Echocardiography Testing Research Articles

Abstract 9447: The Clinical Penetrance of the Transthyretin V122I Variant in Older Black Patients With Heart Failure: The Screening for Cardiac Amyloidosis With Nuclear Imaging in Minority Populations Study

Introduction: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed cause of heart failure (HF) among patients aged > 60 years. While the V122I variant that is associated with hereditary ATTR-CM is present in 3.4% of self-identified Black individuals in the US (or 1.5 million people), the phenotypic penetrance of this allele remains incompletely defined owing to age-dependent expression and limited methods for disease ascertainment. Methods: The Screening for Cardiac Amyloidosis with Nuclear Imaging in Minority Populations (SCAN-MP) study is a currently accruing multisite cohort designed to determine the prevalence of ATTR-CM using Tc-99m-Pyrophosphate imaging in older (age > 60 years) Black and Hispanic individuals with HF. TTR genotype is determined by 4-exon targeted PCR, while functional, biochemical, and echocardiographic testing is performed. Data are presented here as an interim analysis performed using Kruskal-Wallis testing for the first 240 self-identified Black participants. Results: The prevalence of V122I was 6.7% (n=16 carriers of whom 7 had ATTR-CM), yielding a phenotypic penetrance of 44% (95% CI 20%, 70%) at a median age of 82 (IQR 74, 85) years. Allele carriers with ATTR-CM (Group 3) were older and more likely male, with lower 6-minute walk distance and LVEF, when compared to carriers without ATTR-CM (Group 2, Table) or wild-type, non-amyloid HF controls (Group 1). Other functional, biochemical, and echocardiographic parameters were predictably different between Group 3 and the other groups but similar between Groups 1 and 2 except for prealbumin levels (Group 1: 25 mg/dl vs. Group 2: 20.5 mg/dl, p < 0.05). Conclusion: The clinical penetrance of V122I among elderly Black individuals with HF and a median age of 82 years was 44%, suggesting that genotype alone is insufficient to infer ATTR-CM as the cause of HF in this clinical context. Prealbumin concentration may be useful to identify ATTR-CM in V122I carriers.

Abstract 15365: The Regulatory Role of Sirtuin 6 in Diabetic Cardiomyopathy

Introduction: DCM is a complex disease with many possible causes and multifactorial pathophysiology, but its underlying mechanisms are poorly understood, and no specific therapeutic guideline has yet been established. Increasing evidence suggests that coronary microvascular dysfunction (CMD) might be one of the primary mechanisms in DCM development. CMD is characterized by impaired endothelial-dependent vasodilation, but detailed mechanisms have yet to be elucidated. Sirtuin 6 (Sirt6) has been implicated in obesity, insulin resistance, type 2 diabetes mellitus, and cardiovascular diseases. Sirt6 protects EC from premature senescence, oxidative stress, and atherosclerosis by sustaining high eNOS levels and preserving cell replication. How Sirt6 regulates coronary microvascular function remains to be determined. Methods: Inducible Sirt6 global knockout, endothelial-specific knockout, and wild-type (WT) mice were fed a diet high in fat and sugar (HFHS), and blood lipid and glucose were measured. Coronary arteries were isolated, and endothelial-dependent vasodilation (EDD) was assessed using myography (DMT). Echocardiography and treadmill exercise exertion tests were performed to evaluate cardiac function. Myocardial blood flow (MBF) was measured by doppler. Cardiac fibrosis was detected using trichrome staining, and molecular pathways were elucidated via gene and protein analysis. Results: Our preliminary data show that Sirt6 was downregulated in diabetes. The EDD of coronary arterioles Sirt6 global knockout and endothelial-specific knockout treated with HFHS was impaired, and the mediator of coronary vasodilation switched from NO to H 2 O 2 in the Sirt6 knockout mice. Compared to the WT mice, myocardial blood flow was decreased, ejection fraction (EF) was not changed, the running distance was reduced, and E/E’ ratio was increased in Sirt6 knockout mice. The Sirt6 targeted proteins were identified. Conclusions: Our suggest Sirt6 regulated coronary microvascular function through endothelial cells, and ablation of Sirt6 in endothelial cells caused CMD and diastolic dysfunction. Further genetic profiling will elucidate the pathways and mechanisms converging with Sirt6 to regulate microvascular function.

Normalization of Cardiac Function After Bariatric Surgery Is Related to Autonomic Function and Vitamin D

PurposeSubclinical cardiac dysfunction is common in patients with obesity. Bariatric surgery is associated with normalization of subclinical cardiac function in 50% of the patients with obesity. The aim of this study was to identify predictors for a lack of improvement of subclinical cardiac dysfunction 1-year post-bariatric surgery.MethodsPatients who were referred for bariatric surgery were enrolled in a longitudinal study. Inclusion criteria were age 35–65 years and BMI ≥ 35 kg/m2. Patients with a suspicion of or known cardiovascular disease were excluded. Conventional and advanced echocardiography, Holter monitoring, and blood tests were performed pre- and 1-year post-bariatric surgery. Subclinical cardiac dysfunction was defined as either a reduced left ventricular ejection fraction, decreased global longitudinal strain (GLS), diastolic dysfunction, arrhythmia, or an increased BNP or hs Troponin I.ResultsA total of 99 patients were included of whom 59 patients had cardiac dysfunction at baseline. Seventy-two patients completed the 1-year follow-up after bariatric surgery. There was a significant reduction in weight and cardiovascular risk factors. Parameters of cardiac function, such as GLS, improved. However, in 20 patients cardiac dysfunction persisted. Multivariate analysis identified a decreased heart rate variability (which is a measure of autonomic function), and a decreased vitamin D pre-surgery as predictors for subclinical cardiac dysfunction after bariatric surgery.ConclusionAlthough there was an overall improvement of cardiac function 1-year post-bariatric surgery, autonomic dysfunction and a decreased vitamin D pre-bariatric surgery were predictors for a lack of improvement of subclinical cardiac dysfunction.Graphical abstract

Slowing Heart Rate Protects Against Pathological Cardiac Hypertrophy.

We aimed to determine the pathophysiological impact of heart rate (HR) slowing on cardiac function. We have recently developed a murine model in which it is possible to conditionally delete the stimulatory heterotrimeric G-protein (Gαs) in the sinoatrial (SA) node after the addition of tamoxifen using cre-loxP technology. The addition of tamoxifen leads to bradycardia. We used this approach to examine the physiological and pathophysiological effects of HR slowing. We first looked at the impact on exercise performance by running the mice on a treadmill. After the addition of tamoxifen, mice with conditional deletion of Gαs in the SA node ran a shorter distance at a slower speed. Littermate controls preserved their exercise capacity after tamoxifen. Results consistent with impaired cardiac capacity in the mutants were also obtained with a dobutamine echocardiographic stress test. We then examined if HR reduction influenced pathological cardiac hypertrophy using two models: ligation of the left anterior descending coronary artery for myocardial infarction and abdominal aortic banding for hypertensive heart disease. In littermate controls, both procedures resulted in cardiac hypertrophy. However, induction of HR reduction prior to surgical intervention significantly ameliorated the hypertrophy. In order to assess potential protein kinase pathways that may be activated in the left ventricle by relative bradycardia, we used a phospho-antibody array and this revealed selective activation of phosphoinositide-3 kinase. In conclusion, HR reduction protects against pathological cardiac hypertrophy but limits physiological exercise capacity.

Skin microcirculation in middle-aged men with newly diagnosed arterial hypertension according to remote laser Doppler flowmetry data.

This work aims to study the functional state of resistive skin microvessels in patients with newly diagnosed arterial hypertension (AH), using portable laser Doppler flowmetry (LDF) devices. The study included 89 men aged 30 to 60 years (44.4 ± 8.5) who had no known medical complaints, subjectively considered themselves healthy, and did not take medications on a regular basis. All the men underwent LDF on the left forearm, daily blood pressure (BP) monitoring (DBPM) on the left arm, echocardiography, and laboratory tests. According to DBPM data, the men were divided into two groups. The control group (CG) consisted of 30 men with normal BP, and 59 men were included in the AH group. According to LDF data, in men with AH, there is a decrease in the amplitude (tone increase) of neurogenic and myogenic vasomotion, a decrease in the amplitude of pulse oscillations of microcirculatory flow, a decrease in perfusion efficiency of endothelial, neurogenic, myogenic and pulse mechanisms of tissue perfusion regulation. Of all tone-forming mechanisms, only the myogenic mechanism has a weak negative correlation with systolic blood pressure level. The amplitude of pulse oscillations demonstrates the highest degree of correlation with blood pressure parameters. The functional disorders of vasomotor activity of resistive skin microvessels revealed in men with AH have minor correlations with the level of blood pressure. Despite this, the use of portable devices for remote LDF may be a useful method for the dynamic monitoring of patients with hypertension, which requires further research. • In early arterial hypertension (AH) perfusion efficiency in skin is reduced. • Neurogenic and myogenic vasomotor tones increase with the development of AH. • Pulse oscillations demonstrate the highest correlation with blood pressure. • Wrist-mounted LDF monitors are promising for early hypertension monitoring.

Comparison of Diagnostic Accuracy of Magnetic Resonance Imaging and Transient Elastography Fibro Scan for Detecting Liver Fibrosis

Objective: Diagnosing liver fibrosis without resorting to invasive surgery is in high demand but underserved. The focus of this study is on the diagnostic accuracy of MRI and the transient elastography fibro scan for liver fibrosis. Methodology: After the ethical approval from institute review board, sixty patients with liver fibrosis were selected by random sampling technique underwent multiparametric MR, transesophageal echocardiography (TE), and blood testing in this single-center cross-sectional study. Noninvasive treatment alternatives were weighed against histological information including stage and grade (such as MR fat and iron content). The diagnostic accuracy of each method for F3 and F4 hepatic fibrosis, as well as for advanced fibrosis, was evaluated using ROC curve analysis. Each technique was evaluated based on its accuracy (F3–F4). Results: Magnetic resonance elastography was used to find significant correlations between fibrosis stage and collagen content (r = 0.66; P = 0.001), as well as between inflammatory grade and collagen content (r = 0.53; P = 0.036). The MRE, TE, DCE-MRI, DWI, and APRI all had AUCs of 0.78 or above, while the AUC for identifying advanced fibrosis was 0.71. Advanced fibrosis AUC values were between 0.94 and 0.77, 0.79 and 0.79, and 0.70 and 0.70. (F3–F4). Practical implication: This study will to determine which diagnostic technique is better suited to accurately diagnose the liver fibrosis patients. Conclusion: The strongest correlation was seen between histological markers and MRI. The ability of magnetic resonance imaging to detect advanced liver fibrosis and cirrhosis was also superior to that of transient elastography fibro scans. Keywords: MRI, Liver fibrosis, diagnostic accuracy, transient elastography fibro scan

Noninvasive Cardiac Radioablation for Ventricular Tachycardia: Results of the STARNL-1 Trial

<h3>Purpose/Objective(s)</h3> Radioablation or stereotactic arrhythmia radiotherapy is a promising new last-resort treatment modality for patients with recurrent ventricular tachycardia (VT) who are considered therapy refractory. Experience with radioablation is steadily growing worldwide as result of promising efficacy and safety results. Prospective trials are needed to confirm these results. The STARNL-1 study was designed to prospectively evaluate the efficacy and safety of cardiac radioablation in patients with therapy-refractory ventricular tachycardia. <h3>Materials/Methods</h3> The prospective STARNL-1 trial is a single-arm, pre-post, intervention study. In 6 patients, the pro-arrhythmic cardiac region was identified and treated with a single stereotactic radiotherapy fraction of 25 Gy. Patients who were considered therapy-refractory, with recurrences after (multiple) VT ablations and high doses of class 1-3 anti-arrhythmic drugs, were included. For this analysis, the number of treated VT-episodes 6-months before and after treatment, excluding events in the 6-week blanking period, were compared. Safety analysis included evaluation of (serious) adverse events, echocardiography and lung function tests. <h3>Results</h3> All six patients (6/6, 100%) included in the STARNL-1 trail completed the 6-month follow-up. All patients were male (age range 55-83 years) and had an ischemic cardiomyopathy (median ejection fraction: 38% [range 24-52]. The median planning target volume was 187ml (range 93-372.2) and radiation beam-on times were all below 7 minutes. There were no significant alterations in hs-Troponin-T as a marker for myocardial injury comparing baseline (2-3h before treatment) to 3h (+9.7% [-2.3;31.1], p=0.34), 12h (+13.3 [-2.1;17.8], p=0.22) and 24h (+8.0% [9.8;53.3], p=0.40) post-treatment. The median number of treated VT episodes significantly reduced from 24 (range: 6-107) in the 6 months before treatment to 3 (range 0-15) after treatment, p=0.028. The median reduction percentage was 88.0% (range 85-100%). No serious treatment related adverse events occurred during follow-up. Comparing 3 months after treatment with baseline, the median change in ejection fraction was +12% (range: -27 to +33) and the median reduction in 1 second forced expiratory volume (FEV1) and diffusion capacity (DLCO) were both below <15%. <h3>Conclusion</h3> The results of the prospective STARNL-1 evaluating cardiac radioablation for therapy-refractory VT patients are very promising with regards to efficacy and safety.

Prognostic implication of premature ventricular contractions in patients without structural heart disease.

Premature ventricular contractions (PVCs) are a common form of arrhythmia associated with an unfavourable prognosis in patients with structural heart disease. However, the prognostic significance in absence of heart disease is debated. With this study, we aim to investigate whether subjects with PVC, without structural heart disease, have a worse prognosis than the general population. Patients evaluated for PVC at a secondary care centre in Stockholm County from January 2010 to December 2016 were identified. We included patients without history of previous heart disease who had undergone echocardiography and exercise test with normal findings. Based on sex and age, we matched the PVC cohort to a four times bigger control group from the general population and compared the outcome in terms of mortality and cardiovascular morbidity during a median follow-up time of 5.2 years. We included 820 patients and 3,264 controls. Based on a non-inferiority analysis, the PVC group did not have a higher mortality than the control group (0.44, CI 0.27-0.72). Sensitivity analysis with propensity score matching confirmed this result. PVC patients, who after thorough evaluation showed no signs of structural heart disease, did not have a worse prognosis when compared to an age- and sex- control group based on the general population.

Tracking Health, Performance and Recovery in Athletes Using Machine Learning.

Training and competitive periods can temporarily impair the performance of an athlete. This disruption can be short- or long-term, lasting up to several days. We analyzed the health indicators of 3661 athletes during an in-depth medical examination. At the time of inclusion in the study, the athletes were healthy. Instrumental examinations (fluorography, ultrasound examination of the abdominal cavity and pelvic organs, echocardiography, electrocardiography, and stress testing “to failure”), laboratory examinations (general urinalysis and biochemical and general clinical blood analysis), and examinations by specialists (ophthalmologist, otolaryngologist, surgeon, cardiologist, neurologist, dentist, gynecologist (women), endocrinologist, and therapist) were performed. This study analyzed the significance of determining the indicators involved in the implementation of the “catabolism” and “anabolism” phenotypes using the random forest and multinomial logistic regression machine learning methods. The use of decision forest and multinomial regression models made it possible to identify the most significant indicators of blood and urine biochemistry for the analysis of phenotypes as a characterization of the effectiveness of recovery processes in the post-competitive period in athletes. We found that the parameters of muscle metabolism, such as aspartate aminotransferase, creatine kinase, lactate dehydrogenase, and alanine aminotransferase levels, and the parameters of the ornithine cycle, such as creatinine, urea acid, and urea levels, made the most significant contribution to the classification of two types of metabolism: catabolism and anabolism.

Cardiac External Counterpulsation Attenuates Myocardial Injury by Regulating NRF2-mediated Ferroptosisin and Oxidative stress Injury.

Objectives To explore the role of the external counterpulsation (ECP) myocardial injury by controlling NRF2-mediated ferroptosis and oxidative stress damage in acute myocardial infarction. Methods Twenty acute myocardial infarction (AMI) participants hospitalized from January 2021 to January 2022 were enrolled. In addition, 20 healthy individuals who had a physical examination at our hospital served as normal controls. Before the AMI patients were given ECP therapy, the blood samples were collected and echocardiography was performed as the data of AMI cohort. Then, the blood samples were collected and echocardiography was performed following the ECP therapy as the data of AMI + ECP cohort. The heart function was assessed by echocardiography test. Results Our findings demonstrated that ECP could reduce heart damage in patients with AMI. In the current study, we found that ECP could reduce heart damage in patients with AMI through increasing the LV-EF% and enhancing LVEDV and LVESV, and the difference was statistically significant (P < 0.05). ECP could reduce the levels of oxidative stress and ferroptosis markers in blood samples of AMI patients, which was through the upregulation of NRF2 and HO-1 expression, and the difference was statistically significant (P < 0.05). Taken together, all data implied that ECP was able to attenuate myocardial injury by regulating NRF2-mediated ferroptosis and oxidative stress in AMI patients, and the difference was statistically significant (P < 0.05). Conclusion Our findings in this research are that cardiac ECP is able to attenuate myocardial injury by regulating NRF2-mediated ferroptosis and oxidative stress injury in AMI patients. This certainly gives the possibility of a clinically effective treatment for AMI patients, although further clinical trials need to be validated.

Haemodynamic forces as predictors of cardiac remodelling and outcome in heart failure with reduced ejection fraction treated with sacubitril/valsartan

Abstract Background Angiotensin receptor-neprilysin inhibitor (ARNI) is a cornerstone of treatment in heart failure (HF) with reduced ejection fraction (HFrEF), but its effectiveness shows interindividual differences. Objectives To evaluate the predictive value of echo-derived hemodynamic forces (HDF), together with other echocardiographic, biohumoral and cardiopulmonary parameters on a) response to ARNI after 6 months; b) adverse cardiovascular events at follow-up. Methods Eighty-nine consecutive HFrEF patients from two HF centers performed clinical evaluation, laboratory analyses, rest echocardiography and cardiopulmonary exercise testing. Response to ARNI at 6 months was considered in patients without HF admissions, death, or urgent heart transplant and with a ≥50% reduction in NT-proBNP levels and/or ≥10% increase in left ventricle ejection fraction. After 6 months, patients were followed up for a composite endpoint of cardiovascular death, HF-related hospitalization and new-onset atrial fibrillation. Results Response to ARNI was documented in 45/89 (51%) of patients. At baseline, responders and non-responders were paired in clinical assessment, conventional echocardiography, functional status and therapy. At multivariate logistic regression analysis, HDF-derived whole cardiac cycle left ventricle strength (wLVS) was the only independent predictor of ARNI response at 6 months (odds ratio 1.36, 95% confidence interval 1.10–1.67; p=0.004). A wLVS ≥3.7% showed a good accuracy in predicting ARNI response (AUC = 0.736, 0.607–0.840; p&amp;lt;0.0001). During a median of 33 (IQR 23–41) months, wLVS increase from baseline to 6-month (ΔwLVS) showed a high discrimination ability at time-dependent ROC analysis (optimal cut-off: ≤0.5%; AUC=0.811, 0.69–0.90; p&amp;lt;0.0001), stratified prognosis at Kaplan-Meier analysis (log-rank p&amp;lt;0.0001), and remained an independent prognostic predictor of the composite endpoint (hazard ratio 0.76, 0.61–0.95; p&amp;lt;0.01) even after adjusting for clinical, functional and conventional echocardiographic parameters. Conclusions HDF analysis may help predict ARNI response and optimize follow-up and medical/device strategies in patients with HfrEF. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Fondazione Toscana Gabriele Monasterio, Pisa, Italy

Clinical parameters and cardiovascular risk factors related to heart failure with preserved ejection fraction: a comparative analysis between HFA-PEFF and H2FPEF Scores

Abstract Background Heart failure with preserved ejection fraction (HFpEF) diagnosis remains challenging, since several mechanisms (diastolic and systolic reserve abnormalities, chronotropic incompetence, ventricular or vascular stiffening, atrial dysfunction, pulmonary hypertension, impaired vasodilation, endothelial dysfunction, energetic abnormalities and autonomic dysfunction) play different roles in HFpEF development. European Society of Cardiology HF guidelines recently suggested a stepwise non-invasive diagnostic approach consisting of three steps: the first is clinical, the second includes echocardiographic and laboratory data (natriuretic peptides), named HFA-PEEF score, and finally, in case of inconclusive findings, diastolic stress echocardiography is recommended. On the other hand, in United States, another multiparametric score, named H2FPEF, has been proposed for HFpEF diagnosis, and including, in addition to echocardiographic parameters, also clinical data; thereby more applicable in the outpatient clinical arena. Purpose Whether there is a clinical overlap between the two scores (HFA-PEEF and H2FPEF) as well as whether the addition of clinical data to the HFA-PEEF could improve its ability to identify different HFpEF phenotypes is still an open issue and these were the aims of our study. Methods HFA-PEEF and H2FPEF scores were systematically applied on 1,156 consecutive subjects with preserved ejection fraction who undergone cardiovascular evaluation at the Cardiovascular Prevention Center of Fondazione Don Gnocchi &amp; University of Parma. All subjects underwent cardiovascular risk assessment followed by echocardiography and cardiopulmonary exercise testing; due to the outpatient (non-acute) setting of the evaluation, natriuretic peptides assay was not performed. Clinical data and cardiovascular risk factors data were compared between different groups of HFpEF risk. Results According to H2FPEF score, low risk (&amp;lt;40%) of HFpEF was found in 659 (57%), moderate in 300 (26%) and high (&amp;gt;75%) in 197 (17%); according to HFA-PEEF score, 675 (58%) had 0 or 1 point, 253 (22%) had 2 points and 230 (20%) had 3 or 4 points (moderate-to-high risk). Patients with higher HFA-PEEF score were older (p&amp;lt;0.001), had higher prevalence of HTN (p&amp;lt;0.001), diabetes (p&amp;lt;0.001), obesity (p&amp;lt;0.001), sedentary lifestyle (p&amp;lt;0.001), AF (p&amp;lt;0.001) and CCS (p&amp;lt;0.001) (figure 1). More specifically, AF was associated to a 6.3-fold higher risk (p&amp;lt;0.001) of high (3–4) HFA-PEEF Score, age &amp;gt;75 years to a 4.6-fold higher risk, HTN to a 3.6-fold higher risk (p&amp;lt;0.001), CCS to a 3.3-fold higher risk (p&amp;lt;0.001), obesity to a 2.2-fold higher risk (p&amp;lt;0.001), diabetes to a 1.9-fold higher risk (p&amp;lt;0.001) and sedentary to a 1.7-fold higher risk (p=0.001). Conclusions Although HFA-PEEF score does not include clinical data, patients with older age, atrial fibrillation, hypertension, hypertensive heart, diabetes, sedentary lifestyle and chronic coronary syndrome show a higher ESC risk of HFpEF. Funding Acknowledgement Type of funding sources: None.

Association of anti-citrullinated peptide antibodies with the progression of aortic stenosis

Abstract Background/Purpose Aortic stenosis (AS) is common in an aging population, but disease activity biomarkers are lacking. The pathophysiology of calcific AS shares many similarities with atherosclerosis, including lipid deposition, inflammation, and calcification. Citrullination is a part of many chronic inflammatory processes and citrullinated proteins have been found within atherosclerotic plaque. Thus, we investigated whether the presence of anti-citrullinated peptide antibody, especially anti-CCP antibody, might be associated with AS. Methods A retrospective observational study was conducted for 678 patients who underwent echocardiography and anti-CCP antibody test between April 2004 and July 2020. Anti-CCP antibody status was regarded as positive when concentrations exceeded the upper limit of normal (ULN), and any lower value was considered negative. The anti-CCP antibody-positive group was subdivided into two groups: low-positive for ≥ ULN but &amp;lt; the median, and high-positive ≥ the median value (Figure 1A). Also, aortic valve (AV) tissues were obtained from the patients with AS or not at the time of surgical aortic valve replacement or heart transplantation, who did not have rheumatoid arthritis. We analyzed the presence of citrullinated proteins in the AV by immunohistochemistry and Western blotting. Results 241 (35.5%) subjects showed AV degeneration in baseline echocardiography. They had a higher anti-CCP antibody positivity rate (42.7% vs. 34.6%, p=0.035) than the subjects without AV degeneration. Of total patients, 331 (48.8%) subjects underwent follow-up echocardiography (median follow-up duration 4.6 years [interquartile range 2.0–8.0 years]). AS progression, which was defined as an increase of at least one grade in AS severity classification on follow-up echocardiography, was observed in 34 (10.3%) patients. The progression of AS occurred more in the high-positive group than in the low-positive or negative group (19.0% vs. 11.3% vs. 8.4%, respectively; p=0.041) (Figure 1B). In multivariate analysis, the high-positivity of anti-CCP antibody was an independent predictor of AS progression (Odds ratio: 2.312; 95% confidence interval: 1.006–5.310; p=0.048) (Figure 1C). Increased citrullination was visualized in areas with diseased AV compared with normal AV tissue by immunohistochemistry (Figure 2A, 2B) and Western blotting (Figure 2C, 2D). These results suggested the possible association with the citrullinated peptide-related inflammation process and the pathophysiology of AS. Conclusion A positive result of anti-CCP antibody, especially with a high titer, was associated with AV degenerative change at baseline echocardiography. Also, anti-CCP antibody positivity was an independent factor for predicting the progression of AS. These findings suggest that citrullination can be a part of the pathophysiology of AS. Furthermore, the anti-CCP antibody can be a biomarker predicting AS progression. Further research will be needed. Funding Acknowledgement Type of funding sources: None.

Echocardiographic diversity associated with exercise capacity in heart failure precursor stage B: the Project Baseline Health Study

Abstract Background The current paradigm to stage heart failure (HF) defines precursor stage B (or “pre-HF”) as having any subclinical change in cardiac structure or function. Yet, HF risk factors and type of cardiac abnormality may induce clinically relevant heterogeneity in HF stage B. Therefore, we assessed clinical and echocardiographic heterogeneity within stage B HF and its association with exercise capacity in a large community-based sample. Methods 2071 participants to the Baseline Health Study (50.4±17.0 years, 56.2% women, 37.8% hypertensive) underwent echocardiography and physical performance testing including 6-minute walk (6MWT) and treadmill exercise test. We defined echocardiographic profiles of left and right heart remodeling and dysfunction using sex-specific internal reference values. We assessed HF stages (0-A-B-C-D) following HF societies recommendations. stage B participants were stratified according to presence/absence of HF risk factors and to the most severe echocardiographic abnormality present (reduced ejection fraction (EF), left ventricular (LV) hypertrophy/diastolic dysfunction or other abnormalities). We reported associations between physical performance metrics and HF (sub)stages. Results Stage B HF was present in 516 participants (24.9%). Within stage B HF, we observed a large diversity in echocardiographic profiles. Yet, stage B participants without HF risk factors (n=96, 18.6% of stage B) predominantly presented echo abnormalities other than LV diastolic dysfunction, hypertrophy and reduced EF, while their physical performance profile resembled that of people with normal echocardiography without HF risk factors. In contrast, stage B participants with HF risk factors (n=420) were characterized by LV diastolic dysfunction, hypertrophy or reduced EF, three phenotypes associated with lower 6MWT distance and lower exercise capacity. Concomitant presence of HF risk factors and LV dysfunction/hypertrophy was associated with worst physical performance. Conclusions We observed a wide clinical and echocardiographic diversity affecting physical performance in HF precursor stage B when defined by the current staging paradigm. Concomitant presence of HF risk factors and LV dysfunction/hypertrophy may mark individuals at highest risk for progression towards overt HF. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): This research was made supported by an institutional research grant from Verily Inc. (CA, USA) and by the Research Foundation Flanders (Belgium).

Nitro-oxidative stress impairs single cardiomyocyte adrenergic reserve in a murine model of HFpEF

Abstract Background Exercise intolerance is the central symptom of patients with heart failure and preserved ejection fraction (HFpEF). Underlying reduced cardiac functional reserve in response to adrenergic stimuli (stress testing) has been suggested but the molecular mechanisms are insufficiently understood. In cardiomyocytes, nitric oxide (NO) modifies contractility and is required to achieve a full adrenergic response. Recently, dysregulation of NO release has been described to contribute to HFpEF. In a murine model of HFpEF, we investigated cardiomyocyte's adrenergic functional reserve and the role of NO in cardiomyocyte contractility, calcium handling and adrenergic reserve. Methods Firstly, the effects of NO on sarcomere shortening and calcium handling (Fura-2) were studied in isolated, adult ventricular cardiomyocytes (AMVMs) from 8–10 weeks old, male C57BL/6J mice. Secondly, male C57BL/6J mice (12w) were fed regular CHOW (Sham) or a high fat diet (D12492, Research Diet) and L-NAME (1g/l, via the drinking water) for 15 weeks to induce HFpEF. At week 27, mice underwent echocardiography and exercise testing (treadmill). In AMVMs isolated from HFpEF and Sham mice, we quantified sarcomere shortening, calcium handling (Fura-2), release of NO (CuFL2) and reactive oxygen species (DCF) before and after the addition of isoproterenol (ISO, 1μM), in the absence and presence (40 min preincubation) of an inhibitor of inducible NO Synthase (1400W) or a denitrosylating agent (glutathione). Results In AMVMs, addition of the NO donor SNAP (10μM) increased calcium transient amplitude and accelerated relaxation time. Inhibition of NO synthesis with L-NAME (100μM) impaired adrenergic response upon exposure to ISO. HFpEF mice (evident by diastolic dysfunction (e/e' ratio) and lung edema (wet lung weight / TL)) exhibited significantly reduced exercise capacity (running distance). In AMVMs isolated from HFpEF mice, NO and ROS release were increased at baseline, associated with an increased sarcomere shortening amplitude and faster relaxation and calcium removal as compared to Sham. Strikingly, after the addition of ISO, the adrenergic functional reserve (cellular inotropy and lusitropy) was significantly lower in HFpEF vs. Sham AMVMs. Preincubation with the iNOS inhibitor 1400W or glutathione restored adrenergic inotropic and lusitropic reserve in HFpEF AMVMs. Conclusion In HFpEF, adrenergic reserve is impaired on a single cardiomyocyte level. This is at least partially related to an increase in NO release. Pharmacologic inhibition of iNOS improved adrenergic reserve in HFpEF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DFG

Evaluation of myocardial work in patients recovered from the severe form of COVID-19

Abstract Background/Introduction The impact of COVID-19 goes beyond its acute form, and can lead to the persistence of symptoms and the emergence of systemic disorders, defined as Post-Covid or Long-Covid. Purpose Assess the late impact on the cardiorespiratory system of patients recovered from severe Covid. Methods We performed cross-sectional study that included patients over 18 years of age who recovered from the severe form of COVID-19 after at least 60 days of their discharge. Patients and healthy controls were enrolled to perform transthoracic echocardiography (TTE) and cardiopulmonary exercise testing (CPET). Results A total of 52 patients and 24 controls were enrolled. The standard TTE parameters (end diastolic diameters, left ventricular ejection fraction, diastolic function and right ventricular systolic function) showed no difference when compared to the control group. When analyzing the myocardial work, there was a higher Wasted MW (GWW): 135 mmHg% vs 84.5 mmHg% (p=0.002), with lower MW Efficiency (GWE): 94 vs. 96 (p=0.003); as well as lower values of global strain: cases = 18.6% vs. 20.1% (p=0.009). No differences were found in the Constructive MW (GWC) and MW Global Index (GWI). In the CPET data we found lower peak values for the VO2: 24 ml/kg/min vs. 32.75 ml/kg/min (p&amp;lt;0.001); for the Heart Rate: 162 bpm vs. 175 bpm (p&amp;lt;0.001); for the Ventilation: 79.3 L/min vs. 109.85 L/min (p&amp;lt;0.001) and Respiratory Exchange Ratio: 1.12 vs. 1.19 (p=0.004). There was no difference in the maximum load reached, neither in the oxygen pulse values and in the Ve/CO2 slope. In relation to the oxygen kinetics, there was a significant reduction in OUES%: 85% vs. 98% (p=0.03); as well as an extended T½: 112 s vs. 88.5 s (p&amp;lt;0.001); and a slowing of the fall in heart rate in recovery time, as measured by the Heart Rate decay: −17.32 bpm vs. −22.08 bpm (p=0.005). Conclusion Patients recovered from the severe form of COVID-19 had higher GWW with lower efficiency (GWE). Such findings, added to changes in oxygen kinetics during exercise, may point to a possible cardiocirculatory mechanism associated with decreased aerobic capacity. Funding Acknowledgement Type of funding sources: None.

A chromatin mark by SETD7 regulates myocardial inflammation in obesity-related heart failure with preserved ejection fraction

Abstract Background Obesity is a major risk factor for heart failure with preserved ejection fraction (HFpEF). Post-translational modification of histones by chromatin modifying enzymes (CMEs) are emerging as pivotal regulators of gene transcription in cardiovascular disease. Purpose To investigate the role of chromatin remodelling in obese HFpEF (obHFpEF). Methods Gene expression profiling of CMEs (PCR array) was performed in left ventricular (LV) myocardial specimens from obHFpEF patients and age-matched control donors (n=8/group). Among myocardial CMEs, the methyltransferase SETD7 showed the highest variation in gene expression. Hence, we investigated the role of SETD7 and its chromatin mark H3K4me1 in a murine model of obHFpEF. Mice with cardiomyocyte-specific deletion of SETD7 (c-SETD7−/−) and control littermates (SETD7fl/fl) were subjected to high fat diet feeding and L-NAME treatment for 15 weeks to induce obHFpEF. Echocardiography and Treadmill exhaustion test were performed. ChIP-Seq datasets were employed to determine the biological pathways regulated by SETD7, whereas chromatin immunoprecipitation assays (ChIP) were performed to investigate SETD7/H3k4me1 enrichment on target gene promoters. SETD7 gain- and loss-of-function experiments were performed in cultured neonatal rat ventricular myocytes (NRVMs) exposed to palmitic acid (200μM) for 48h. Selective inhibition of SETD7 by (R)-PFI-2 was performed in skinned cardiomyocytes isolated from left ventricular specimens of obHFpEF patients. Passive stiffness, a main feature of HFpEF, was assessed before and after (R)-PFI-2 treatment. Results CMEs profiling showed SETD7 as the top-ranking transcript (fold change, 7.36, P&amp;lt;0.01) in myocardial specimens from obHFpEF patients as compared to controls. ChIP-Seq in CMs showed a strong enrichment of SETD7 and H3k4me1 on the promoter of NF-kB p65 gene, a master regulator of inflammation. SETD7 and H3k4me1 were upregulated in HFpEF vs. control mouse hearts, showed enrichment on NF-kB p65 promoter and were associated with IL-1β and IL-6 upregulation. In HFpEF mice, cardiomyocyte-specific deletion of SETD7 protected against LV hypertrophy, diastolic dysfunction (assessed by E/E' ratio) and lung congestion while improving exercise tolerance. At the molecular level, SETD7 deletion blunted H3K4me1 enrichment on p65 promoter thus preventing the upregulation of inflammatory genes and myocardial apoptosis. In cultured CMs exposed to PA, SETD7 inhibition by (R)-PFI-2 prevented H3k4me1-driven p65 upregulation, whereas SETD7 overexpression mimicked HFpEF features. Moreover, knockdown of NF-kB p65 prevented IL-1β/IL-6 transcription in SETD7-overexpressing CMs. Of clinical relevance, (R)-PFI-2 reduced passive stiffness in skinned CMs isolated from obHFpEF patients. Conclusions Our results unveil a new epigenetic mechanism underpinning inflammation in obHFpEF. Targeting SETD7 may represent a novel therapeutic approach to prevent HFpEF in obesity. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation

Role of combined exercise stress echocardiography and cardiopulmonary exercise test in chronic thromboembolic disease

Abstract Background Chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension could cause significant exercise limitations. However, interventional or surgical treatments for CTEPD with mild pulmonary hypertension or normal pressure are on controversy. Purpose We aimed to evaluate cardiopulmonary function through cardiopulmonary exercise test (CPET) with stress echocardiography and to determine whether exercise pulmonary hypertension can explain exercise limitations in CTEPD patients with mPAP &amp;lt;30mmHg. Methods Patients diagnosed as CTEPD with mPAP less than 30mmHg was derived from our pulmonary hypertension center registry from April 2014 to October 2021.Transthoracic echocardiography (TTE) was performed at baseline (resting state) and immediately after CPET. TTE derived parameters and CPET parameters were compared with hemodynamic parameters measured by right catheterization. Results Total 37 patients were enrolled. Of these, Thirty-five patients had previously been diagnosed with CTEPH and had undergone PEA, BPA, or both. Most of the patients complained dyspnea of WHO functional class II or III. Pulmonary vascular resistance (PVR) was slightly higher than normal (185.0±102.2 dyne sec cm–5). Also VO2max was decreased in CPET (23.1±6.5 mL/kg/min). In correlation analysis, the higher the mPAP and PVR at rest, the lower VO2max during exercise. Meanwhile basal right ventricular (RV) function was normal, an increase in RVSP was notably observed during exercise (RVSP: pre-exercise 36.2±11.9, post-exercise 60.7±19.3, p value &amp;lt;0.001). Furthermore RV function deteriorated during exercise (TAPSE: pre-exercise 16.1±4.8, post-exercise 12.9±5.0, p value &amp;lt;0.001). Conclusions CTEPD patients with mild or normal PAP showed limited exercise capacity with exercise induced hypertension. Even in the mPAP less than 30mmHg, PVR and mPAP was significantly associated with exercise capacity. CPET with stress echocardiography could help to identify the main cause of exercise limitation in CTEPD patients and possibly provide the guideline for treatment plan. Funding Acknowledgement Type of funding sources: None.

Exercise-induced ventricular arrythmia in asymptomatic patients with Mitral Valve Prolapse

Abstract Introduction Mitral Valve Prolapse (MVP) is associated with complex ventricular arrythmia (VA) and sudden cardiac death but risk stratification remains unclear. Exercise induces an hyperadrenergic state and could trigger VA, however, data on exercise-induced VA (EIVA) in MVP patients are scarce. Objective To describe EIVA prevalence, origin, characteristics and associated features in MVP patients. Methods In this observational prospective study, 64 MVP asymptomatic patients (58±14 years, 41 men) with mild to severe mitral regurgitation (MR) and without left ventricular (LV) dysfunction, underwent echocardiography and symptom-limited exercise testing. Continuous 12-lead ECG monitoring was performed throughout testing. Severe EIVA was defined as ventricular triplets, sustained or non-sustained ventricular tachycardia (NSVT) or ventricular fibrillation. Results All patients exercised at maximal intensity until exhaustion. EIVA was observed in 54 (84%) subjects including 12 (19%) patients with severe EIVA (7 triplets, 5 NSVT). Severe EIVA originated mainly from the mitral apparatus (all but one) and occurred at high exercise intensity (median 90% of predicted workload) or during early recovery phase. Compared to the rest of the cohort the patients with severe EIVA had similar resting ECG characteristics, similar LV dimension and function, similar degree of MR and mitral apparatus morphology. Finally, severe EIVA was not associated with an alteration of exercise tolerance. Conclusion Exercise frequently unmasks ventricular arrythmia in patients with MVP. EIVA appears not linked to MVP features nor to exercise tolerance and seems to provide additional phenotyping information that could be linked to prognosis. Funding Acknowledgement Type of funding sources: None.

Low chronotropic index predicts rehospitalization in post-acute myocardial infarction patients with preserved or mildly reduced left ventricular ejection fraction

Abstract Background There are limited data about the clinical utility of combined stress echocardiography and cardiopulmonary exercise testing (CPET-ESE) in predicting prognosis in patients after acute myocardial infarction (AMI) with preserved left ventricular ejection fraction (LVEF). Aim To assess prognostic parameters using CPET-ESE in post-AMI patients with preserved or mildly reduced LVEF. Methods Eighty-seven patients after the first AMI with LVEF &amp;gt;40% were followed for 2 years (median 1.93 years IQR 1.16–2.41). The composite end-point was all-cause mortality or rehospitalization due to ischaemic heart disease (AMI, unstable angina, percutaneous coronary intervention/coronary artery bypass grafting) or heart failure exacerbation. All patients underwent symptom-limited CPET-ESE on a semi-supine cycle ergometer 3 to 5 weeks after AMI. The chronotropic index was calculated as the percent of heart rate reserve. Six patients refused to complete the survey and they were not included in the analysis. Results Follow-up was conducted in 81 consecutive patients (mean age 59±10 years, 62% males, 50% AMI with ST-segment elevation, 85% on beta-blockers). Mean LVEF was 56±9% and peak VO2 18.5±5.0 mL/kg/min. There were no deaths during follow-up. The composite end-point occurred in 13 patients. In multivariate Cox regression analysis after correction for demographic and clinical variables, only chronotropic index correlated with the composite end-point (HR 0.93, 95% CI 0.87–0.99, p=0.026). A positive predictive value of 33.3% and a negative predictive value of 91.3% (sensitivity 61.5%, specificity 76.5%, area under the curve, AUC 71%) for predicting the composite end-point was established for the chronotropic index ≤36.8% (Fig. 1). There was a statistically significant difference in the composite end-point occurrence (p&amp;lt;0.01) between subgroups with the chronotropic index above and below that threshold (Fig. 2). Conclusions In patients after the first AMI with preserved or mildly reduced left ventricular systolic function, a lower chronotropic index is a predictor of rehospitalization in 2-year follow-up. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Centre of Postgraduate Medical Education, Warsaw, Poland