ECG Voltage Research Articles

Correlation of ECG and cardiac MRI for assessment of ventricular hypertrophy and dilatation in adults with repaired tetralogy of Fallot

BackgroundSurgically repaired Tetralogy of Fallot (rTOF) is associated with progressive right ventricular hypertrophy (RVH) and dilation (RVD). Accurate estimation of RVH/RVD is vital for the ongoing management of this patient population. The utility of the ECG in evaluating patients with rTOF with pre-existing right bundle branch block (RBBB) has not been studied. We aimed to determine the sensitivity/specificity of currently established ECG criteria in detecting RVH/RVD in this patient population. MethodsWe included consecutive patients diagnosed with rTOF who underwent CMR performed at our regional referral centre between January 2012 and December 2019. Each CMR was assessed for LVH, LVD, RVH and or RVD. The ECG corresponding to the CMR was then used to determine RVH/LVH for specificity and sensitivity analysis. ResultsOur study included 163 consecutive rTOF patients. The specificity for ECG-based criteria for LVH was 100.00% (95% C.I. (87.75, 100.00)), and the sensitivity was 7.19% (95% C.I. (3.15, 12.83)). When RBBB was present, specificity for RVH was 100.00% (95% C.I. (84.56, 100.00)), and sensitivity was 7.69% (95% C.I. (3.75, 13.69)). When RBBB was absent, specificity for RVH was 100.00% (95% C.I. (15.81, 100.00)), and sensitivity was 0.00% (95% C.I. (0.00, 33.63)). A regression model with the entire group of 163 ToF patients, based on the Sokolow-Lyon criterion (sum of R in V1 + S in V5/V6), produced a new suggested criterion for the diagnosis of RVH in patients with rTOF, which was a sum of R in V1 + S in V5/V6 greater than 13.25 mm. This model's sensitivity for RVH detection was 69.1%, and specificity was 36.8%. ConclusionsStandard ECG voltage criteria have poor sensitivity for detecting right and left ventricular chamber hypertrophy and dilatation in patients with rTOF, so current ECG criteria should not be used to monitor RVH/RVD in this patient population.

The Impact of Coronary Sinus Reducer on Arrhythmic Properties in Patients with Refractory Angina.

Treatment with a coronary sinus reducer (CSR) is a new therapeutic option for refractory angina patients. Preclinical studies have shown antiarrhythmic properties of coronary sinus narrowing. The possible antiarrhythmic effect of CSR implantation is unknown. This study aimed to determine the possible antiarrhythmic effects of CSR implantation as assessed by high-resolution electrocardiogram (hrECG) parameters. 24 patients from the Crossroad study randomized to either CSR treatment (n = 12) or a sham procedure (n = 12) had hrECG recorded at baseline and after 6 months. T-peak and T-end interval (TpTe) defined as the time difference between the peak amplitude of the T wave and the global end of the T wave, spatial angle between QRS complex and T axis defined as the angle between the ventricular depolarization and repolarization vectors using maximal (QRSTP) and mean (QRSTM) vector amplitudes and spatial ventricular gradient (SVG) calculated as integral of ECG voltages over the entire QRST complex were analyzed. Additionally, we analyzed parameters of QT and heart rate variability using time and frequency domain. At baseline, all analyzed parameters were comparable between both groups and heart rate remained constant. The intragroup analysis did not show any significant change in TpTe, QRSTP, QRSTM, SVG, QT, and heart rate variability at follow-up. Furthermore, intergroup comparison between CSR implantation and sham procedure also did not show any significant difference in the change of analyzed parameters. Compared to the sham procedure, CSR implantation did not demonstrate a significant impact on the arrhythmogenic substrate assessed with hrECG. Unique Identifier: NCT04121845, https://classic.clinicaltrials.gov/ct2/show/NCT04121845.

Transthyretin cardiac amyloidosis in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: experience of a single center.

Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. We report our single center experience on ATTR-CA detection among TAVR candidates to provide insights on the prevalence and clinical features of dual pathology as compared to lone AS. Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: "ATTR-CA+": patients with confirmed ATTR-CA at DPD bone scintigraphy; "ATTR-CA-": patients with negative DPD bone scintigraphy or a negative RAISE score; "ATTR-CA indeterminate": patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA- patients were compared. Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in six. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA-, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1% (95% CI 2.6-14.7%). As compared to ATTR-CA - patients, ATTR-CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, we describe for the first time bifascicular block as an ECG feature highly specific of patients with dual pathology (50.0% vs. 2.7%, P<0.001). Of note, pericardial effusion was rarely found in patients with lone AS (16.7% vs. 1.2%, P=0.027). No difference in procedural outcomes was observed between groups. Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features might lead to selective DPD bone scintigraphy with a satisfactory positive predictive value.

Efficient data transmission on wireless communication through a privacy-enhanced blockchain process.

In the medical era, wearables often manage and find the specific data points to check important data like resting heart rate, ECG voltage, SPO2, sleep patterns like length, interruptions, and intensity, and physical activity like kind, duration, and levels. These digital biomarkers are created mainly through passive data collection from various sensors. The critical issues with this method are time and sensitivity. We reviewed the newest wireless communication trends employed in hospitals using wearable technology and privacy and Block chain to solve this problem. Based on sensors, this wireless technology controls the data gathered from numerous locations. In this study, the wearable sensor contains data from the various departments of the system. The gradient boosting method and the hybrid microwave transmission method have been proposed to find the location and convince people. The patient health decision has been submitted to hybrid microwave transmission using gradient boosting. This will help to trace the mobile phones using the calls from the threatening person, and the data is gathered from the database while tracing. From this concern, the data analysis process is based on decision-making. They adapted the data encountered by the detailed data in the statistical modeling of the system to produce exploratory data analysis for satisfying the data from the database. Complete data is classified with a 97% outcome by removing unwanted data and making it a 98% successful data classification.

Robust Classification of Cardiac Arrhythmia Using a Deep Neural Network

Machine learning has become increasingly useful in various medical applications. One such case is the automatic categorization of ECG voltage data. A method of categorization is proposed that works in real time to provide fast and accurate classifications of heart beats. This proposed method uses machine learning principles to allow for results to be determined based on a training dataset. The goal of this project is to develop a method of automatically classifying heartbeats that can be done on a low level and run on portable hardware.

Robust Classification of Cardiac Arrhythmia Using a Deep Neural Network

Machine learning has become increasingly useful in various medical applications. One such case is the automatic categorization of ECG voltage data. A method of categorization is proposed that works in real time to provide fast and accurate classifications of heart beats. This proposed method uses machine learning principles to allow for results to be determined based on a training dataset. The goal of this project is to develop a method of automatically classifying heartbeats that can be done on a low level and run on portable hardware.

116 A CASE REPORT OF ISOLATED CARDIAC LIGHT CHAIN AMYLOIDOSIS WITHOUT HEART FAILURE: AN UNDER-RECOGNISED PRESENTATION

Abstract Background Cardiac involvement in light-chain amyloidosis (AL) usually represents a brick in the wall of a multi-system disease. The presence of cardiac deposition of free light chains (FLCs) is the main determinant of survival. Isolated cardiac AL is un uncommon scenario characterised by a challenging diagnostic and therapeutic work-up. Case Summary A 57-year-old asymptomatic man presented for an incidental finding of myocardial necrosis at the ECG performed for newly-diagnosed arterial hypertension. Alongside signs of previous myocardial infarction, transthoracic echocardiography showed a severely increased left ventricular (LV) wall thickness not consistent with ECG voltages, segmental akinesia with normal LV systolic function with ‘apical sparing’ pattern. Laboratory assessment showed an unexpectedly high level of natriuretic peptide and persistently abnormal troponin in the absence of symptoms or signs of heart failure or ongoing ischemia. Coronary angiogram confirmed the coronary artery disease. Before revascularization, a complete diagnostic work-up was carried. Serum electrophoresis detected a monoclonal gammopathy that was further investigated by serum immunofixation, revealing high lambda FLCs concentration. Fat pad, bone marrow and salivary glands biopsies resulted negative for amyloid deposition. Finally, endomyocardial biopsy was consistent with AL amyloidosis. Urgent percutaneous revascularization was performed and the patients was timely started on chemotherapy. Discussion The diagnosis of isolated cardiac AL amyloidosis is challenging and carries important therapeutic implications. As the short-term prognosis might be severely compromised, an accurate diagnostic flow-chart have to be systematically pursued to obtain a precise diagnosis and address the optimal, tailored management.

Transthyretin cardiac amyloidosis in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: a single center experience

Abstract Background Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. Methods Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99mTc-DPD cardiac scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: “ATTR-CA+”: patients with confirmed ATTR-CA at 99mTc-DPD cardiac scintigraphy; “ATTR-CA−”: patients with negative 99mTc-DPD cardiac scintigraphy or a negative RAISE score; c) “ATTR-CA indeterminate”: patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA− patients were compared. Results Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in 6. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA−, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1%. As compared to ATTR-CA− patients, ATTR-CA+ patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, bifascicular block was more common. No difference in procedural outcomes and 1-year mortality was observed between groups. Conclusions Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features may effectively lead to selective 99mTc-DPD cardiac scintigraphy with a satisfactory positive predictive value. Funding Acknowledgement Type of funding sources: None.

Improvement of a convolutional neural network using synthetic ECGs for the diagnosis of different atrial rhythms

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The diagnostic capacity of convolutional neural networks has demonstrated its potential for the diagnosis of different ECG alterations. An important limitation of these networks is that there are classes that are underrepresented in the population, such as the Brugada pattern compared to right bundle branch block or Atrial Flutter (AFL) compared to atrial fibrillation (AF). This asymmetry that exists in any population ECG database is one of the limitations (F1-Score) that could be improved, either with even larger databases (impractical) or by creating synthetic representations of the ECG. Purpose Using a tool that allows the drawing of specific electrocardiographic patterns first and subsequently, the random creation of different ECGs based on said pattern, the diagnostic capacity of any unbalanced convolutional network could be improved. Methods Initially, a database with 95,000 ECGs from our health area was used. From this data set, 5,810 ECGs were taken that were labeled in three classes (1) Sinus Rhythm (SR), 2) AF and 3) AFL by two arrythmologists, 4,637 for training and 1,173 for validation. It was observed that the network was unbalanced (SR: 81.3% of the total, FA: 16.4% of the total and AFL: 2.2% of the total). After having demonstrated the good capacity of the network for the diagnosis of these three atrial rhythms, it was observed that the diagnostic dispersion matrix erred precisely between the ECGs of AF and AFL (figure 1). Based on this idea, it was decided to create a random pattern-based ECG creation tool. Different atrial flutter patterns were created and 2000 ECGs were synthetically created with variations of the ECG frequency, voltages and morphology. A new neural network was subsequently trained with the addition of these ECGs to the original database and its diagnostic capacity was evaluated on the same initial validation set. Results The new network showed a 88,3% sensitivity (vs 82,6%), a 100% specificity (vs 98,5%) and an 92% (vs 87,8%) accuracy. It specially had an improvement in AFL ECGs (70,2% vs 61%) and minor improvements in AF ECGs (90,8% vs 89,4%) and SRs ECGs (100% vs 98,6%) accuracy. Conclusions The creation of synthetic ECGs to improve the diagnostic capacity of neural networks for infrequent events is feasible. This application allows the development of networks applicable in real life, in this case, for the diagnosis of atrial arrhythmias.

P316 TRANSTHYRETIN CARDIAC AMYLOIDOSIS IN PATIENTS WITH SEVERE AORTIC STENOSIS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT: A SINGLE CENTER EXPERIENCE

Abstract Background Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR–CA) remains difficult in this subset. Methods Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR–CA based on clinical assessment underwent 99mTc–DPD cardiac scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR–CA in AS, was retrospectively calculated to rule–out ATTR–CA in the remaining patients. Patients were categorized as follow: “ATTR–CA +”: patients with confirmed ATTR–CA at 99mTc–DPD cardiac scintigraphy; “ATTR–CA –”: patients with negative 99mTc–DPD cardiac scintigraphy or a negative RAISE score; c) “ATTR–CA indeterminate”: patients not undergoing ATTR–CA assessment with a positive RAISE score. The characteristics and outcomes of ATTR–CA + and ATTR–CA – patients were compared. Results Of 107 included patients, ATTR–CA suspicion was posed in 13 patients and confirmed in 6. Patients were categorized as follow: 6 (5.6%) ATTR–CA +, 79 (73.8%) ATTR–CA –, 22 (20.6%) ATTR–CA indeterminate. Excluding ATTR–CA indeterminate patients, the prevalence of ATTR–CA was 7.1%. As compared to ATTR–CA – patients, ATTR–CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, bifascicular block was more common. No difference in procedural outcomes and 1–year mortality was observed between groups. Conclusions Among severe AS patients, ATTR–CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. The procedural and mid–term outcomes following TAVR seems unaffected by ATTR–CA status.

383 ECG in biopsy-proven and clinically suspected myocarditis: morpho-functional correlates and prognostic implications

Abstract Aims A distinction exists between biopsy-proven (BP) and clinically suspected (CS) myocarditis, the latter being an exclusion diagnosis based on clinical and instrumental findings. A clear diagnostic and prognostic role of the ECG in these two groups of patients has not yet been defined. (i) To describe frequency and characteristics of ECG findings in myocarditis, and to assess any difference between CS and BP myocarditis; (2) to identify morpho-functional correlates between ECG and cardiac magnetic resonance (CMR); and (iii) to evaluate the prognostic value of ECG findings. Methods and results 162 patients were included (median age 36 years, 70% male, median follow-up 32.9 months), 36 with BP and 126 with CS myocarditis. All patients underwent CMR; for ECG-CMR correlates, the ECG nearest in time to CMR was assessed. Surrogate outcome was defined as left ventricular (LV) ejection fraction (EF) &amp;lt;50% and/or NYHA class &amp;gt;I during follow-up. In the entire cohort ECG alterations were numerous: T-wave inversion (TWI) (82%), fragmented QRS (34%), low voltages (14%), ST elevation (STE) (13%). Compared to CS myocarditis, BP myocarditis patients showed higher frequency of non-sinus rhythm (17% vs. 2%, P &amp;lt; 0.001), long QT (28% vs. 0%, P &amp;lt; 0.001), lateral TWI (36% vs. 19%, P = 0.031) and bundle branch block (19% vs. 2%, P &amp;lt; 0.001). BP myocarditis patients had worse clinical features at diagnosis: heart failure (64% vs. 6%, P &amp;lt; 0.001), arrhythmic (14% vs. 4%, P = 0.029) and fulminant presentation (14% vs. 0%, P &amp;lt; 0.001), and presented higher LV end-diastolic volume and lower LVEF by echocardiography and CMR (109.5 mL/m2 vs. 85.50 ml/m2, P &amp;lt; 0.001; 31.5% vs. 59%, P &amp;lt; 0.001). A correlation was observed between number of myocardial segments with oedema at CMR and low ECG voltages (P = 0.010) and between late gadolinium enhancement (LGE) mass at CMR and lateral STE (P = 0.004 and P = 0.049, respectively). Several ECG alterations correlated with the surrogate outcome: long QT (P = 0.029), lateral TWI (P = 0.006), left bundle branch block (P &amp;lt; 0.001), ventricular ectopic beats (P = 0.020), and atrial fibrillation (P &amp;lt; 0.001). Conclusions A significant difference in ECG findings between CS and BP myocarditis has been demonstrated: ECG alterations are more frequent and more severe in BP myocarditis and correlate with prognosis. Moreover, ECG alterations identified patients with pathologic morpho-functional correlates.

Abstract 13007: Change in QRS 3D Voltage Time Integral (3D QRS Area) Predicts Left Ventricular Reverse Remodeling in Sacubitril-Valsartan Treated Patients With Left Bundle Branch Block

Introduction: The instantaneous absolute 3D ECG voltage integrated over the duration of QRS (VTI QRS-3D ) is an improved marker of left ventricular (LV) electrical dyssynchrony compared to QRS duration (QRSd). Among patients with left bundle branch block (LBBB) receiving heart failure medical therapy, the relationship between electrical remodeling assessed by VTI QRS-3D and structural LV remodeling is unclear. Hypothesis: Reduction in VTI QRS-3D is correlated with left ventricular reverse remodeling. Methods: We retrospectively studied heart failure patients with underlying LBBB who were treated with sacubitril-valsartan for ≥3 months between January 2014 - June 2019. Echocardiograms and 12-lead ECGs were collected pre and post sacubitril-valsartan treatment. ECGs were converted to orthogonal X, Y, Z leads using Kors matrix, to then obtain VTI QRS-3D . Echocardiographic LV measures included end-diastolic volume (LVEDV), end-systolic volume (LVESV) and ejection fraction (LVEF). We calculated the Pearson correlations between electrical variables and changes in echocardiographic measures pre to post treatment. Results: We included 56 patients (mean age 64.0±13.5 years, men 53.6%, baseline LVEF 25.2±9.1%). ΔVTI QRS-3D was strongly correlated with improvement in all 3 echocardiographic measures (all p ≤0.01). ΔVTI QRS-3D outperformed ΔQRSd in predicting echocardiographic response (Table). Conclusions: In heart failure patients with LBBB on medical therapy, electrical remodeling assessed as reduction in VTI QRS-3D is strongly predictive of LV structural and functional reverse remodeling.

Abstract 13592: QRS 3D Voltage Time Integral (3D QRS Area) is a Predictor for Pacing Induced Cardiomyopathy

Introduction: The instantaneous absolute 3D ECG voltage integrated over the duration of QRS (VTI QRS-3D ), also measured as 3D QRS area, is a marker for left ventricular electrical dyssynchrony in patients with left bundle branch block. Hypothesis: We sought to investigate if VTI QRS-3D predicts pacing induced cardiomyopathy in patients with chronic (&gt;3 months) right ventricular pacing (RVp). Methods: We retrospectively evaluated RVp ECGs from consecutive patients with pacing induced cardiomyopathy (left ventricular ejection fraction ≤50%) and compared to patients with normal ejection fraction (&gt;50%). Patients were excluded if they did not have ECG and/or echocardiogram. 12-lead ECGs were converted to orthogonal X, Y, Z leads using Kors matrix. VTI QRS-3D was obtained by voltage-time-integral from root-mean-squared 3D ECG. Results: We analyzed 320 RVp patients (age 73 ± 14 years, 40% female), 206 with preserved ejection fraction (LVEF 60.4 ± 4.1%) and 114 with pacing induced cardiomyopathy (LVEF 29.2 ± 8.1%). Pacing induced cardiomyopathy was associated with a longer QRS duration, larger QRS voltage and larger VTI QRS-3D (Table). VTI QRS-3D ≥90 μVs had 81% sensitivity to identify pacing induced cardiomyopathy (specificity 47%). Conclusions: In the setting of chronic right ventricle pacing, QRS 3D voltage time integral ≥90 μVs on ECG can be used as a screening tool to identify patients needing further evaluation for cardiomyopathy.

Abstract 9536: Prediction of Drug-Induced QTc Prolongation With an ECG Based Machine Learning Model

Introduction: Initiation of QTc-prolonging medications may lead to the rare but potentially catastrophic event, torsades de pointes (TDP). At present, no adequate, generalizable tools exist to predict drug-induced long QTc (LQT); machine learning from ECG data is a promising approach. Hypothesis: Prediction of drug-induced LQT using an ECG-based machine learning model is feasible, and outperforms a model trained on baseline QTc, age, and sex alone. Methods: We identified baseline 12-lead ECGs with QTc values &lt; 500 ms for patients who had not received any known, conditional, or possible QTc prolonging medication per CredibleMeds at the time of ECG or within the past 90 days. We matched these with ECGs from the same patients while they were taking at least one CredibleMeds drug (“on-drug” ECGs). Using 5-fold cross-validation, we trained and tested two machine learning models using the baseline ECGs of the 92,848 resulting pairs to predict drug-induced LQT (≥500 ms) in the on-drug ECGs: a deep neural network using ECG voltage data, and a gradient-boosted tree using the baseline QTc. Age and sex were also inputs to both models. Results: On-drug LQT prevalence was 16%. The ECG model demonstrated superior performance in predicting on-drug LQT (area under the receiver operating characteristic curve (AUC) = 0.756) compared to the QTc model (0.710). At a potential operating point (Figure), the ECG model had 89% sensitivity and 95% negative predictive value. Even in the subset of patients with baseline QTc &lt; 470/480 ms (male/female; post-drug LQT prevalence = 14%), the ECG model demonstrated good performance (AUC = 0.736). Conclusions: An ECG-based machine learning model can stratify patients by risk of developing drug-induced LQT better than a model using baseline QTc alone. This model may have clinical value to identify high-risk drug starts that would benefit from closer monitoring and others who are at low risk of drug-induced LQT.

Protein Aggregation Is an Early Manifestation of Phospholamban p.(Arg14del)-Related Cardiomyopathy: Development of PLN-R14del-Related Cardiomyopathy.

The p.(Arg14del) pathogenic variant (R14del) of the PLN (phospholamban) gene is a prevalent cause of cardiomyopathy with heart failure. The exact underlying pathophysiology is unknown, and a suitable therapy is unavailable. We aim to identify molecular perturbations underlying this cardiomyopathy in a clinically relevant PLN-R14del mouse model. We investigated the progression of cardiomyopathy in PLN-R14Δ/Δ mice using echocardiography, ECG, and histological tissue analysis. RNA sequencing and mass spectrometry were performed on cardiac tissues at 3 (before the onset of disease), 5 (mild cardiomyopathy), and 8 (end stage) weeks of age. Data were compared with cardiac expression levels of mice that underwent myocardial ischemia-reperfusion or myocardial infarction surgery, in an effort to identify alterations that are specific to PLN-R14del-related cardiomyopathy. At 3 weeks of age, PLN-R14Δ/Δ mice had normal cardiac function, but from the age of 4 weeks, we observed increased myocardial fibrosis and impaired global longitudinal strain. From 5 weeks onward, ventricular dilatation, decreased contractility, and diminished ECG voltages were observed. PLN protein aggregation was present before onset of functional deficits. Transcriptomics and proteomics revealed differential regulation of processes involved in remodeling, inflammation, and metabolic dysfunction, in part, similar to ischemic heart disease. Altered protein homeostasis pathways were identified exclusively in PLN-R14Δ/Δ mice, even before disease onset, in concert with aggregate formation. We mapped the development of PLN-R14del-related cardiomyopathy and identified alterations in proteostasis and PLN protein aggregation among the first manifestations of this disease, which could possibly be a novel target for therapy.

B-PO04-182 CARDIAC RESYNCHRONIZATION THERAPY IN PACING INDUCED CARDIOMYOPATHY - REDUCTION IN QRS 3D VOLTAGE TIME INTEGRAL (3D QRS AREA) PREDICTS ECHOCARDIOGRAPHIC RESPONSE

The instantaneous absolute 3D ECG voltage integrated over the duration of the QRS (VTIQRS-3D), also measured as 3D QRS area, is a marker for left ventricular electrical dyssynchrony in patients with left bundle branch block undergoing cardiac resynchronization therapy (CRT). Among patients with pacing induced cardiomyopathy (PICM), we sought to investigate if the reduction in VTIQRS-3D after CRT is associated with improvement in echocardiographic left ventricle ejection fraction (LVEF). We conducted a retrospective study of all CRT upgrades for PICM at our center from 2014 -2018. ECGs were obtained prior to CRT and within 6 months after CRT. 12-lead ECGs were converted to orthogonal X, Y, Z leads using Kors matrix. VTIQRS-3D was obtained by voltage-time-integral from the root-mean-squared 3D ECG. Echocardiograms were obtained prior to CRT and 3-12 months after CRT. We used linear regression models to evaluate predictors of change in LVEF. We included 114 patients (age 74 ± 11 years, 26% female) who underwent CRT upgrade for PICM. Baseline LVEF was 29.2 ± 8.1% and LVEF improved by 14.0 ± 10.5% with CRT. Increase in LVEF was predicted by larger VTIQRS-3D (p=0.03) but not baseline QRS duration (p=0.2). Further, reduction in both QRS duration and VTIQRS-3D with CRT predicted increase in LVEF (both p=0.03), but only reduction in VTIQRS-3D remained statistically significant in multivariable models. In patients with pacing induced cardiomyopathy, a larger reduction in QRS 3D voltage time integral with CRT upgrade independently predicts a greater echocardiographic response.

Electrocardiographic Versus Echocardiographic Left Ventricular Hypertrophy in Severe Aortic Stenosis.

Although ECG used to be a traditional method to detect left ventricular hypertrophy (LVH), its importance has decreased over the years and echocardiography has emerged as a routine technique to diagnose LVH. Intriguingly, an independent negative prognostic effect of the “electrical” LVH (i.e., by ECG voltage criteria) beyond echocardiographic LVH was demonstrated both in hypertension and aortic stenosis (AS), the most prevalent heart valve disorder. Our aim was to estimate associations of the ECG-LVH voltage criteria with echocardiographic LVH and indices of AS severity. We retrospectively manually analyzed ECG tracings of 50 patients hospitalized in our center for severe isolated aortic stenosis, including 32 subjects with echocardiographic LVH. The sensitivity of single traditional ECG-LVH criteria in detecting echocardiographic LVH was 9–34% and their respective specificity averaged 78–100%. The ability to predict echocardiographic LVH was higher for S-waves than R-waves (mean area under the receiver operating curve (AUC): 0.62–0.70 vs. 0.58–0.65). Among combinations of R- and S-waves, the discriminating ability was highest for the Cornell voltage (AUC: 0.71) compared to the Sokolow–Lyon, Romhilt and Gubner–Ungerleider voltage (AUC: 0.62–0.68). By multiple regression, peak aortic pressure gradient was positively related to the Sokolow–Lyon (β = 1.7 ± 0.5, p = 0.002) and Romhilt voltage (β = 1.3 ± 0.5, p = 0.01), but not Cornell (0.5 ± 0.3, p = 0.2) or Gubner-Ungerleider voltage (β = 0.0 ± 0.5, p > 0.9), regardless of LV mass index. In conclusion, echocardiographic LVH and stenosis severity appear to have distinct associations with traditional ECG-LVH criteria in AS. A moderate diagnostic superiority of the Cornell voltage criterion with regard to anatomic LVH might result from its unique ability to include depolarization vectors in both the frontal and horizontal plane with consequent lesser sensitivity to the confounding effect of obesity.

Cardiac Amyloidosis: Internist and Cardiologist Insight

Cardiac amyloidosis (amyloid cardiomyopathy) is a disease damage to the heart caused by extracellular amyloid deposition. In some cases, there may be local damage to the structures of the heart, for example, the atria; more often, heart damage is part of a systemic (generalized) pathology. Depending on the amyloid precursor protein, 36 types of amyloidosis are described, among which hereditary and acquired forms are distinguished. Cardiac amyloidosis is diagnosed 1) in the case of the amyloid infiltration in the myocardial bioptates or 2) in the case of non-cardiac amyloid deposition and the left ventricular wall thickening &gt;12 mm without arterial hypertension and other reasons. The heart is most often affected in AL-, ATTR-, AA-, AANF-types of amyloidosis. Cardiac amyloidosis should be considered in patients with a heart failure with an unclear etiology, especially with preserved left ventricular ejection fraction, refractory to treatment, with proteinuria and CKD 4-5, in patients with idiopathic atrial fibrillation and conduction disturbances, in patients with left ventricular wall thickening of unclear etiology, low ECG voltage, unexplained arterial hypotension and pulmonary hypertension. Screening for cardiac amyloidosis should include non-invasive methods such as electrophoresis and immunofixation of blood and urine proteins, the free light lambda and kappa chains of immunoglobulins, 99Tc-DPD scintigraphy, genetic testing (if hereditary variants of amyloidosis are suspected), as well as a histological examination of biopsy samples stained with Congo red and polarizing microscopy.

THE RELATION BETWEEN PULMONARY HYPERTENSION MEASURED BY STANDARD TRANSTHORACIC ECHOCARDIOGRAPHY AND T WAVE AND R WAVE ALTERNANS IN ELECTROCARDIOGRAM

Background: While the exact frequency of pulmonary hypertension is unknown, it is estimated that about 1,000 new cases occur a year in the United States. Females are more often affected than males. Onset is typically between 20 and 60 years of age. It was first identified by Ernst von Romberg in 1891.Aim of the work: To determine the correlation between ECG voltage variability and presence & severity of pulmonary hypertension.Patients and Methods: This study was conducted on 80 patients who presented to the outpatient clinic of Ain Shams university hospital and Nasser institute hospital, in the period between May 2019 and March 2020. Patients were divided into 40 patients with pulmonary hypertension (PASP>35 mm Hg) and 40 patients (age and sex matched) with normal pulmonary artery pressure, patients were subjected to full history taking, ECG, laboratory investigations, complete transthoracic Echocardiography.Results: We found that there was no statistically significant difference between both groups as regards the incidence of QT dispersion, T wave alternans and QRS alternans. In addition, there was no statistically significant difference between the degree of pulmonary hypertension and incidence of QT dispersion, T wave alternans and QRS alternans.Conclusion: In the present study we found that there is no significant relation between T wave alternans, R wave alternans and QT dispersion as parameters of ECG voltage variability and PAH. In addition, there is no significant relation between the degree of pulmonary hypertension and the degree of QT dispersion, T wave alternans and QRS alternans.

Speckle tracking echocardiography in patients with stroke

Abstract Introduction Global longitudinal strain (GLS) via speckle tracking echocardiography (STE) has emerged as a quantitative technique to estimate myocardial function and has been shown to have clinical utility in a variety of settings. The use of this technique in patients with a stroke is limited. Purpose Comparative analysis of myocardial deformation indicators in patients with a stroke, depending on the severity and subtype. Results 230 patients with an acute cerebrovascular accident (132 men and 98 women) were included in our study, with the mean age of 64,9±10,8. Transient ischemic attack (TIA) was diagnosed in 39 (17%), acute ischemic stroke (AIS) in 191 (83%) patients. The type of an ischemic stroke in each patient was classified as one of the following traditional stroke subtypes: large-artery atherosclerosis (LAA) was diagnosed in 85 (44,5%), cardioembolic infarcts were diagnosed in 58 (30,4%), lacunar infarcts were diagnosed in 32 (16,8%) and in 16 (8,4%) the stroke was of another determined or undetermined etiology. There was no significant difference in left ventricular (LV) ejection fraction (EF) between the subgroups of TIA and AIS - 63.0% [60.0; 65.0] and 62.0% [58.0; 65.0], respectively. The LV GLS was within normal limits and amounted to 19.9±2.6 in the TIA group where as in the group of patients with stroke there was a significant (p&amp;lt;0.01) decrease in GLS below standard values - 17.1±3.8. The LV EF showed no significant difference between the groups of stroke subtypes. However, a decrease in GLS was found in the series from cardioembolic infarct &amp;gt; lacunar infarct &amp;gt; LAA - 17.5±3.7 &amp;gt; 16.5±6.5 &amp;gt; 16.2±3.2 (p=0,7). A decrease in GLS was significantly more often observed in male patients. A decrease in the level of GLS in patients with a stroke is associated with duration of type 2 diabetes, stroke severity by the National Institutes of Health Stroke Scale (NIHSS) score, ECG voltage criteria for LVH, increase in heart rate, LV mass/BSA, relative wall thickness (RWT) according to echocardiography. Significant differences in GLS from the size of the stroke focus according to CT scanning/ magnetic resonance imaging were not detected. Conclusion GLS via STE in patients with a stroke correlates with the severity of a stroke, the severity of LV remodeling, risk factors for cardiovascular events and requires a further study to assess the long-term prognosis Funding Acknowledgement Type of funding source: None