. Conclusion COPD severity influences the HFpEF with tendency to increase diastolic dysfunction and TR, which could be improved with COPD management. Assessment of left ventricular diastolic dysfunction is pivotal.

Diastolic function assessment with four-dimensional flow cardiovascular magnetic resonance using automatic deep learning E/A ratio analysis

BackgroundDiastolic left ventricular dysfunction is a powerful contributor to the symptoms and prognosis of patients with heart failure. In patients with depressed left ventricular systolic function the EA ratio is the first step to defining the grade of diastolic dysfunction. Doppler echocardiography is the preferred imaging technique for diastolic function assessment, while CMR is less established as a method. Previous 4D Flow-based studies have looked at the EA ratio proximally to the mitral valve, requiring manual interaction. In this study we compare an automated, deep learning-based, and two semiautomated approaches for 4D Flow CMR-based EA ratio assessment to conventional, gold standard echo-based methods. MethodsNinety-seven subjects with chronic ischemic heart disease underwent a cardiac echo followed by an MRI investigation. 4D Flow-based EA ratio values were computed using three different approaches; two semi-automated, assessing the EA ratio by measuring the inflow velocity (MVvel) and the inflow volume (MVflow) at the mitral valve plane, and one fully automated, creating a full LV segmentation using a deep learning-based method within which the EA ratio could be assessed without constraint to the mitral plane (LVvel). ResultsMVvel, MVflow, and LVvel EA ratios were strongly associated with Echo EA ratio (R2= 0.60, 0.58, 0.72). LVvel peak E and A showed moderate association to Echo peak E and A, while MVvel values were weakly associated. MVvel and MVflow EA ratios were very strongly associated with LVvel (R2= 0.84, 0.86). MVvel peak E was moderately associated with LVvel, while peak A showed strong association (R2= 0.26, 0.57). Discussion and ConclusionPeak E, peak A and EA ratio are integral to the assessment of diastolic dysfunction and may expand the utility of CMR studies in patients with cardiovascular disease. While underestimation of absolute peak E and A velocities was noted, the EA ratio measured with all three 4D Flow methods was strongly associated with the gold standard Doppler echocardiography. The automatic, deep learning-based method performed best, with the most favorable runtime of ~40seconds. As both semiautomatic methods associated very strongly to LVvel, they could be employed as an alternative for estimation of EA ratio.

Noninvasive Assessment of Cardiopulmonary Hemodynamics Using Cardiovascular Magnetic Resonance Pulmonary Transit Time.

Introduction: Pulmonary transit time (PTT) is the time it takes blood to pass from the right ventricle to the left ventricle via the pulmonary circulation, making it a potentially useful marker for heart failure. We assessed the association of PTT with diastolic dysfunction (DD) and mitral valve regurgitation (MVR). Methods: We evaluated routine stress perfusion cardiovascular magnetic resonance (CMR) scans in 83 patients including assessment of PTT with simultaneously available echocardiographic assessment. Relevant DD and MVR were defined as exceeding Grade I (impaired relaxation and mild regurgitation). PTT was determined from CMR rest perfusion scans. Normalized PTT (nPTT), adjusted for heart rate, was calculated using Bazett's formula. Results: Higher PTT and nPTT values were associated with higher grade DD and MVR. The diagnostic accuracy for the prediction of DD as quantified by the area under the ROC curve (AUC) was 0.73 (CI 0.61-0.85; p = 0.001) for PTT and 0.81 (CI 0.71-0.89; p < 0.001) for nPTT. For MVR, the diagnostic performance amounted to an AUC of 0.80 (CI 0.68-0.92; p < 0.001) for PTT and 0.78 (CI 0.65-0.90; p < 0.001) for nPTT. PTT values < 8 s rule out the presence of DD and MVR with a probability of 70% (negative predictive value 78%). Conclusion: CMR-derived PTT is a readily obtainable hemodynamic parameter. It is elevated in patients with DD and moderate to severe MVR. Low PTT values make the presence of DD and MVR-as assessed by echocardiography-unlikely.

Prevalence of Cardiovascular Involvement in Patients With COVID-19 Disease

Background: Coronaviruses are a huge family of viruses that lead to various diseases from a common cold to more unadorned illnesses for example SARS-CoV and MERS-CoV. Common symptoms of this infection include respiratory symptoms. In addition, this disease can also manifest with an acute cardiovascular (CV) syndrome. The aim of this study was to determine the frequency of CV involvement in patients with COVID-19 disease admitted to Afzalipour Hospital in Kerman. Methods: In this study, all patients who were diagnosed with COVID-19 disease and were hospitalized and monitored due to disease conditions were eligible to enter the study. At the beginning of the patient’s hospitalization, the patients’ vital signs were recorded and the first 12-lead electrocardiography was taken. Then, patients underwent cardiac monitoring and echocardiography at the beginning of hospitalization and afterwards during the course of disease. Preliminary tests including biochemistry, blood cell count, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) and troponin were also performed for patients. Results: The mean age of patients with COVID-19 was 55.63 years and 20.2% of them had a history of heart disease. More than half of these patients were men. Ejection fraction was normal in 87.8% of patients. There was a significant relationship between diastolic dysfunction grade and the history of heart disease (P=0.02). Conclusion: Since the incidence of underlying diseases such as diabetes, hypertension and cardiac disorders can raise the risk of corona viruses’ disease and also increase the mortality rate of this disease in these people, it is suggested that more attention be paid to the observance of health protocols for people with underlying diseases, and that people with underlying diseases be given priority in vaccinating against this disease.

Renal Transplant in Patient with Low Ejection Fraction and Diastolic Dysfunction Grade III: A Case Report

Renal Transplant in Patient with Low Ejection Fraction and Diastolic Dysfunction Grade III: A Case Report

Hypertrophic Cardiomyopathy—Septal Perforator Arteries Doppler Flow Dynamics

Patients with hypertrophic cardiomyopathy (HCM) have been shown to exhibit abnormal diastolic vessel flow; however, flow pattern profiles and their possible association with different grades of diastolic dysfunction have not been studied. Color Doppler two-dimensional echocardiography permits visualization of the septal perforator arteries, and pulsed-wave Doppler allows recording of diastolic septal artery flow (SAF). Through routine visualization of the septal perforator arteries and acquisition of SAF, we noticed 3 patterns of SAF in patients with HCM. In this study, we aimed to assess the feasibility of the acquisition of SAF and to describe types of SAF in an HCM cohort and their associations with diastolic function. We reviewed two-dimensional echocardiograms and the electronic records of 108 patients with HCM in whom septal artery color and spectral Doppler had been performed. The peak diastolic and end-diastolic velocities, diastolic slope, diastolic flow time-velocity integral, and systolic flow reversal of the septal perforator arteries were recorded with pulsed-wave Doppler. Echocardiographic and clinical characteristics were analyzed. A reproducible pulsed-wave Doppler tracing was recorded in 54% of patients with HCM. Three distinct patterns of SAF were identified: type 1-smooth, linear holodiastolic velocity decrease; type 2-with presence of an atrial dip; and type 3-biphasic velocity decrease with an early, rapid diastolic slope and a mid-to-late gentle slope. These 3 SAFs correlated with different grades of diastolic dysfunction. Septal artery flow could be detected in more than 50% of patients with HCM. Three distinct types of SAF were identified, correlating with different grades of diastolic dysfunction. These 3 types of SAF can provide additional information about left ventricular end-diastolic pressure and diastolic function in patients with HCM in whom diastolic function may be difficult to determine.

Frequency of RV Diastolic Dysfunction in Chronic Heart Failure Patients

Objectives: In this cross-sectional study we aim to assess the frequency of RVDD in chronic heart failure patients with reduced EF who visited as outpatient in a tertiary care hospital.&#x0D; Methodology: We included consecutive patients with chronic heart failure who had reduced EF. We assessed these patients for RVDD if they had normal RV systolic function and pulmonary artery pressures. The RVDD was categorized as normal, impaired relaxation, pseudonormal filling and restricted filling according to ASE guideline. RVDD grades were compared with LV systolic dysfunction and diastolic dysfunction grades.&#x0D; Results: Out of 199 patients evaluated, 66.3% (132) were male will with the mean age of 56.8 ± 12 years. The majority, 176, 88.4% of patients were with diagnosis if ICMP. The RVDD was noted in 112 (56.3%) patients out of which 30 (26.8%) had stage 1 (impaired relaxation) 78 (69.6%) had stage 2 (pseudonormal) and 4 (3.6%) patients had grade 3 (restrictive filling) RVDD. When compared a statistically significant association (P &lt; 0.001) was observed between LV and RV diastolic dysfunction.&#x0D; Conclusion: RVDD is under diagnosed entity of neglected ventricle which is significantly associated with LV systolic and diastolic dysfunction even if the RV systolic function is normal. The prognostic significance of this diastolic ventricular interaction needs to be further investigated.

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

Echocardiographic estimation of pulmonary artery wedge pressure: invasive derivation, validation, and prognostic association beyond diastolic dysfunction grading.

Grading of diastolic function can be useful, but indeterminate classifications are common. We aimed to invasively derive and validate a quantitative echocardiographic estimation of pulmonary artery wedge pressure (PAWP) and to compare its prognostic performance to diastolic dysfunction grading. Echocardiographic measures were used to derive an estimated PAWP (ePAWP) using multivariable linear regression in patients undergoing right heart catheterization (RHC). Prognostic associations were analysed in the National Echocardiography Database of Australia (NEDA). In patients who had undergone both RHC and echocardiography within 2 h (n = 90), ePAWP was derived using left atrial volume index, mitral peak early velocity (E), and pulmonary vein systolic velocity (S). In a separate external validation cohort (n = 53, simultaneous echocardiography and RHC), ePAWP showed good agreement with invasive PAWP (mean ± standard deviation difference 0.5 ± 5.0 mmHg) and good diagnostic accuracy for estimating PAWP >15 mmHg [area under the curve (95% confidence interval) 0.94 (0.88-1.00)]. Among patients in NEDA [n = 38,856, median (interquartile range) follow-up 4.8 (2.3-8.0) years, 2756 cardiovascular deaths], ePAWP was associated with cardiovascular death even after adjustment for age, sex, and diastolic dysfunction grading [hazard ratio (HR) 1.08 (1.07-1.09) per mmHg] and provided incremental prognostic information to diastolic dysfunction grading (improved C-statistic from 0.65 to 0.68, P < 0.001). Increased ePAWP was associated with worse prognosis across all grades of diastolic function [HR normal, 1.07 (1.06-1.09); indeterminate, 1.08 (1.07-1.09); abnormal, 1.08 (1.07-1.09), P < 0.001 for all]. Echocardiographic ePAWP is an easily acquired continuous variable with good accuracy that associates with prognosis beyond diastolic dysfunction grading.

Evaluation of disease progression in patients with ATTR amyloidosis with cardiomyopathy following treatment with patisiran: post-hoc analysis of the APOLLO-B study

Abstract Introduction Transthyretin-mediated (ATTR) amyloidosis is a progressive, fatal disease in which cardiac deposition of transthyretin (TTR) amyloid commonly manifests as cardiomyopathy. Patisiran, an RNA interference therapeutic that reduces TTR synthesis, is approved for the treatment of hereditary ATTR amyloidosis with polyneuropathy. The Phase 3 APOLLO-B study (NCT03997383) evaluated the clinical efficacy and safety of patisiran in patients with ATTR amyloidosis with cardiomyopathy (CM). Purpose This post-hoc analysis evaluated disease progression in APOLLO-B patients following treatment with patisiran vs placebo, based on the European Society of Cardiology (ESC) expert consensus on monitoring patients with ATTR amyloidosis with CM every 6–12 months using three domains: Clinical/Functional, Laboratory Biomarker, and Imaging/Electrocardiography (ECG). Methods Patients with ATTR amyloidosis with CM were randomised (1:1) to intravenous patisiran 0.3 mg/kg or placebo every 3 weeks for 12 months. Disease progression was defined at Month 12 (M12) relative to baseline using Clinical/Functional criteria (≥1 heart failure-related hospitalisation, increased New York Heart Association class ≥1, decline in Kansas City Cardiomyopathy Questionnaire ≥5, or decline in 6-minute walk test ≥30 metres), Laboratory Biomarker criteria (increased N-terminal prohormone B-type natriuretic peptide ≥30% and absolute change ≥300 ng/L, troponin I ≥30%, or ATTR disease stage ≥1), and Imaging/ECG criteria (conduction disturbances or change in left ventricular wall thickness ≥2 mm, change in diastolic dysfunction grade ≥1, or change in systolic function measurements). One marker from each domain provides the minimum criteria for disease progression. Results At M12, the patisiran group (N = 180) had improved odds of no disease progression compared with the placebo group (N = 178; odds ratio [OR] 1.4; 95% confidence interval [CI] 0.77, 2.55) (Figure). The patisiran group had benefits in Clinical and Functional markers vs placebo at M12 (OR 1.58; 95% CI 1.03, 2.42). Patisiran also showed favourable changes in Laboratory Biomarkers vs placebo at M12 (OR 2.14; 95% CI 1.33, 3.43) and a favourable trend in Imaging assessments/ECG vs placebo at M12 (OR 1.31; 95% CI 0.80, 2.15). Conclusion In this post-hoc analysis of APOLLO-B, fewer patisiran-treated patients had disease progression with respect to clinical, functional, and biomarker parameters vs placebo. The risk of disease progression was lower by Clinical/Functional and Laboratory Biomarker composite criteria, and trended lower by individual criterion from the ESC consensus statement among patisiran-treated patients at 12 months vs placebo patients. Long-term follow-up will further assess the impact of patisiran in patients with ATTR amyloidosis with CM.Figure 1

The prognostic role of left atrial strain in young patients after ST elevation myocardial infarction: a 3D echocardiographic study

Abstract Background LA volume previously demonstrated its role as significant predictor of adverse events after AMI. The prognostic value of LA strain is less studied. Left atrial strain has been used as a more accurate alternative to assessing LA performance. 3D echocardiography compared with 2D measurements better reflect the entire atrial myocardium, leading to a more accurate estimation of LA function. Purpose In this study we aimed to assess the prognostic value of LA strain parameters determined by 3D echocardiography in young patients after STEMI. Patients and methods: We enrolled 112 patients in this study - 84 young patients with a first STEMI treated by primary PCI and 28 healthy age and sex matched controls. All patients underwent standard transthoracic echocardiography. In addition to conventional echocardiographic parameters, 3D acquisitions of the left atrium were performed. 3D LA longitudinal strain parameters were determined using the automated function 4D Auto LAQ. Patients were followed up for one year after STEMI, the primary endpoint being the occurrence of MACE. Results Compared to the control group, patients with STEMI had lower values of all LA strain parameters. There were also significant differences between MACE and non-MACE groups. Patients with MACE at follow up had lower reservoir strain (15.16 ± 2.58 vs. 22.71 ± 5.25), lower conduction strain (-8.62 ± 1.77 vs. -10.97 ± 1.44) and lower pumps strain (-9.36 ± 1.51 vs. -12.73 ± 2.53), compared to those from the non-MACE group. All LA strain parameters proved to have very good predictive abilities for MACE in ROC analysis (AUC = 0.894, 95 %CI, P &amp;lt; 0.0001 for LASr 3D, AUC = 0.854, 95 %CI, P &amp;lt; 0.0001 for LASct 3D, and AUC = 0.883, 95%CI, P &amp;lt; 0.0001 for LAScd 3D). For each variable we determined a cut off value as follows: 17.5 (Sb 91.7%, Sp 86.7%) for LASr 3D, -10.5 (Sb 75% Sp 86.7%) for LASct 3D, and -9.05 (Sb 75% Sp 91.7%) for LAScd 3D. LASr 3D under 17, and LASct 3D over -10.5 determined an approximately 2-fold increase in adverse events after STEMI. Univariate COX regression analysis showed that all parameters had a significant effect on MACE, while multivariate analysis identified only reservoir and pump functions as independent predictors for adverse events. LASr 3D values showed a proportional decrease with worsening diastolic dysfunction, demonstrating significant differences between diastolic dysfunction grades. We determined LASr 3D cut-off values for discriminating between different degrees of diastolic dysfunction. Conclusion 3D LA reservoir and pump strain proved to be independent predictors for MACE at one year follow up after STEMI in young patients. Beyond its prognostic role, LASr 3D may be helpful as a complementary method to evaluate diastolic dysfunction in young STEMI patients. Further larger scale studies are needed to validate these findings.

Application of a novel echocardiographic scoring system to estimate left ventricular filling pressure in aortic stenosis

Abstract Background Despite the increased number of aortic stenosis (AS) patients, non-invasive estimation of the left ventricular (LV) filling pressure (FP) is often challenging partly because of unavailability of E/e' due to the presence of mitral annular calcification (MAC). Recently, an echocardiographic scoring system to estimate LVFP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score was proposed. Because VMT score can be applied for patients with significant MAC, we hypothesized that VMT score could be an alternative parameter of E/e' in AS. Purpose To test whether VMT score could be used as an alternative marker of LVFP to E/e' in AS patients. Methods We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LVFP. LV diastolic dysfunction (DD) was graded according to the ASE / EACVI guidelines. Using two-dimensional echocardiographic images, time sequence of opening of mitral and tricuspid valves was assessed and scored to 0 to 2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). This was based on the phenomenon in which early-diastolic opening of the mitral valve becomes earlier than tricuspid valve with an increase in LV FP and pulmonary artery pressure. When the inferior vena cava was dilated, 1 point was added and VMT score was finally calculated as 0 to 3. Results Overall, PAWP was 12±7 mmHg and elevated (≥15 mmHg) in 29 patients. MAC was observed in 82 patients. Although E/e' was higher in patients with elevated PAWP than in those without (23±11 vs 18±8, P=0.007), its predictive ability to elevated PAWP was non-significant (c-index: 0.59, P=0.13), resulting in low specificity of DD grading to predict elevated LVFP (sensitivity: 79%, specificity: 36%). In contrast, VMT score predicted elevated LVFP with c-index of 0.74 (P&amp;lt;0.001). When VMT score was used instead of E/e', diagnostic accuracy of DD grading was improved (c-index: 0.57 vs 0.82, P&amp;lt;0.001). Conclusion VMT score could be an alternative marker of LVFP to E/e' in AS patients.

Abstract 12693: Invasive Derivation, Validation, and Prognostic Association of a Quantitative Echocardiographic Estimate of Pulmonary Artery Wedge Pressure

Background: Grading of diastolic dysfunction (DD) commonly leads to indeterminate classifications and provides little information on treatment effect or disease progression. A quantitative non-invasive estimate of LV filling pressures would have clinical utility. Aim: To invasively derive and validate a quantitative echocardiographic estimation of pulmonary artery wedge pressure (PAWP), and to compare its prognostic performance with diastolic dysfunction grading. Methods: Echocardiographic measures were used to estimate PAWP (ePAWP) using multivariable linear regression in patients undergoing right heart catheterization (RHC). Prognostic associations were analyzed in the National Echocardiography Database of Australia (NEDA). Results: In patients who underwent both RHC and echocardiography within two hours (n=90), ePAWP was derived using left atrial volume index (LAVi), mitral peak early velocity (E), and pulmonary vein peak systolic velocity (PVs). In an external validation cohort (n=53), ePAWP showed good agreement with invasive PAWP (mean±SD difference 0.5±5.0 mmHg) and good diagnostic accuracy for estimating PAWP &gt;15mmHg (area under the curve [95% confidence interval] 0.94 [0.88-1.00]). Among patients in NEDA (n=38,856, median [interquartile range] follow-up 4.8 [2.3-8.0] years, 2,756 cardiovascular deaths), ePAWP associated with cardiovascular death even after adjustment for age, sex, and diastolic dysfunction grading (hazard ratio (HR) 1.08 [1.07-1.09]) and provided incremental prognostic information to diastolic dysfunction grading (C-statistic: 0.68 vs. 0.65, p&lt;0.001). Increased ePAWP associated with worse prognosis across all grades of diastolic function (HR normal: 1.07 [1.06-1.09]; indeterminate: 1.08 [1.07-1.09]; abnormal: 1.08 [1.07-1.09]. Conclusion: Echocardiographic ePAWP is an easily acquired continuous variable with good accuracy that associates with prognosis beyond diastolic dysfunction grading.

Abstract 12632: Clinical Outcomes Across Groups of Ejection Fraction and Grades of Diastolic Dysfunction

Introduction: Previous studies have examined the association of diastolic dysfunction (DD) with cardiovascular (CV) outcomes. Understanding how clinical outcomes for those with a normal ejection fraction (EF) and DD compared to those with reduced EF is important in mitigating CV risk and optimizing management. Methods: 153,305 patients with echocardiograms performed at our institution between 2009 and 2022 were included in this analysis and divided into 2 cohorts: A) Normal EF patients (n=136,455) who were further stratified by grade of DD; and B) low EF (EF&lt;50%, n=16,850) patients who were further stratified by EF into four groups. Patients were followed for CV hospitalization or death. Results: Over a median follow up of 3.42 years, 23,946 (16%) patients died. There were 31,113 (20%), 13,305 (9%), and 1,269 (1%) hospitalizations for any CV diagnosis, heart failure (HF), or cardiac arrest (CA), respectively. After adjustment for age, CAD, HF, DM, hypertension, AF and CKD, the risk of all-cause mortality and of CV or HF hospitalizations increased steadily with increasing grade of DD in patients with normal EF (Table). The same was observed in cohort B with worsening EF, to greater extent than in patients with preserved EF (Table). The risk of hospitalization for CA in patients with grade III DD, however, was comparable to that of patients with an EF &lt;25% (HR=0.97, 95% CI 0.58-1.62, p=0.90) and worse than patients in better EF quartiles (p&lt;0.001). Patients with grade II DD had a CA hospitalization risk comparable to those with EF between 36-40% (HR=1.11, 95% CI 0.79-1.57, p=0.54). Conclusions: Although systolic dysfunction is associated with worse overall death and HF hospitalizations than DD, the risk of CA in patients with grade II and III DD is comparable to that of patients with moderate and severe systolic dysfunction, respectively. Future studies are needed to examine the mechanisms of CA in DD, and optimal treatment strategies for these patients.

Abstract 17428: Severity of Diastolic Dysfunction Predicts Risk of Myocardial Infarction

Background: Diastolic dysfunction (DD) is known to be a predictor of mortality. However, the impact of DD on the risk for myocardial infarction (MI) is not well defined. Research Question: We sought to examine whether DD is an independent predictor of risk of MI in patients with a preserved ejection fraction. Methods: This was a retrospective study of consecutive patients who underwent an echocardiogram that showed normal systolic function and had ≥3 months of follow-up. DD was graded using the contemporaneous guidelines at the time of the echocardiogram. Subsequent MI was determined by the presence of an inpatient encounter with a primary diagnosis of MI. Results/Data: 136,455 patients were included (mean age 56 years; 58% women). DD was present in 18.3% of patients (14.1% Grade 1, 3.8% Grade 2, 0.4% Grade 3). Patients with DD were more likely to be older (71 vs 53 years) and have coronary artery disease (27% vs 12%), diabetes (27% vs 14%), hypertension (69% vs 47%) and hyperlipidemia (64% vs 41%), among other comorbidities. Survival free from MI was significantly lower as diastolic dysfunction severity increased (Figure 1). Multivariate Cox proportional hazards modeling demonstrated that DD was an independent predictor of MI (hazard ratios [CI]: Grade 1: 1.51 [1.35-1.69]; Grade 2: 1.92 [1.64-2.25]; Grade 3: 2.82 [1.94-4.09]). Conclusions: Our data demonstrate that the risk of MI is significantly increased in the presence of DD, with higher risk at higher grades of DD. The increased risk associated with grade 3 DD is comparable to that from a prior history of coronary artery disease. These findings suggest that the severity of DD may be a useful tool in risk stratifying patients for risk of MI.

Abstract 11578: Predicting 30- and 90-day Hospital Admission Rates Using 3-Dimensional Echocardiography Volume-Curve Parameters

Introduction: This study compares impact of 3D echocardiography-derived novel volume-time parameters to established diastolic dysfunction grades with the aim to improve diagnostic and prognostic prediction of hospital admissions. Methods: Subjects (100 heart-failure (HF) and 11 controls) completed 3D-echocardiograms. Under 2016 ASE Guidelines ‘normal’ and ‘grade 1’ were classified as ‘lower-grade’ (n=64), while ‘grade 2’ and ‘grade 3’ as ‘higher-grade’ (n=38). Early passive filling rate to late passive filling rate ratio was calculated, with early-filling and atrial contraction volumes normalized to total filling volume and body surface area. VC based analysis was classified into ‘normal’ (n=37; atrial contraction enhanced, normal, early enhanced) and ‘abnormal’ (n=74; mid-filling enhanced, delayed filling and restrictive-constrictive). Both methods were compared for 30- and 90-day hospital admissions. Results: The mean age is 67.4 years (SD: 11.1) with 51.4% male. Overall, 9.0% (n=10) and 16.2% (n=18) of the subjects were admitted within 30-days and 90- days, respectively. For 30-day admission, 60% and 40% were lower-grade and higher-grade groups by ASE, respectively, (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.26 to 3.23, p-value = 0.89); For admission within 90-days, 50% were in lower-grade and 50% in higher-grade groups of ASE, respectively, (HR 1.37; 95% CI, 0.54 to 3.45, p-value = 0.51). Kaplan-Meier curves and log rank test showed significant differences between VC groups with (p-value =0.021 and p-value&lt;0.001) in at risk of admission within 30- and 90-days, respectively. Conclusions: Volume curve analysis provides a better diagnostic and prognostic tool for predicting near term hospital admissions in HF patients. Kaplan-Meier Curves depicting admission within 30- and 90- days by VC and ASE Group

Abstract 18574: Association Between Left Ventricular Diastolic Function and Right Ventricular Morphology and Function Assessed With Automated 3D Software Analysis

Background: Left ventricular (LV) diastolic dysfunction (DD) is a hallmark of heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) function is a strong and independent prognostic factor in this population, but its correlation with LV DD has not yet been explored. 3D echocardiography allows for accessible, accurate, reproducible analyses of RV function. Our study aims to assess the association between LV diastolic function and RV function (measured via automated 3D echocardiography software) Hypothesis: The RV enlarges and its systolic function decreases, in a graded fashion, with increasing degrees of LV DD Methods: We conducted a prospective, single-center, cross-sectional cohort study in patients with clinically indicated echocardiography and 3D RV assessment. We excluded patients with non-WHO group 2 pulmonary hypertension, non-sinus rhythm during echocardiogram, and those with a LVEF &lt;40%. We conducted an interim analysis of the first 187 patients. Patients were stratified according to DD grading, and different RV parameters were compared using ANOVA Results: 187 patients underwent interim analysis, 65% were women. Mean age 60±17 years, 64% African-American, 16% Hispanic, 12% Caucasian. Mean BMI 29±6 kg/m 2 . Mean LVEF and LV GLS were 57±10% and -17.7±3.6, respectively. A graded worsening in RV systolic function and morphology were noted in patients with DD. Patients with grade II/ III DD had worse RV EDV (146±42 mL), RV FAC (32±9%), TAPSE (19±5 mm), and RVEF (40±9%), than patients without DD (RV EDV 114±36 mL, p=0.0011; RV FAC 39±7.4%, p&lt;0.001; TAPSE 21±5 mm, p&lt;0.001; and RVEF 47±8%, p&lt;0.001), and grade I DD Conclusion: Our results suggest that there is a graded worsening in the RV function and morphology as LV diastolic function worsens in patients with preserved EF. This denotes the importance of widespread, accurate, and reproducible RV assessment during standard echocardiography