Elevated Left Ventricular Research Articles

Alteration of cardiac structure and function and its prognostic value in patients with Takayasu arteritis: a cardiac magnetic resonance study.

To investigate the prevalence and characteristics of late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) and its prognostic value in patients with Takayasu arteritis (TA). Sixty TA patients with a CMR examination were retrospectively included. All TA patients were divided into with LGE-positive and LGE-negative groups. Bi-ventricular function and location, distribution, and pattern of left ventricular (LV) LGE were evaluated in both LGE-positive and LGE-negative groups. Primary outcome was defined as a composite of cardiovascular death, hospitalization for heart failure, coronary artery revascularization, and stroke. Univariate and multivariate Cox proportional hazard regression analyses were used to evaluate the association between variables and primary outcomes. Sixty consecutive TA patients were enrolled in this study. The mean age was 38.2 ± 13.8 years and 54 patients (54/60, 90.0%) were female. LGE-positive was observed in twenty-one (21/60, 35%) patients in the total patients with TA. LGE was predominantly distributed in the middle wall and subendocardial. The patchy and infarcted LGE patterns were the most common. Compared with the LGE-negative group, the LGE-positive group had reduced LV ejection fraction (P = 0.033), elevated LV end-diastolic volume index (P = 0.008), LV end-systolic volume index (P = 0.012), and LV mass (P = 0.008). During a median follow-up period of 1,892 days (interquartile range: 1,764-1,988 days), the primary outcomes occurred in thirteen patients. In the univariate analysis, LGE-positive (hazard ratio [HR] = 4.478, 95% confidence interval [CI]: 1.376-14.570; P = 0.013) were independently associated with the primary outcomes. However, LGE-positive did not retain its value as an independent predictor of primary outcomes in the multivariate analysis. Instead, LVMI (HR = 1.030, 95%CI: 1.013-1.048; P = 0.001) was the strongest independent predictor of primary outcomes in patients with TA. The Kaplan-Meier plot revealed that patients with LVMI ≥ 57.5 g/m2 have a worse prognosis. LGE-positive detected by CMR was observed in 35% of total TA patients with different distributions and patterns. LGE is associated with adverse LV remodeling and worsen cardiac function. However, LVMI rather than LGE can provide independent prognostic information in patients with TA.

Elevated carbohydrate antigen 125 (CA125) is associated with incident heart failure and mortality in acute coronary syndrome.

Carbohydrate antigen 125 (CA125), a mucin produced by serosal cells in response to mechanical and inflammatory stimuli, has emerged as an important biomarker to guide risk stratification in heart failure (HF). The prognostic value of CA125 in acute coronary syndrome (ACS) patients is less explored. In a cohort of 524 ACS patients (73% males, mean age 67±12years), we assessed the associations between CA125 and the risk for HF and death during a median follow-up period of 27.3months for incident HF and 39.5months for mortality. Plasma CA125 was measured within 24h after admission in the entire cohort and after 6weeks in a subgroup of 115 elderly patients (>75years of age). We also assessed the relationships between baseline CA125 and echocardiographic parameters of cardiac structure and function at 1year post-ACS in this subgroup. Baseline CA125 was associated with incident HF in the entire cohort in a Cox proportional hazards model adjusted for age, sex, cardiovascular (CV) risk factors (diabetes, smoking, hypertension, previous HF, previous ACS and previous stroke), renal function and revascularization {hazard ratio [HR] 1.46 [95% confidence interval (CI) 1.10-1.93] per 1-standard deviation [SD] CA125 increase; P=0.009}. In the detailed follow-up subgroup, elevated baseline CA125 predicted subsequent deterioration of left ventricular (LV) ejection fraction (LVEF), defined as a >5% absolute LVEF decrease in patients with LVEF≥50% at discharge [odds ratio (OR) 3.31 (95% CI 1.15-9.54) per 1-SD baseline CA125 increase; P=0.027]. We also found significant correlations between high baseline CA125 and larger LV volumes (LV end-diastolic volume index, Spearman's r=0.329, P<0.001; LV end-systolic volume index, r=0.391, P<0.001) and left atrial volume index (r=0.320, P<0.001) at 1year post-ACS, indicative of adverse cardiac remodelling. Elevated baseline and follow-up CA125 were associated with increased mortality, independently of age and sex [HR 1.37 (95% CI 1.09-1.71), P=0.006, per 1-SD baseline CA125; HR 1.98 (95% CI 1.06-3.67), P=0.031, per increasing 6week CA125 tertile]. The relationship between 6week CA125 and incident mortality remained significant in the fully adjusted model [HR 2.23 (95% CI 1.15-4.35) per increasing CA125 tertile; P=0.018]. We report independent associations between elevated CA125, LV dysfunction, cardiac remodelling, incident HF and mortality post-ACS. Our results warrant further evaluation of CA125 as a potential biomarker for risk stratification and management of ACS patients, both at the time of the acute coronary event and during follow-up.

Abstract P419: Left Ventricular Diastolic Dysfunction in Preeclamptic Patients: A Systematic Review and Meta-Analysis

Introduction: Preeclamptic (PE) patients are at a 4-fold higher risk for developing heart failure later in life. Pathological cardiac remodeling, and the ensuing left ventricular (LV) dysfunction during hypertensive pregnancy are thought to precede heart failure in these patients. Specifically, several observational studies employing echocardiography demonstrate exaggerated LV diastolic function alterations in PE patients suggestive of diastolic dysfunction. Objective: Thus, to consolidate the evidence supporting diastolic dysfunction in preeclampsia, we sought to systematically review the clinical literature, and conduct a meta-analysis on the pooled data pertaining to LV diastolic function. Methods: Three databases, MEDLINE (Ovid), Embase (Elsevier), and Scopus (Elsevier) were searched from inception to January 26, 2024 and the search results were uploaded to Covidence for screening. The diastolic function data—early diastole mitral flow to annulus velocity ratio (E/e’), isovolumic relaxation time (IVRT), early to late diastole mitral flow velocity ratio (E/A), and E wave deceleration time (DT)—were extracted, and subsequently used to perform meta-analysis using Cochrane’s RevMan Web (Mean Difference, MD; random effects models with inverse variance weighting). Results: A total of 63 from 5013 screened studies were eligible for inclusion and of these, only the studies reporting E/e’ (34/63), IVRT (18/63), E/A (38/63), and DT (16/63) were included in the meta-analysis. Our analysis showed that E/e’ is increased (MD of 2.33 [95% CI, 1.77 to 2.89], p&lt;0.00001) in PE patients when compared to healthy pregnant women indicating elevated LV filling pressures. Further, PE patients exhibited significantly higher IVRT (MD of 8.88 msec [95% CI, 6.07 to 11.68], p&lt;0.00001) and lower E/A (MD of -0.16 [95% CI, -0.25 to -0.06], p=0.001), collectively suggesting that the myocardial relaxation is impaired in preeclampsia. Interestingly, DT (MD of 3.10 msec [95% CI, -5.43 to 11.62], p=0.48) was not found to be different between the groups. Conclusions: Our findings demonstrate that PE patients develop LV diastolic dysfunction during pregnancy which may be mediated by hypertension caused pressure overload. Given that diastolic dysfunction is a hallmark characteristic of heart failure with preserved ejection fraction (HFpEF), future longitudinal studies examining cardiac function during pregnancy and postpartum will help determine if PE patients are destined to develop HFpEF.

Abstract Mo101: 3-Mercaptopyruvate Sulfurtransferase is a Critical Regulator of Branched-Chain Amino Acid Catabolism in Cardiometabolic HFpEF

Background: Heart failure with preserved ejection fraction (HFpEF) is among the leading causes of cardiovascular mortality and morbidity. Recent multi-omics data sets underscore severely impaired branched-chain amino acid (BCAA) catabolism in the failing hearts of HFpEF patients. 3-mercaptopyruvate sulfurtransferase (3-MST) is a mitochondrial hydrogen sulfide (H 2 S) synthase that regulates mitochondrial biogenesis, function, and substrate metabolism. Research Questions and Goals: In the current study, we aimed to elucidate the role of 3-MST in myocardial BCAA catabolism in cardiometabolic HFpEF. Methods: 3-MST knockout or wild-type (WT) mice were subjected to control or L-NAME and high fat diet - induced HFpEF. Echocardiographic measurements, invasive hemodynamic assessment, and exercise capacity testing were conducted to determine HFpEF severity. Metabolomic analysis was performed to study BCAA catabolism. Additionally, a H 2 S donor, SG1002 was administered to increase H 2 S bioavailability in the setting of 3-MST deficiency and HFpEF. Results: We observed progressive deterioration in left ventricular (LV) diastolic function and exercise performance from mice subjected to HFpEF. Genetic ablation of 3-MST further-exacerbated HFpEF severity as evidenced by significantly increased E/e’ ratio, elevated LV end-diastolic pressure, and reduced exercise performance. Metabolomic analysis revealed pathological accumulation of intermediate metabolites of BCAA in the HFpEF hearts, suggesting a major derangement in myocardial BCAA catabolism. 3-MST KO hearts exhibited further BCAA catabolic defects as compared to those from WT. Importantly, H 2 S donor treatment significantly attenuated BCAA catabolic defect and alleviated HFpEF severity in both WT and 3-MST KO HFpEF mice. Conclusion: Our results demonstrate that deficiency of 3-MST impairs myocardial BCAA catabolism, which results in exacerbated HFpEF severity in a “two-Hit” mouse model of HFpEF. These data suggest 3-MST is critically involved in physiological substrate metabolism within the mitochondria and exerts beneficial effects in HFpEF. Future experiments are underway to delineate the mechanisms by which 3-MST regulates BCAA catabolism.

Evaluation of left ventricular filling pressure by echocardiography in patients with atrial fibrillation

BackgroundEchocardiography is widely used to evaluate left ventricular (LV) diastolic function in patients suspected of heart failure. For patients in sinus rhythm, a combination of several echocardiographic parameters can differentiate between normal and elevated LV filling pressure with good accuracy. However, there is no established echocardiographic approach for the evaluation of LV filling pressure in patients with atrial fibrillation. The objective of the present study was to determine if a combination of several echocardiographic and clinical parameters may be used to evaluate LV filling pressure in patients with atrial fibrillation.ResultsIn a multicentre study of 148 atrial fibrillation patients, several echocardiographic parameters were tested against invasively measured LV filling pressure as the reference method. No single parameter had sufficiently strong association with LV filling pressure to be recommended for clinical use. Based on univariate regression analysis in the present study, and evidence from existing literature, we developed a two-step algorithm for differentiation between normal and elevated LV filling pressure, defining values ≥ 15 mmHg as elevated. The parameters in the first step included the ratio between mitral early flow velocity and septal mitral annular velocity (septal E/e’), mitral E velocity, deceleration time of E, and peak tricuspid regurgitation velocity. Patients who could not be classified in the first step were tested in a second step by applying supplementary parameters, which included left atrial reservoir strain, pulmonary venous systolic/diastolic velocity ratio, and body mass index. This two-step algorithm classified patients as having either normal or elevated LV filling pressure with 75% accuracy and with 85% feasibility. Accuracy in EF ≥ 50% and EF < 50% was similar (75% and 76%).ConclusionsIn patients with atrial fibrillation, no single echocardiographic parameter was sufficiently reliable to be used clinically to identify elevated LV filling pressure. An algorithm that combined several echocardiographic parameters and body mass index, however, was able to classify patients as having normal or elevated LV filling pressure with moderate accuracy and high feasibility.

Non-invasive assessment of left ventricular filling pressure in aortic stenosis.

The assessment of left ventricular (LV) filling pressure (FP) is important for the management of aortic stenosis (AS) patients. Although, it is often restricted for predict LV FP in AS because of mitral annular calcification and a certain left ventricular hypertrophy. Thus, we tested the predictive ability of the algorithm for elevated LV FP in AS patients and also applied a recently-proposed echocardiographic scoring system of LV FP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score. We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LV FP. LV diastolic dysfunction (DD) was graded according to the ASE/EACVI guidelines. The VMT score was defined as follows: time sequence of opening of mitral and tricuspid valves was scored to 0-2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava was dilated, one point was added and VMT score was finally calculated as 0-3. Of the 116 patients, 29 patients showed elevated PAWP. Ninety patients (93%) and 67 patients (63%) showed increased values for left atrium volume index (LAVI) and E/e', respectively when the cut-off values recommended by the guidelines were applied and thus the algorism predicted elevated PAWP with a low specificity and positive predictive value (PPV). VMT≥2 predicted elevated PAWP with a sensitivity of 59%, specificity of 90%, PPV of 59%, and negative predictive value of 89%. An alternative algorithm that applied tricuspid regurgitation velocity and VMT scores was tested, and its predictive ability was markedly improved. VMT score was applicable for AS patients. Alternative use of VMT score improved diagnostic accuracy of guideline-recommended algorism.

Abstract P493: A Multivariate Analysis of Genetic Risk Scores for Heart Failure and Left Ventricular Mass Derived From Multi-Ancestry Populations and Left Ventricular Mass Amongst African Americans: The Jackson Heart Study

Background: Increased left ventricular (LV) mass is an outcome of LV remodeling that can result in development of left ventricular hypertrophy (LVH), a maladaptive disorder that increases the risk of heart failure. Elevated LV mass is a sensitive predictor of adverse cardiovascular events. African Americans experience a disproportionate burden of heart failure risk and development of LVH. The influence of genetics on this health disparity is unclear and a topic of interest. Genome-wide association studies (GWAS) have uncovered many variants associated with numerous adverse cardiovascular outcomes, such as heart failure and LV phenotypes. However, the relevance of these studies for African Americans may be limited as these analyses have been conducted in multi-ancestry populations with limited representation of African heritage. The question of whether these genetic risk variants can be used to predict LV phenotypes in an independent African American population remains unanswered. Hypothesis: Variant loci that have been associated with heart failure and LV mass in multi-ancestry populations will be associated with LV mass amongst African Americans in the Jackson Heart Study (JHS). Methods: Thirty-nine (39) SNPs associated with heart failure and ten (10) SNPs associated with LV mass were identified from two published studies in which participants of African ancestry or Black individuals comprised less than 15% and 2%, respectively. Using the published effect size estimates, genetic risk scores (GRSs) for heart failure and LV mass were computed for 2,175 African American participants (mean age 55, 63% female) in the JHS with complete data and consent for genetic research. We assessed the linear association of heart failure and LV mass GRSs with LV mass indexed to height (LVM h ) and indexed to body surface area (LVM bsa ). A multivariate general linear model was fit to both LVM h and LVM bsa containing both GRS predictors and accounting for age, sex, BMI (mean 31.5), diabetes (22%), and hypertension (52%). No multicollinearity was noted among these explanatory variables using variance inflation factors. Due to non-constant error variance, a log transformation was conducted on both LV mass response variables. Type III MANOVA Pillai tests were run to assess the effects of the GRSs on the log LVM bsa and log LVM h values. Conclusion: When accounting for age, BMI, sex, diabetes, and hypertension, we found that neither the heart failure GRS (p-val = 0.4012) nor the LV mass GRS (p-val = 0.8332) had an effect on both log LVM bsa and log LVM h . There is insufficient evidence to suggest that heart failure and LV mass variants derived from predominantly European multi-ancestry populations are linearly associated with log LV mass amongst African Americans in the Jackson Heart Study. Our work highlights the need for greater recruitment and targeted studies of populations with African ancestry for GWAS of LV phenotypes.

Effect of sacubitril/valsartan on the hypertensive heart in continuous light-induced and lactacystin-induced pre-hypertension: Interactions with the renin-angiotensin-aldosterone system

This study investigated whether sacubitril/valsartan or valsartan are able to prevent left ventricular (LV) fibrotic remodelling and dysfunction in two experimental models of pre-hypertension induced by continuous light (24 hours/day) exposure or by chronic lactacystin treatment, and how this potential protection interferes with the renin-angiotensin-aldosterone system (RAAS). Nine groups of three-month-old male Wistar rats were treated for six weeks as follows: untreated controls (C), sacubitril/valsartan (ARNI), valsartan (Val), continuous light (24), continuous light plus sacubitril/valsartan (24+ARNI) or valsartan (24+Val), lactacystin (Lact), lactacystin plus sacubitil/valsartan (Lact+ARNI) or plus valsartan (Lact+Val). Both the 24 and Lact groups developed a mild but significant systolic blood pressure (SBP) increase, LV hypertrophy and fibrosis, as well as LV systolic and diastolic dysfunction. Yet, no changes in serum renin-angiotensin were observed either in the 24 or Lact groups, though aldosterone was increased in the Lact group compared to the controls. In both models, sacubitril/valsartan and valsartan reduced elevated SBP, LV hypertrophy and fibrosis and attenuated LV systolic and diastolic dysfunction. Sacubitril/valsartan and valsartan increased the serum levels of angiotensin (Ang) II, Ang III, Ang IV, Ang 1–5, Ang 1–7 in the 24 and Lact groups and reduced aldosterone in the Lact group. We conclude that both continuous light exposure and lactacystin treatment induced normal-to-low serum renin-angiotensin models of pre-hypertension, whereas aldosterone was increased in lactacystin-induced pre-hypertension. The protection by ARNI or valsartan in the hypertensive heart in either model was related to the Ang II blockade and the protective Ang 1–7, while in lactacystin-induced pre-hypertension this protection seems to be additionally related to the reduced aldosterone level.

What underlies sex differences in heart failure onset within the first year after a first myocardial infarction?

Women are more likely to develop heart failure (HF) after myocardial infarction. However, diagnosis and reperfusion are often delayed. To compare the prevalence of HF after primary percutaneous coronary intervention (PPCI)-treated ST segment myocardial infarction (STEMI) between sexes and to study its associations with comorbidities, infarct size, and left ventricular (LV) systolic and diastolic dysfunctions (DD). The patients with PPCI-treated anterior STEMI, from the CIRCUS study cohort, were followed up for 1 year and HF events were recorded. Evaluation of ejection fraction (LVEF) and DD were performed at baseline and at 1 year. The elevated LV filling pressure (LVFP) included Grades 2 and 3 DD. Of the 791 patients from the CIRCUS study, 135 were women. At 1 year, the proportion of patients who developed HF was 21% among men and 34% among women (p = 0.001). In the subset of 407 patients with available diastolic parameters, the rate of HF was also higher in women. HF during the initial hospitalization was comparable between the sexes. However, women had a higher incidence of rehospitalization for HF within the first year after STEMI (14.1% vs. 4.1%, p = 0.005). Women were older with a higher prevalence of hypertension. The infarct size and LVEF were similar between the sexes. Elevated LVFP was observed more frequently in women than in men during the initial hospitalization and at 1 year (26% vs. 12%, p = 0.04, and 22% vs. 12%, p = 0.006, respectively). Interestingly, only initial elevated LVFP (HR 5.9, 95% CI: 2.4-14.5, p < 0.001), age, and hypertension were independently associated with rehospitalization for HF. After PPCI-treated anterior STEMI, despite comparable infarct size and LVEF, women presented a higher proportion of rehospitalization for HF than men. That was likely due to a greater DD associated with older age and hypertension.

Prognostic Significance of Elevated Left Ventricular Filling Pressures with Exercise: Insights from a Cohort of 14,338 Patients

Exercise echocardiography can assess for cardiovascular causes of dyspnea other than coronary artery disease. However, the prevalence and prognostic significance of elevated left ventricular (LV) filling pressures with exercise is understudied. We evaluated 14,338 patients referred for maximal symptom-limited treadmill echocardiography. In addition to assessment of LV regional wall motion abnormalities (RWMAs), we measured patients' early diastolic mitral inflow (E), septal mitral annulus relaxation (e'), and peak tricuspid regurgitation velocity before and immediately after exercise. Over a mean follow-up of 3.3±3.4years, patients with E/e' ≥15 with exercise (n=1,323; 9.2%) had lower exercise capacity (7.3±2.1 vs 9.1±2.4 metabolic equivalents, P<.0001) and were more likely to have resting or inducible RWMAs (38% vs 18%, P<.0001). Approximately 6% (n=837) had elevated LV filling pressures without RWMAs. Patients with a poststress E/e' ≥15 had a 2.71-fold increased mortality rate (2.28-3.21, P<.0001) compared with those with poststress E/e' ≤ 8. Those with an E/e' of 9 to 14, while at lower risk than the E/e' ≥15 cohort (hazard ratio [HR]= 0.58 [0.48-0.69]; P<.0001), had higher risk than if E/e' ≤8 (HR= 1.56 [1.37-1.78], P<.0001). On multivariable analysis, adjusting for age, sex, exercise capacity, LV ejection fraction, and presence of pulmonary hypertension with stress, patients with E/e' ≥15 had a 1.39-fold (95% CI, 1.18-1.65, P<.0001) increased risk of all-cause mortality compared with patients without elevated LV filling pressures. Compared with patients with E/e' ≤ 15 after exercise, patients with E/e' ≤15 at rest but elevated after exercise had a higher risk of cardiovascular death (HR= 8.99 [4.7-17.3], P<.0001). Patients with elevated LV filling pressures are at increased risk of death, irrespective of myocardial ischemia or LV systolic dysfunction. These findings support the routine incorporation of LV filling pressure assessment, both before and immediately following stress, into the evaluation of patients referred for exercise echocardiography.

Diagnostic accuracy of mitral E/e' and time between E and e' in predicting elevated left ventricular filling pressure in patients with nonvalvular atrial fibrillation undergoing coronary angiography

Abstract Background Assessment of left ventricular (LV) diastolic function using Doppler echocardiography is very challenging in atrial fibrillation (AF) because of the absence of mitral A wave and beat-to-beat variability. While mitral E/e’ retains its value in predicting elevated LV filling pressure (LVFP) in patients with AF, cut-off points remain variable. Moreover, the diagnostic accuracy of this parameter and the time between E and e’ (T E-e’) in predicting elevated LVFP in AF is unknown. Therefore, this study aims to determine the sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV, NPV) of mitral E/e’ and T E-e’ in predicting elevated LVFP among adult patients with nonvalvular AF undergoing coronary angiography in the Philippines from October 2022 to January 2023. Purpose Knowledge about the diagnostic accuracy of mitral E/e’ and T E-e’ in predicting elevated LVFP in adult Filipino patients with nonvalvular AF can lead to better management of left ventricular diastolic dysfunction (LVDD) in the Philippines. This study can also serve as a baseline for further studies to develop international recommendations for classifying LVDD in patients with nonvalvular AF. Methods A total of 44 adult patients with nonvalvular AF who underwent invasive measurement of LVEDP during coronary angiography then Doppler assessment of LVFP within 24 hours were included in this cross-sectional study. The primary outcome was determination of diagnostic accuracy of mitral E/e’ and T E-e’ in predicting elevated LVFP in the study population. Independent Samples T-test and Fisher’s Exact test were used to determine the difference of mean and frequency between patients with and without elevated LVFP. Area under the receiver operating characteristic curve (AUROC), Sn, Sp, NPV and PPV were used to determine the diagnostic accuracy of mitral E/e’ and T E-e’ to predict elevated LVFP. All statistical tests were two-tailed tests. Shapiro-Wilk test was used to test the normality of the continuous variables. STATA v13.1 was used for data analysis at 95% confidence interval. Results Overall, lateral E/e’ ≥ 9.8 has the highest diagnostic accuracy (82%) in predicting elevated LVFP in patients with nonvalvular AF with Sn of 83%, Sp of 80%, PPV of 89% and NPV of 70%. Average E/e’ ≥ 10.7 is also specific at 80%. Average E/e’ ≥ 10.7 and lateral TE-e’ ≥ 4.3 have the largest AUROC of 0.79 (95% CI 0.6550 to 0.9358) and 0.67 (95% CI 0.4888 to 0.8445), respectively. Of the T E-e’, lateral ≥ 4.3 ms has the highest diagnostic accuracy (70%) in predicting the same outcome but with poor AUROC (0.67; 95% CI 0.49 to 0.84). Conclusion Mitral E/e’ is accurate in predicting elevated LVFP in adult Filipino patients with nonvalvular AF. Lateral E/e’ ≥ 9.8 and average E/e’ ≥ 10.7 can be used as cut-offs to predict elevated LVFP in this population. T E-e’ has no additional diagnostic value to mitral E/e’ in predicting elevated LVFP in this study.

Abstract 16196: E/e' Predicts Exercise Capacity in Participants Undergoing Exercise Stress Test

Introduction: The ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (e’) is a surrogate for left ventricular (LV) filling pressure. Post-stress E/e’ has been shown to predict exercise capacity, but few studies have investigated this correlation with baseline E/e’. Our aim was to evaluate the relationship between baseline E/e’ and exercise capacity during stress test. Methods: All patients undergoing exercise stress testing at University of Virginia from 1/2015 through 9/2015 with the required echo data were included in this study. E/e’ was categorized into quartiles. ANOVA was used to evaluate the relationship between quartiles of E/e’ and exercise duration or METS. Multivariate linear regression was used to adjust for the variables: age, sex, ejection fraction, systolic blood pressure, heart rate, and regional wall motion abnormalities. Results: Baseline characteristics of the 312 participants based on E/e’ quartiles are shown in Table 1; those with higher E/e’, on average, had higher baseline SBP, were older, and had a higher percentage of females. There was a significant difference in exercise duration and METS between E/e’ quartiles (Table 2A) [p &lt; 0.001]. There was an inverse correlation between E/e’ and exercise capacity; the significance was more pronounced with increasing E/e’ (Table 2A) and was present even after adjusting for multiple covariates (Table 2B). Conclusions: Baseline E/e’ correlates with exercise capacity (both duration of exercise and total METS achieved). This suggests that elevated LV filling pressures at rest can predict exercise capacity and may be targeted in future studies to improve exercise tolerance.

Abstract 14176: Cardiac Structure and Function in Relation to Health-Related Quality of Life in Heart Failure Patients With Preserved Ejection Fraction: Results From the PARAGON-HF Study

Background: Health-related quality of life (HRQL) is reduced in patients with heart failure with preserved ejection fraction (HFpEF). However, the extent to which HRQL outcomes are related to cardiac structure and function in patients with HFpEF is not well understood. Methods: We examined the association between baseline echocardiographic measures and longitudinal Kansas City Cardiomyopathy Questionnaire (KCCQ) measures in patients with HFpEF in the PARAGON-HF trial using longitudinal regression models adjusted for age, sex, baseline KCCQ score, randomization, and other important clinical confounders. Results: Among 1,094 patients with baseline KCCQ data at randomization and a baseline echocardiogram within 6 months of enrollment, the mean age was 74 years and 53% were women. Over 3 years, 78% completed KCCQ measures at baseline, 12, 24, and 36 months. Missing values for non-survivors (n=116) were imputed as zero to avoid survival bias. Posterior wall thickness, septal E/e’, and right ventricular (RV) end diastolic area were negatively associated with the KCCQ Overall Summary Score, and a similar pattern of associations was observed for the KCCQ Clinical Summary Score (Table). Pulmonary artery systolic pressure was additionally negatively associated with the KCCQ Total Symptom Score. Notably, left ventricular (LV) size, septal wall thickness, LV ejection fraction, LV strain, and left atrial size were not significantly associated with longitudinal changes in KCCQ. Conclusion: In patients with HFpEF, increased LV posterior wall thickness, elevated LV filling pressure, elevated pulmonary pressure, and RV enlargement - together suggestive of more advanced diastolic dysfunction - are associated with a decline in KCCQ scores and may influence future worsening of quality of life.

Left ventricular rotational mechanics and left ventricular volumes: is there a relationship in healthy adults?-three-dimensional speckle-tracking echocardiography-derived insights from the MAGYAR-Healthy Study.

Left ventricular (LV) rotational mechanics play a crucial role in LV pump function by strengthening and improving its efficacy. Dependence of LV rotational parameters on left atrial volumes has already been demonstrated. The evaluation of the effect of LV rotational mechanics on LV volumes was purposed in a population of healthy subjects by three-dimensional speckle-tracking echocardiography (STE). The study comprised 175 healthy subjects with a mean age of 32.8±12.2 years (79 males). All subjects underwent a complete physical examination, laboratory assessments, standard 12-lead electrocardiography and two-dimensional Doppler and three-dimensional STE, the results of these examinations were within the normal range. Increased basal LV rotation was associated with increased LV volume measured in end-systole and impaired LV ejection fraction. Increased apical LV rotation was associated with reduced LV volumes assessed in end-diastole and in end-systole and increased ejection fraction of the LV. Elevated basal LV rotation showed associations with increased LV mass. In case of increasing basal LV rotation, apical LV rotation showed a decreasing tendency and LV twist showed a tendency of increasing. Similarly, lower basal LV rotation and increased LV twist were seen with increasing apical LV rotation. Increasing LV end-diastolic volume was associated with increasing LV volume measured in end-systole and preserved ejection fraction of the LV. Increasing LV end-systolic volume was associated with increasing LV end-diastolic volume and reduction of LV ejection fraction. Increasing LV volumes were associated with increasing LV mass. While increased LV volumes were associated with reduced apical LV rotation and twist, basal LV rotation did not show significant changes. LV rotational mechanics are strongly associated with LV volumes in healthy adults suggesting its volume-dependence.

Phenotyping heart failure by echocardiography: imaging of ventricular function and haemodynamics at rest and exercise.

Traditionally, congestive heart failure (HF) was phenotyped by echocardiography or other imaging techniques according to left ventricular (LV) ejection fraction (LVEF). The more recent echocardiographic modality speckle tracking strain is complementary to LVEF, as it is more sensitive to diagnose mild systolic dysfunction. Furthermore, when LV systolic dysfunction is associated with a small, hypertrophic ventricle, EF is often normal or supernormal, whereas LV global longitudinal strain can reveal reduced contractility. In addition, segmental strain patterns may be used to identify specific cardiomyopathies, which in some cases can be treated with patient-specific medicine. In HF with preserved EF (HFpEF), a diagnostic hallmark is elevated LV filling pressure, which can be diagnosed with good accuracy by applying a set of echocardiographic parameters. Patients with HFpEF often have normal filling pressure at rest, and a non-invasive or invasive diastolic stress test may be used to identify abnormal elevation of filling pressure during exercise. The novel parameter LV work index, which incorporates afterload, is a promising tool for quantification of LV contractile function and efficiency. Another novel modality is shear wave imaging for diagnosing stiff ventricles, but clinical utility remains to be determined. In conclusion, echocardiographic imaging of cardiac function should include LV strain as a supplementary method to LVEF. Echocardiographic parameters can identify elevated LV filling pressure with good accuracy and may be applied in the diagnostic workup of patients suspected of HFpEF.

Complexity of left ventricular strains in response to elevated volumes in healthy adults – Detailed analysis from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

IntroductionCardiac haemodynamics is described by the Frank-Starling law, which states that the strength of the left ventricular (LV) systolic contraction is related to the LV diastolic filling, with other words LV stroke volume increases as LV volume increases due to the stretching of the myocyte. The purpose of the present study was to examine how the increasing LV volumes affect LV contractility represented by three-dimensional (3D) speckle-tracking echocardiography (3DSTE) -derived LV strains in healthy adults. MethodsThis is post-hoc analysis of the MAGYAR-Healthy Study employing a novel method for technical analysis of echocardiographic datasets. The present study consisted of 301 healthy adults. Due to inferior image quality, 127 subjects have been excluded, therefore the remaining population included 174 subjects (mean age: 32.9 ± 12.1 years, 80 males). All cases have undergone complete two-dimensional Doppler echocardiography extended with 3DSTE. ResultsLV global longitudinal (gLS) and area (gAS) strains were lowest in case of the highest LV end-diastolic volume (EDV). LV global radial (gRS) and 3D (g3DS) strains tendentiously increased with increasing LV-EDV. When segmental analysis was performed, increased LV-EDV was associated with increase of basal LV-RS and LV-3DS. Increased LV strains were associated with increased LV ejection fraction (EF) due to higher LV-EDV for LV-gRS (and LV-g3DS), lower LV-ESV for LV-gCS and lower LV-EDV and LV-ESV for LV-gLS (and LV-gAS). With increasing LV-gRS, LV-gCS and LV-g3DS, all LV strains increased except LV-gLS. With increasing LV-gLS, LV-gRS did not show any increase, LV-gCS and LV-g3DS were the highest when LV-gLS was the highest, while LV-gAS increased simultaneously. With increasing LV-gAS, all LV strains increased. ConclusionsThere is a complex contractility pattern of LV segments/regions in response to elevated LV volumes in healthy circumstances.

Estimating elevated left ventricular end-diastolic pressure by automated left atrial strain analysis in patients with aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background The evaluation of left ventricular (LV) filling pressure using left atrial (LA) reservoir strain on echocardiography has demonstrated high feasibility and good accuracy. Other LA strain components, such as conduit and booster strain, may show additional diagnostic value for the detection of elevated LV filling pressure. The current automated LA strain analysis has the potential to predict elevated LV end-diastolic pressure (LVEDP) using all LA strain components. Aims The aim of this study is to assess the diagnostic accuracy of automated LA strain for the detection of elevated LVEDP as measured by invasive catherization in comparison to conventional echocardiographic parameters. Methods We included the patients with aortic stenosis (AS) who underwent echocardiography within 48 hours prior to transcatheter aortic valve implantation and had LVEDP measured by catherization during procedure. Patients with atrial fibrillation, previous mitral valve surgery, and mitral stenosis were excluded. LA strain components were measured from apical 4-chamber view using commercial software (AutoStrain LA, Tomtec). (Abstract Picture 1) Elevated LVEDP was defined as a threshold of LVEDP ≥16 mmHg. The cut-off value of conventional echocardiographic parameters for detection of elevated LVEDP were determined according to current guidelines. Results A total of 95 patients (84 ± 7 years, 53% men) were included in this study. Elevated LVEDP was shown in 42 patients. The sensitivity and diagnostic accuracy for the detection of elevated LVEDP on automated LA strain were the best among conventional echocardiographic parameters, including peak reservoir LA strain. (Abstract picture 2) The diagnostic accuracy of automated LA strain was similar between in patients with LV ejection fraction ≥ 50% and those with LV ejection fraction &amp;lt;50% (82% vs 86%). Conclusions Automated LA strain analysis demonstrated superior diagnostic accuracy for the detection of elevated LVEDP in patients with AS. It might thus serve as a non-invasive and accurate alternative method for assessment of elevated LV filling pressure.

P73: Subclavian Artery Cannulation For Left Ventricular Unloading During Extracorporeal Membrane Oxygenation Support

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective mechanical circulatory support for cardiac insufficiency following cardiac surgery especially cardiac surgery with extracorporeal circulation, which can quickly restore the perfusion of vital organs. However, retrograde blood flow in the aorta during VA-ECMO may lead to increased left ventricular (LV) afterload, elevated LV filling pressure, mitral insufficiency, and elevated left atrial pressure, which may subsequently result in reduced coronary blood flow and pulmonary edema, thus aggravating the patient’s condition. Therefore, LV unloading is necessary during VA-ECMO. The optimal approach for LV unloading remains undefined, but the percutaneous access has been increasingly used over time. To addresss this issue, we have attempted to use cannulation of the subclavian artery for left ventricular unloading during VA-ECMO. This study aims to describe our method and report the preliminary results in three patients. Methods: Three patients with low cardiac output syndrome after cardiac surgery. All 3 patients had difficulty weaning from cardiopulmonary bypass (CPB) due to overfilling and contractile weakness of the heart, low mean arterial pressure<80mmHg, and left atrial pressure of >20 mmHg. Decision was made to start ECMO support immediately, and LV unloading was initiated via cannulation of the subclavian artery (Table 1). Given the differences in the surgical approaches and condition of patients, three methods were used to achieve LV unloading via the subclavian artery.Methods of LV unloading with cannulation via the subclavian artery during VA-ECMO in three patients with low cardiac output syndrome after cardiac surgery: 1) VA-ECMO with LV unloading via subclavian artery; 2) femoral vein-to-subclavian artery VA-ECMO with LV unloading via a 4-branched graft; 3) LV bypass via femoral artery-subclavian artery. Results: In all patients, the subclavian artery cannula was withdrawn at postoperative days 2-3, and ECMO was successfully weaned on postoperative day 4. One patient developed cardiac tamponade within 24 hour of surgery, echocardiography showed an LVEF of 55%. During an exploratory thoracotomy, a large amount of blood clot about 500 mL was found in the pericardium and removed, and the patient recovered uneventfully. Table 2 summarizes the postoperative courses of the 3 patients with different LV unloading methods. Conclusion: This study partly illustrated that LV drainage via the subclavian artery could safely and effectively reduce the LV load, prevent VA-ECMO-related complications, and minimize the risk of trauma and infection during LV examinations. Certainly, whether the subclavian artery approach is the optimal strategy for LV unloading as well as patient risks and benefits remains to be further investigated.Figure 1. ECMO + LV unloading schematic diagram of Case 1 (femoral artery + femoral vein+ subclavian artery)Figure 2. ECMO + LV unloading schematic diagram of Case 2 (femoral artery + femoral vein + four branches aortic graft)Figure 3. LV unloading schematic diagram of Case 2 (femoral artery + subclavian artery)

Myocardial function including estimates of myocardial work in young adults born very preterm or with extremely low birthweight - a cohort study

BackgroundPreterm birth and low birthweight have been associated with increased risk of heart failure and cardiovascular disease in young adulthood. However, results from clinical studies of myocardial function are not consistent. Echocardiographic strain analyses allow detection of early stages of cardiac dysfunction, and non-invasive estimates of myocardial work can provide additional information on cardiac function. We aimed to evaluate left ventricular (LV) myocardial function including measures of myocardial work in young adults born very preterm (gestational age < 29 weeks) or with extremely low birthweight (< 1000 g) (PB/ELBW), compared with term-born age- and sex matched controls.Methods63 PB/ELBW and 64 controls born in Norway in the periods 1982–1985, 1991–1992, and 1999–2000 were examined with echocardiography. LV ejection fraction (EF) and LV global longitudinal strain (GLS) were measured. Myocardial work was estimated from LV pressure-strain loops after determination of GLS and construction of a LV pressure curve. Diastolic function was evaluated by determination of the presence or absence of elevated LV filling pressure, including measures of left atrial longitudinal strain.ResultsThe PB/ELBW with mean birthweight 945 (standard deviation (SD) 217) grams, mean gestational age 27 (SD 2) weeks, and mean age 27 (SD 6) years had LV systolic function mainly within normal range. Only 6% had EF < 50% or impaired GLS >-16%, but 22% had borderline impaired GLS between − 16% and − 18%. Mean GLS in PB/ELBW (-19.4% (95% confidence interval (CI) -20.0, -18.9)) was impaired compared to controls (-20.6% (95% CI -21.1, -20.1)), p = 0.003. Lower birthweight was associated to more impaired GLS (Pearson correlation coefficient − 0.2). Means of EF, measures of diastolic function including left atrial reservoir strain, global constructive and wasted work, global work index and global work efficiency was similar in PB/ELBW and controls.ConclusionThe young adults born very preterm or with extremely low birthweight had impaired LV-GLS compared to controls, although systolic function mainly within normal range. Lower birthweight was associated with more impaired LV-GLS. These findings could indicate an elevated lifetime risk of developing heart failure in preterm born individuals. Measures of diastolic function and myocardial work were similar compared to controls.

Cardiologic Manifestations in Omicron‐Type Versus Wild‐Type COVID‐19: A Systematic Echocardiographic Study

Background Information about the cardiac manifestations of the Omicron variant of COVID-19 is limited. We performed a systematic prospective echocardiographic evaluation of consecutive patients hospitalized with the Omicron variant of COVID-19 infection and compared them with similarly recruited patients were propensity matched with the wild-type variant. Methods and Results A total of 162 consecutive patients hospitalized with Omicron COVID-19 underwent complete echocardiographic evaluation within 24 hours of admission and were compared with propensity-matched patients with the wild-type variant (148 pairs). Echocardiography included left ventricular (LV) systolic and diastolic, right ventricular (RV), strain, and hemodynamic assessment. Echocardiographic parameters during acute infection were compared with historic exams in 62 patients with the Omicron variant and 19 patients with the wild-type variant who had a previous exam within 1 year. Of the patients, 85 (53%) had a normal echocardiogram. The most common cardiac pathology was RV dilatation and dysfunction (33%), followed by elevated LV filling pressure (E/e' ≥14, 29%) and LV systolic dysfunction (ejection fraction <50%, 10%). Compared with the matched wild-type cohort, patients with Omicron had smaller RV end-systolic areas (9.3±4 versus 12.3±4 cm2; P=0.0003), improved RV function (RV fractional-area change, 53.2%±10% versus 39.7%±13% [P<0.0001]; RV S', 12.0±3 versus 10.7±3 cm/s [P=0.001]), and higher stroke volume index (35.6 versus 32.5 mL/m2; P=0.004), all possibly related to lower mean pulmonary pressure (34.6±12 versus 41.1±14 mm Hg; P=0.0001) and the pulmonary vascular resistance index (P=0.0003). LV systolic or diastolic parameters were mostly similar to the wild-type variant-matched cohort apart from larger LV size. However, in patients who had a previous echocardiographic exam, these LV abnormalities were recorded before acute Omicron infection, but not in the wild-type cohort. Numerous echocardiographic parameters were associated with higher in-hospital mortality (LV ejection fraction, stroke volume index, E/e', RV S'). Conclusions In patients with Omicron, RV function is impaired to a lower extent compared with the wild-type variant, possibly related to the attenuated pulmonary parenchymal and/or vascular disease. LV systolic and diastolic abnormalities are as common as in the wild-type variant but were usually recorded before acute infection and probably reflect background cardiac morbidity. Numerous LV and RV abnormalities are associated with adverse outcome in patients with Omicron.