Echocardiographic Results Research Articles

Prediction of left ventricular ejection fraction improvement in patients with ischemic cardiomyopathy after coronary artery bypass grafting based on cardiac magnetic resonance.

To investigate the risk factors of left ventricular ejection fraction (LVEF) improvement in patients with ischemic cardiomyopathy (ICM) after coronary artery bypass grafting (CABG), and to construct a model that predicts LVEF improvement. A retrospective analysis was performed on 106 ICM patients who received CABG and underwent cardiac magnetic resonance (CMR) at Beijing Anzhen Hospital, Capital Medical University from January 2017 to June 2022. Patients were divided into two groups with improved LVEF and no improved LVEF based on the results of postoperative 6-month transthoracic echocardiography. To analyze the risk factors affecting the LVEF non-improvement after CABG and establish a prediction model. There was LVEF non-improvement in 30.2% (32/106) of patients. Multivariate analysis showed that the number of transmural scar segments and left ventricular end-systolic volume index (LVESVI) were independent risk factors in LVEF non-improvement after CABG [odds ratio (OR) =2.398, 95% confidence interval (CI): 1.607-3.579, P<0.001; OR =1.036, 95% CI: 1.009-1.063, P=0.008]. The model is built and internally verified. ROC showed that the area under the curve (AUC) was 0.866 (95% CI: 0.792-0.940), calibration curve showed that the probability predicted by the model matched well with the clinical results, and decision curve analysis (DCA) showed that the model had good clinical applicability. During the mean follow-up time of 1.5 years, the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in the LVEF non-improvement group was higher (5.4% vs. 25.0%, P=0.009), and the NYHA grading was higher (P=0.016), when compared to the LVEF improvement group. The prediction model based on the number of transmural scar segments and LVESVI has good diagnostic efficacy. Our findings help to identify patients with improved LVEF and thus guide the selection of clinical treatment strategies.

Mitral regurgitation in atrial fibrillation: Is a simple repair enough to tackle a complex problem?

BackgroundClinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. MethodsBetween January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. ResultsValve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4–9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %–62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219–8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. ConclusionsDespite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes.

Increasing detection of heart valve disease in Farnborough Primary Care Network using auscultation artificial intelligence in the community pharmacy setting

Abstract Introduction Cardiovascular disease causes a quarter of all deaths in the UK, making it a top NHS priority1. One such cardiovascular disease, heart valve disease (HVD), is serious with worse outcomes than many cancers2. Yet diagnosed early, before a patient deteriorates, HVD can be treated effectively with valve replacement or repair. A large proportion of patients however are estimated to be undiagnosed or untreated each year in England (≤53% with severe symptomatic aortic stenosis, ≤41% with moderate/severe mitral valve regurgitation, ≤81% with moderate or greater tricuspid valve regurgitation)3. HVD is often detected when GPs identify a heart murmur upon cardiac auscultation. Patients are referred to echocardiography to confirm diagnosis and severity. By using digital stethoscope to perform auscultation, community pharmacists have the potential to assist with and increase the detection of HVD. Aim To determine if community pharmacists can identify undiagnosed HVD using digital auscultation with eMurmur® stethoscope artificial intelligence (AI), and compare subsequent echocardiography referrals against those from GPs. Methods A community echocardiography service and pharmacy within a single PCN were identified based on interest, capacity, and infrastructure to undergo the service evaluation (SE). Pharmacy patients aged &amp;gt;75 years, or with type 2 diabetes, angina/myocardial infarction, atrial fibrillation or high blood pressure, were invited for HVD assessment by the pharmacist. Patients with known HVD or who had an echocardiogram in the past 10 years were excluded. The pharmacist carried out digital stethoscope auscultation and where systolic murmur was detected, patients were referred to a community clinic for full compensation echocardiography. Patient demographic, comorbidity, auscultation, and echocardiography results were collected. Clinic referrals from the community pharmacy were contrasted with referrals from GP practices to compare the number of appropriate referrals over the same period. Results Community pharmacy detected murmur in 39/86 (45%) patients, who were then referred to community echocardiography (mean age 77.8 years). Echocardiography identified: 8 (21%) moderate/severe HVD, 9 (23%) mild HVD, 22 (56%) ‘normal’ or ‘trivial’ HVD. During the SE, 24 referrals were received from GP practices (mean age 65 years): 2 (8%) moderate/severe HVD, 8 (33%) mild HVD, 14 (58%) ‘normal’ or ‘trivial’ HVD. Pharmacy referred 70% more patients with non-trivial HVD than GP practices (17 vs 10 patients). Discussion/Conclusion This SE demonstrates that community pharmacists can identify undiagnosed HVD, in this case referring more patients with non-trivial HVD to echocardiography than GPs. The rapid data sharing enabled by this technology supports quick decision-making for patients with critical disease requiring immediate treatment. Pharmacists can therefore play an important role as a gateway to accessing potentially lifesaving treatment. Patients appeared comfortable attending a digital auscultation service in a community pharmacy setting. Such a proactive service may help reduce the number of people with severe HVD who go undiagnosed and untreated. Limitations of this SE include the small sample size, rendering statistical analysis inappropriate. Additionally, the analysis indicated the number of GP referrals for echocardiography but not how many patients underwent auscultation overall. Therefore we were unable to compare efficiency of murmur detection.

Long-term outcomes, residual symptoms and quality of life in COVID-19 hospitalized patients: A 12-month longitudinal study.

The long-term impact of the coronavirus disease 2019 (COVID-19) pandemic is a critical public health concern. The presence of residual symptoms in COVID-19 survivors has been investigated with various results; however, there is limited data documenting outcomes longer than 6 months post-hospitalization. We aimed to investigate the 12-month lasting effects of COVID-19 in hospitalized patients. From October 2020 through March 2021, 92 patients were enrolled. At admission and 1, 3, 6, and 12 months post-hospitalization, demographic, clinical, laboratory and imaging data, and echocardiography and spirometry test results were recorded. Possible cognitive and functional impairment, as well as the quality of life (QoL), were also assessed. In our cohort (median age: 61 years), 31.5% had severe disease at admission, which correlated with worse laboratory findings and a longer hospital stay (p < 0.001). Inflammatory markers were associated with severity initially, but reverted to normal after 3 months. In total, 55%, 37%, 19%, and 15.5% of patients reported at least one persistent symptom in months 1, 3, 6, and 12, respectively, while "brain fog" persisted up to 12 months in 10% of patients. Spirometry and echocardiography tests returned to normal in most patients during the evaluation, and no one had substantial residual disease. Our study provides insight into the long-term effects of COVID-19 on patients' physical and mental health. Despite the lack of significant residual disease or major complications after a year of thorough follow-up, COVID-19 survivors experienced lasting symptoms and a negative impact on their QoL.

Complimentary Cardiac Computed Tomography Ventricular Volumetry-Derived Metrics of Severity in Patients with Ebstein Anomaly: Comparison with Echocardiography-Based Severity Indices.

Detailed three-dimensional cardiac segmentations using cardiac computed tomography (CT) data is technically feasible in patients with Ebstein anomaly, but its complementary role has not been evaluated. This single-center, retrospective study was aimed to evaluate the complementary role of cardiac CT ventricular volumetry in evaluating the severity of Ebstein anomaly. Preoperative cardiac CT ventricular volumetry was performed in 21 children with Ebstein anomaly. CT-based ventricular functional measures were compared between Carpentier types, and between definitive surgical repair types. The Celermajer severity index measured with echocardiography was correlated with CT-based functional parameters. Total right ventricle (RV) and functional RV (fRV) volumes, fRV fraction, fRV/left ventricle (LV) volume ratio, and end-diastolic CT severity index demonstrated statistically significant differences between Carpentier type A/B and Carpentier type C/D (p < 0.05). The Celermajer severity index measured with echocardiography showed a high positive correlation with the end-diastolic CT severity index (R = 0.720, p < 0.002). There were no statistically significant differences in both echocardiography- and CT-based functional measures between patients with biventricular repair and patients with one-and-a-half or univentricular repair (p > 0.05). Compared with echocardiography, cardiac CT ventricular volumetry can provide the severity of Ebstein anomaly objectively and may be used in select patients when echocardiographic results are inconclusive or inconsistent.

Sex-Related Differences in the Prevalence of Classical, Non-Classical Risk Factors and Management of the Chronic Coronary Syndrome

(1) Background: Coronary artery disease (CAD) remains the leading cause of death in both sexes. The male sex is considered a classical atherosclerosis risk factor, whereas females should be protected by hormonal effects until menopause. Although there are known differences in the development, type, and prognosis of chronic coronary syndrome (CCS) between both sexes, there are no differences in approach in the guidelines. (2) Methods: The sex-related differences in CAD risk factors, treatment, echocardiographic, and angiographic results were assessed among 3291 patients with CCS. (3) Results: Women were older and had a higher prevalence of hypertension, dyslipidaemia, and diabetes mellitus than men. Women were more often treated conservatively than men. There was no difference in the use of beta-blockers and statins among the sexes. The LDL cholesterol goal was less frequently reached by women. Women were treated less often with aspirin than men, but they were treated more often with angiotensin receptor blockers than men. The left ventricle ejection fraction was higher among females. The number of obstructed vessels was higher in men. (4) Conclusions: Women may be more exposed to the risk factors of CAD than men. Men are diagnosed with CAD earlier, and their prevention and therapy are more efficient.

Late clinical and echocardiographic results with the Magna Ease© pericardial aortic bioprosthesis.

The population of candidates to surgical aortic valve replacement (SAVR) is evolving. The Perimount Magna Ease© bioprosthesis has been introduced relatively recently in the practice. We aimed at evaluating its long-term results. This article describes a single-centre cohort of 1016 consecutive SAVRs with the Magna Ease© valve (2008-2014), consisting of an all-comers population. We performed a prospective collection of in-hospital data, systematic clinical and echocardiographic follow-up. Valve-related events were as follows: structural valve deterioration (SVD; according to modified definition criteria), nonstructural valve dysfunction, patient-prosthesis mismatch (PPM). Age at SAVR was 73.4 ± 9.5 years; calcified aortic stenosis was the indication to surgery in 59.6%. A total of 974 patients entered the follow-up; 564 were alive at the last follow-up (median duration: 9.8 years) (up to 13.4 years). New York Heart Association class was I or II in 92.1%. Overall survival at 10 years was 56.8 ± 1.8%. Freedom from SVD at 10 was 96.5 ± 0.8% (Kaplan-Meier) and 97.4 ± 0.6% (competing risks) (28 SVD events after 6.9 ± 3.3 years). There were 15 reinterventions for SVD (redo-SAVR and Transcatheter Aortic Valve Implantation (TAVI)); 10-year freedom from reintervention was 97.8 ± 0.6%. Moderate and severe PPM occurred in 26.8% and 5.4%, respectively, without association with late mortality (P = 0.12 for moderate and P = 0.70 for severe PPM). Freedom from valve-related mortality was 97.8 ± 0.5% at 10 years. In this follow-up of the Magna Ease bioprosthesis for SAVR, data indicate good late outcomes (30-day outcomes are excluded). Continued follow-up is required to further support its use in patients with life expectancy >10-12 years.

Digitalization of ECG in optimization of diagnostics of acute and chronic coronary syndromes

The aim is to study the additional diagnostic possibilities of indicators obtained by digitalization of ECG in patients with ST-elevation myocardial infarction (STEMI) and stable angina (SA).Material and methods. 135 patients were examined, who were divided into groups depending on the diagnosis: 45 people with STEMI and 90 patients with SA. According to the value of the first derivative of the T wave - the maximum speed ratio (MSR) indicator, patients with STEMI were divided into two groups: group I included 25 people with MSR &lt;0.66, group II - 20 patients with MSR ≥0.66. Patients with SA were also distinguished depending on MSR: group A included 41 patients with MSR &lt;0.87 and group B - 49 patients with MSR ≥0.87. The results of echocardiography, Holter ECG monitoring, coronary ventriculography and digitalization of ECG based on the «Smart-ECG» medical software were evaluated.Results. In the STEMI group, significantly lower MSR values of ischemic zone were noted, compared to the group of patients with SA (0.65±0.02, Δ –25.29%, p&lt;0.001), higher STH values in ischemic zone (0.76±0.04 mm, Δ +58.33%, p&lt;0.001), lower left ventricular ejection fraction (LVEF) (51.96±1.21 %, Δ -9.82%, p&lt;0.001), longer ischemia (919.00 (133, 00; 1310.00) min, Δ +3729.17%, p&lt;0.001), lower standart deviation values of N-N intervals (SDNN) (88.11±6.65 ms, Δ -20.88%, p=0.094). Individuals with SA and MSR &lt;0.87 showed slightly higher values of MSR in lead V2, compared to the group of SA and MSR ≥0.87 (2.51±0.08, Δ +8.19%, p=0.058). In patients with STEMI and MSR &lt;0.66 and with SA and MSR &lt;0.87, compared to the group with STEMI and MSR ≥0.66 and with SA and MSR ≥0.87, lower LVEF were detected (respectively (52.00 (47.75; 55.00) %, Δ -10.34%, p=0.071) and (56.73±0.83%, Δ -3.14%, p=0.088).Conclusions. Primary changes in the repolarization phase, which are inherent for patients with STEMI and SA, cause a change in the speed parameters of the differentiated ECG – reducing of MSR (more intense for patients with STEMI), which indicates a pronounced electrical disbalance of the ischemic myocardium. Lower values of MSR result in worse clinical and functional characteristics of the myocardium for STEMI and SA and are associated with negative prognostic markers of ischemia.

Midterm outcomes of aortic valve replacement using a rapid-deployment valve for aortic stenosis: TRANSFORM trial

BackgroundThe use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory–adjudicated data are scarce, however. Here we report final 7-year data on RDV use. MethodsTRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory–adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years. ResultsThe mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm2, respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years. ConclusionsAVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.

Personalized cardiac resynchronization therapy guided by real-time electrocardiographic imaging for non-left bundle branch block patients

Abstract Background Heart failure patients with non-left bundle branch block (non-LBBB) QRS pattern have limited response rate to biventricular pacing (BVP). Objective A personalized cardiac resynchronization therapy (CRT) implantation approach guided by real-time electrocardiographic imaging (ECGi) was studied. Methods Twenty patients with left ventricular ejection fraction (LVEF) ≤35%, QRS duration ≥120ms and non-LBBB (13 right bundle branch block and 7 intraventricular conduction delay) were recruited. During CRT implantation, right atrial, right ventricular, coronary sinus, His-bundle and/or Left-bundle leads were inserted. The total activation time (TAT) with different pacing combinations were measured real-time during implantation by ECGi. The configuration producing shortest TAT would be chosen. Clinical response was defined as ≥1 New York Heart Association (NYHA) class improvement. Echocardiographic response was defined as LV end systolic volume reduction ≥15% and/or LVEF improvement ≥10% at 6-months. Results After ECGi guided CRT implantation, LVEF improved from 26±6% to 34±11% (both p&amp;lt;0.01) and NYHA class improved from 3.0±0.5 to 2.0±0.6 (p&amp;lt;0.01). Both clinical and echocardiographic response rates were 70%. ECGi approach resulted in better acute electrical resynchronization over BVP as measured by TAT reduction (40% vs 14%, p&amp;lt;0.01). Percentage of TAT reduction was found to be a strong predicator for echocardiographic response (AUC for ROC curve 0.91, 95% CI 0.78 – 1.00). A strong positive correlation between percentage TAT reduction and percentage LVEF improvement (Pearson R 0.70, p=0.001) was found. Conclusions ECGi guided CRT implantation in non-LBBB patients generates superior acute electrical resynchronization compared with BVP and is associated with favorable clinical and echocardiographic outcomes.

Left bundle branch area pacing in patients with CRT indication: short-term results &amp; 1-year follow-up

Abstract Background Cardiac resynchronization therapy (CRT) using bi-ventricular pacing is class I recommendation for symptomatic patients with heart failure (LVEF ≤35%), QRS duration ≥150 msec and LBBB QRS morphology. Left bundle branch area pacing (LBBAP) has been reported as an alternative option for CRT. The aim of this study was to assess the feasibility and outcomes of LBBAP in patients eligible for CRT. Methods Patients with CRT indications were subjected to LBBAP. Peri-procedural outcomes &amp; QRS duration were recorded. Changes in New York Heart Association (NYHA) class, need for HF hospitalization, echocardiographic data, lead-device parameters were evaluated at follow-up. HF status was assessed by clinical (no HF hospitalization and improvement in NYHA class) and echocardiographic response (≥5% improvement in LVEF). Results LBBAP was attempted in 16 patients (mean age 59.3 ±7.04 years, 37.5% women, ischemic cardiomyopathy in 33.3%). All patients had baseline LBBB. Pacing threshold and R-wave amplitudes were 0.8 ± 0.3 V at 0.5 ms and 12.1 ± 3.5 mV at implantation and remained stable during mean follow-up of 11.25 ± 3.7 (Range 6-18) months. LBBAP resulted in significant QRS narrowing from 147.5 ± 9.7 to 116 ± 10.2 ms (p &amp;lt; 0.01). LVEF improved from 28.2 ± 2.8% to 38.9 ± 5.1% (p &amp;lt; 0.01). Clinical and echocardiographic improvement was observed in 77% and 74% of patients, respectively. Conclusions LBBAP is feasible, safe and effective. It provides an alternative option for CRT. LBBAP provides low and stable pacing thresholds and is associated with improved clinical and echocardiographic outcomes.

Epicardial fat can predict the in-atrial thrombus in patients with atrial fibrillation

Abstract Background Thromboprophylaxis is important in the management of patients with atrial fibrillation. Epicardial adipose tissue (EAT) is involved in the formation of the pre-thrombotic state. However, the potential of EAT in predicting the risk of thromboembolism in atrial fibrillation remains unknown. Objective To study the imaging features of EAT and its potential in predicting the risk of in-atrial thrombus in atrial fibrillation. Methods Patients were divided into the group with (thrombus group) and without (non-thrombus group) intra-atrial thrombosis according to the results of transesophageal echocardiography (TEE). The EAT volume, mean EAT density and EAT volume/whole heart volume ratio measured on coronary artery CT angiography (CA-CTA) were compared between the two groups. Result A total of 347 atrial fibrillation patients undergoing both TEE and CA-CTA were included and 38 cases were complicated with in-atrial thrombus. Using quartile values, EAT volume, mean EAT density, the ratio of EAT volume/whole heart volume are divided into four grades according to the values. By analyzing the ROC curve and comparing the area under the curve of AUC, EAT volume and EAT volume/whole heart volume ratio show potential diagnostic value in predicting the risk of in-atrial thrombus in atrial fibrillation. In addition, 38 cases without in-atrial thrombus were included in the non-thrombotic group after matching the propensity score by age and gender. On multivariate analysis, patients in the thrombus group had the larger EAT volume (P=0.000, P&amp;lt;0.05) and higher ratio of EAT volume/whole heart volume ratio (P=0.004, P&amp;lt;0.05) when compared with patients in the non-thrombotic group, but there was no difference of mean EAT density (P=0.224, P&amp;gt;0.05) between the two groups. On logistic regression analysis, patients in the thrombus group had the larger EAT volume when compared with patients in the non-thrombotic group (P=0.003, P&amp;lt;0.05). Conclusions EAT may be a potential marker in predicting the risk of in-atrial thrombus in atrial fibrillation. However, much more efforts and testing would be needed before our conclusion could be tried in other people and to elucidate pathogenic mechanisms of EAT.Figure 1Epicardial fat measuremeFigure 2ROC curve

Right and left atrial echocardiographic parameters and outcome in patients with atrial fibrillation

Abstract Background Atrial remodeling in atrial fibrillation (AF) can be evaluated by measuring atrial dimensions, volumes, or function, in the left atrium (LA) but right atrial (RA) changes are often neglected. Purpose The aim of the analysis was to evaluate the power of LA and RA parameters in predicting a composite endpoint (CEP) of all-cause death, any thromboembolism, any acute coronary syndrome, and hospitalization for new or worsening heart failure. Methods From March 2016 to December 2021, patients with ECG-documented AF within 1 year were prospectively enrolled. We retrieved echo data by reviewing clips and collected clinical and laboratory data. Patients were followed up after 1 month and every 6 months thereafter unless clinically relevant events occurred. We considered left and right atrial antero-posterior diameter (iLAAPD, iRAAPD), left and right atrial volume (LAVI, RAVI), left and right atrial sphericity index (LASI, RASI), right and left atrial emptying fraction (RAEF, LAEF). Volumes and diameters were indexed by body surface area. Echo parameters were collected according to the 2015 recommendations of the American Society of Echocardiography. Results We enrolled 489 patients, 300 males (61.3%), median age 75 (IQR 66-80) years, median CHA2DS2VASc 3 (2-5), median HAS-BLED 1 (1-2). Four-hundred fifty-one (92.2%) patients were anticoagulated. Eighty-seven patients (17.8%) had a paroxysmal AF, 141 (28.8%) a persistent AF, 198 (40.5%) a permanent AF, and 63 (12.9%) a first-detected AF. After a median follow-up of 1114 (392-1384) days, 129 (26.3%) achieved the CEP. LAEF &amp;lt; 28% and iRAAPD ≥ 44 mm/m2 showed better sensitivity (respectively 72% and 73%) while iLAAPD and LAVI showed better negative predictive values (both 81%). At multivariable Cox regression analysis (adjusted for CHA2DS2VASc, AF type, and pattern of anticoagulation), building one model for every echocardiographic parameter, LA dimension, volume and function were associated with a higher risk of worse outcome (LAAPD &amp;gt; 22 mm/m2 HR 1.78; 95%CI 1.24-2.57; LAVI ≥ 42 ml/m2 HR 1.50 95%CI 1.03-2.19; LAEF &amp;lt; 28% HR 1.74 95%CI 1.21-2.48) while RASI, LASI, and RA parameters (except for iRAAPD ≥ 44 mm/m2: HR 1.65; 95%CI 1.10-2.47) were not. Comparing those models with a null one (i.e. variables used for adjustments) using the likelihood ratio test, the above-mentioned models demonstrated a significant improvement in predicting the risk of CEP (iLAAPD p=0.0018; LAVI p=0.0347; LAEF p=0.0028; iRAAPD p=0.0148). Visual analysis of multivariable restricted cubic splines regression graphs confirmed iLAAPD and LAVI as the only atrial parameters that refined risk prediction, with their lower limits of CI exceeding the 1 HR line at reference points (Figure). Conclusions In patients with AF, LAVI and iLAAPD allow better discrimination and risk prediction for the composite outcome, while sphericity indexes and most of the RA parameters do not provide adequate predictionFigure

Three-year outcomes following transcatheter versus surgical aortic valve replacement in younger, low surgical risk patients with severe aortic stenosis

Abstract Background/Introduction Prior randomized studies in patients with severe aortic stenosis at low risk for surgery have shown comparable 3-year outcomes with transcatheter aortic valve implantation (TAVI) and surgery. Less is known about the intermediate term outcomes in younger (&amp;lt;75 years) patients at low risk for surgery treated with TAVI or surgery. Purpose To compare 3-year clinical outcomes in younger (&amp;lt;75 years) patients with severe aortic stenosis and low risk for surgery randomly assigned to TAVI or surgery. Methods The Evolut Low Risk randomized trial treated 1414 patients at low surgical risk with a supra-annular, self-expanding TAVI or surgery. Patients less than 75 years of age were selected for this analysis. The primary endpoint was the 3-year occurrence of all-cause mortality or disabling stroke (Kaplan-Meier estimates). Serial echocardiographic outcomes were also compared through 3-year follow-up. Results 703 younger (mean age, 69 years) low-surgical risk (STS PROM, 1.6%) aortic stenosis patients were treated with TAVI (N=352) and SAVR (N=351). At 3 years, the primary endpoint of all-cause mortality or disabling stroke was not different between TAVI (5.7%) or surgery (8.0%, p=0.241). TAVI was associated with lower incidence (0.6%) of disabling stroke compared with surgery (2.9%, p=0.019) and atrial fibrillation (13.3%) compared with surgery (36.4%, p&amp;lt;0.001) while surgery was associated with lower incidence of pacemaker implantation (7.1%) compared with TAVI (21.0%, p&amp;lt;0.001). Valve reintervention rates were low in both groups (1.5% with TAVI; 1.5% with surgery, p=0.962). Mean aortic gradients were significantly lower with TAVI (9.7 mmHg) compared with surgery (12.9 mmHg, p&amp;lt;0.001) and effective orifice areas were significantly larger with TAVI (2.2 cm²) compared with surgery (1.9 cm², p&amp;lt;0.001). There were no differences in the rates of residual moderate or greater paravalvular regurgitation (TAVI: 1.1% and surgery: 0.4%, p=0.626). Conclusion(s) Low risk patients less than 75 years age who underwent TAVI with a supra-annular, self-expanding TAVI had comparable clinical and haemodynamic outcomes with surgery through the 3-year follow-up; additional study through 10 years in these low risk patients is ongoing.

Association between epicardial adipose tissue volume and follow-up echocardiographic outcomes in patients with acute coronary syndrome

Abstract Background The epicardial adipose tissue (EAT) plays important physiological and pathological roles in the regulation of myocardial function. Among obese patients, the development of inflammatory EAT precipitates myocardial dysfunction and heart failure. Recent studies highlighted the possible divergent role of EAT in the pathophysiology of heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, the effect of EAT on left ventricular remodelling among patients with acute coronary syndrome (ACS) remains unclear. Purpose According to the previous our study, patients with ACS had a higher EAT volume. This study evaluated the association of the EAT volume with left ventricular ejection fraction (LVEF) changes over time among patients with ACS. Method This prospective single-centre study selected 197 consecutive Japanese patients, who were hospitalised for ACS between June 2011 and November 2014. Among them, 143 (120 males, 23 females, mean age 64±12 years) patients underwent follow-up with serial echocardiograms. The EAT volume was measured using a multi-slice computed tomography in the hospital. Echocardiography was performed during their hospitalization and follow-up examinations for the next 3 (mean 3.2±1.8) years. They were divided into three groups according to the LVEF: HFrEF, heart failure with mildly reduced ejection fraction (HFmrEF), and HFpEF. Results No correlation existed between the EAT volume at the onset of ACS and LVEF during the follow-up (r=0.033, p=0.695). The peak creatine phosphokinase at ACS onset exhibited the strongest correlation with chronic ejection fraction (r=-0.512, p&amp;lt;0.01). In the chronic phase, the patients with HFrEF had the highest EAT volume (HFrEF, 134±38 ml; HFmrEF, 102±35 ml; and HFpEF, 120±51 ml; p=0.042). However, there was no correlation between the EAT volume and LVEF changes during the follow-up (r=-0.058, p=0.518) (Figure 1). The change in LVEF was not statistically significant among the three groups (HFrEF -4.8±11 %, HFmrEF -1.2±10 % and HFpEF 0.1±9 %, p=0.156). Among patients with chronic HFmrEF and HFpEF, the EAT volume was positively correlated with the body mass index (r=0.373, p=0.029 and r=0.453, p&amp;lt;0.01, respectively). This correlation was not found in patients with chronic HFrEF (Figure 2). Conclusion There was no association between the EAT volume and improvements in LVEF after a follow-up period of 3 years among patients with ACS. Patients with chronic HFrEF had a significantly higher EAT volume despite having a non-obese body mass index. Non obese ACS patients with increased EAT may be prone to HFrEF in the chronic phase.Figure 1Figure 2

Targeting liver angiotensinogen using a GalNAc-siRNA improves cardiac remodeling in spontaneously hypertensive rats

Abstract Background Dysregulation of the Renin-Angiotensin-Aldosterone System (RAAS) leads to hypertension and cardiac hypertrophy. Angiotensinogen (AGT) is the only precursor of all angiotensin peptide products. Liver-specific AGT silencing has been proven to be a promising treatment option in lowering blood pressure (BP) in patients, characterized by full RAAS inhibition and little RAAS escape phenomena. However, the long-term effects of AGT knockdown on cardiac remodeling is still unclear. Purpose To explore the long-term effects of a GalNAc-conjugated siRNA drug R0797070 on AGT inhibition, BP and cardiac functions in Spontaneously Hypertensive Rats (SHRs). Methods In vitro inhibitory activities of siRNAs were assessed in primary rat hepatocytes. The selected siRNA was conjugated with GalNAc based on RIBO-GALSTAR liver targeting system and named R0797070. In vivo effects of repeated doses of R0797070 were evaluated in SHR model. The animals were treated with R0797070 (3 mg/kg, every 8 weeks; subcutaneous injection) or PBS (5 ml/kg, every 8 weeks; subcutaneous injection) for 7 months with the first dose (day1) at the 3 months of age. Captopril (100 mg/kg per day; oral administration) was taken as a positive drug control and Wistar rats were used as normotensive control group. Blood pressure was monitored by tail-cuff method after an initial acclimatization training period. Serum AGT protein was measured by ELISA and liver mRNA expression was detected by qPCR. Echocardiography was used to determine the changes of cardiac morphology and functions，and wheat germ agglutinin (WGA) staining was used to measure myocyte cross-sectional size. Results R0797070 showed 90-99% inhibitory activities on hepatic AGT mRNA at different doses. In SHRs, a single dose of R0797070 at 3 mg/kg resulted in a maximum inhibition of 97% for serum AGT protein with 27 mmHg mean blood pressure (MBP) reduction on Day 15. Daily administration of Captopril could reduce MBP by 33 mmHg on average, while the duration of drug efficacy of R0797070 could reach 2 months with the average 25 mmHg MBP reduction. At the end of study, the echocardiographic results showed that R0797070 significantly reduced left ventricular hypertrophy in the 10-month-old SHRs. Consistently, R0797070 treatment reduced the heart weight by 10%，and LV myocyte size by 17%. Conclusion We showed the long-term effects of a GalNAc-siRNA R0797070 on silencing angiotensinogen expression, reducing blood pressure and left ventricular hypertrophy. Compared to daily oral administration of Captopril and its effect on blood pressure R0797070 demonstrated significant effect on cardiac hypertrophy.Figure 1Figure 2

Left atrial functional changes and its predictive value in the early period after cryoballoon ablation for paroxysmal atrial fibrillation

Abstract Introduction/Purpose In patients with paroxysmal atrial fibrillation (PAF), functional changes are observed in the left atrium (LA) after the pulmonary vein isolation (PVI) procedure. Although previous studies have investigated the altered mechanical functions of the LA with radiofrequency (RF) ablation, changes in the LA functions in the early period after cryoablation (CB-2) and the relationship between early period serial echocardiographic follow-ups after cryoablation and recurrence of atrial fibrillation/atrial tachycardia (AF/AT) have not been clearly demonstrated. This study aims to determine changes in the mechanical functions of LA in patients with PAF during the early period after cryoablation and whether these changes are effective in predicting the risk of recurrence by using echocardiographic parameters including Doppler and strain parameters. Methods Consecutive seventy-seven patients (mean age: 57.5±11.2 years; 57% men) with PAF underwent CB-2 and were prospectively analyzed. All patients were in sinus rhythm before and after the procedure. The LA dimensions, the LA reservoir strain (LASr), the LA atrial contractile strain (LASct), the LA conduit strain (LAScd) and left ventricular diastolic function parameters were evaluated by Doppler echocardiography before and 3 months after the procedure. Patients were monitored with 48-hour Holter at 1-3-6-12th months after the procedure to evaluate for recurrence. Results Acute procedural success was achieved in all cases. No major complications were observed. LASr and LASct showed significant recovery after the procedure (28.3±12.8% vs 34.6±13.8%, p&amp;lt;0.001 and -10.8±7.9% vs -13.9±9.3%, p=0.014 respectively). No significant change was demonstrated in other echocardiographic parameters. During the one-year follow-up after the procedure late recurrence (&amp;gt;3 months) of AF/AT was observed in 9 (11.7%) patients. Although the power of echocardiographic parameters in predicting recurrence was found to be not statistically significant, a downward trend especially in the values of LASr (p=0.068) and LASct (p=0.058) was observed at the 3rd month control echocardiographic results in patients with recurrence. Conclusion Significant improvement in mechanical functions may occur even in the early period after cryoballoon ablation in patients with PAF. In addition, as our study points out strain parameters, indicators of mechanical function tend to decline in patients with late term recurrence.

Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure

The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Ross procedure. The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. isrctn.org Identifier: ISRCTN03530985.

Abstract 16791: Conduction System Response to Cardiac Resynchronization Therapy

Background: Cardiac resynchronization therapy (CRT) can be an effective treatment for cardiomyopathy patients with intraventricular conduction delay. However, significant controversy remains over the effect of QRS duration shortening on CRT outcomes. We hypothesize that reduction in QRS duration following CRT implantation is associated with echocardiographic outcomes. Methods: We included all adult patients with structural heart disease and CRT followed at UCLA. We reviewed all available electrocardiograms (ECG) and echocardiograms. We excluded patients with CRT for complete heart block, congenital heart disease, and those without intrinsic QRS ECGs prior to CRT. Patients were categorized as left bundle branch block (LBBB) if Strauss criteria were met prior to CRT implantation. Other patterns (including right bundle branch block with QRS duration ≥150ms) were classified as IVCD. We evaluated QRS duration before and immediately after CRT implantation. Changes in QRS duration post-CRT implant were calculated in percentage change. Echocardiograms were evaluated for changes in left ventricular end diastolic dimension (LVIDD) and ejection fraction (LVEF) following CRT implantation. Results: We included 108 patients (mean age of implant 66.1±12.8 years, 65% male, 63% nonischemic cardiomyopathy). Of these, 44 patients (41%) had LBBB. After CRT, patients with LBBB had significant decrease in QRS duration (-9.3±17.0% vs +16.9±30.9%, p &lt; 0.001), improvement in LVEF (12.1±10.5% vs 1.85±10.7%, p &lt; 0.001) and reduction in LVIDD (-0.6±0.7cm vs 0.1±0.7cm, p &lt; 0.001) compared to patients with IVCD. Decrease in QRS duration was significantly correlated with both improvement in LVEF (Pearson r = 0.21, p = 0.037) and reduction in LVIDD (Pearson r = 0.28, p = 0.006). Conclusion: CRT resulted in significantly larger decrease in QRS duration amongst patients with LBBB compared to IVCD. QRS duration reduction was, in turn, significantly correlated with improvements in LVIDD and LVEF. This likely reflects the proximal nature of true LBBB, and the ability of CRT to utilize the remaining distal Purkinje system for impulse propagation. Further research on the electrical and mechanical response to CRT can help guide optimization of target populations.

Abstract 13402: Outcomes of Cardiac Resynchronization Therapy in Ischemic versus Non-Ischemic Cardiomyopathy: A Patient-Level Meta-Analysis of 7 Randomized Clinical Trials

Background: Data on whether CRT results in better clinical and echocardiographic outcomes in patients with NICM versus patients with ICM are conflicting. Objective: To determine if there are differences in clinical and echocardiographic outcomes of CRT in patients with ICM versus NICM. Methods: We analyzed patient-level data from 7 CRT trials (MIRACLE, MIRACLE-ICD, MIRACLE-ICD II, COMPANION, RAFT, MADIT-CRT, REVERSE) using Bayesian Hierarchical Weibull survival regression modeling, adjusted for baseline characteristics and presence of an ICD, to determine the effect of etiology of cardiac dysfunction on time to all-cause mortality alone and in combination with heart failure hospitalization (HFH). Kaplan-Meier (KM) survival curves were developed with unadjusted frequentist analyses. Linear regression was used to assess the effect of etiology of cardiomyopathy on echocardiographic measurements. Results: Of the 6252 patients included, 1535 (25%) were women, the median age was 66 (IQR 58-73), 3704 (59%) had ICM, and 3778 (60%) received CRT. Of those who received CRT, 2207 (58%) patients had ICM. Overall, CRT increased the time to HFH or death (hazard ratio (HR) 0.67, 95% credible interval (CrI) 0.56-0.82, p&lt;0.001) with no difference by etiology (HR ratio 1.06, CrI 0.87-1.29, p=0.57). CRT increased the time to death (HR 0.71, CrI 0.55-0.93, p=0.019) with no difference by etiology (HR ratio 1.06, CrI 0.80-1.43, p=0.70), although overall event rate was higher in ICM. CRT in ICM increased the median survival and time free of HFH (70 versus 50 months, p=0.0015) and had borderline effect in NICM (p=0.05) (Figure). Echocardiographic data that were available for 2430 (39%) patients showed that CRT improvements in LVEF, LVEDD, and LVESD were larger for patients with NICM. Conclusion: CRT increased the time to HFH or death independent of etiology of cardiac dysfunction. However, CRT led to greater increases in LVEF and reductions in ventricular dimensions for patients with NICM.