Global Left Ventricular Systolic Function Research Articles

“A BROKEN TRANSPLANTED HEART”: A CASE OF TAKOTSUBO SYNDROME IN A HEART TRANSPLANT RECIPIENT

Abstract 75–year–old female patient went to the emergency department for oppressive chest pain radiating to the left arm and dyspnea, developed after an argument with family members. The patient underwent heart transplant in 2010 because of chronic ischemic heart disease. In history: systemic arterial hypertension, former smoking, dyslipidemia, and chronic renal failure. At blood tests: TnIHS 78.4 ng/L (<29 ng/L), CK–MB 1.9 microg/L, PROBNP–NT 43,000 pg/ml, creatinine 2 mg/dL. ECG showed inverted T waves in DI, AVL and V4 to V6 (fig 1). Transthoracic echocardiography was remarkable for a moderate reduction in systolic function (EF 38%), akinesia of apical portion, mid–segment of the IVS and mid–segment of posterior wall. Coronarography showed epicardial coronaries free of angiographically significant lesions. We decided to not perform ventriculography to avoid worsening renal function. At clinical stabilization, the patient underwent cardiac MRI with evidence of hypokinesia of the mid–ventricular segments with preserved global systolic function and hypo/akinesia of right ventricular apex with endocavitary thrombosis. Tissue characterization images were compatible with the presence of diffuse phlogistic involvement of the left ventricular myocardium (most evident at the mid–ventricular segments), in the absence of areas of myocardial necrosis. On pre–dimission echocardiogram, global left ventricular systolic function appeared markedly improved (auto EF 52%). DISCUSSION Our case is a rare case of Takotsubo syndrome (TS) in a transplanted heart. While TS accounts for 1–2% of all ACS in the general population, there is no precise data on its prevalence in heart transplant recipients. Although the pathophysiological mechanism underlying TS is still debated, there is evidence of hyperactivation of the sympathetic system with excessive catecholamine release. What is particular in our clinical case is that transplanted heart is denervated (because of resection of the post–ganglionic neural axons), although in some patients there is progressive reinnervation starting around the second year. Myocardial scintigraphy with iodine–123 meta iodobenzylguanidine can be used to study reinnervation. In our case, the presence of typical angor may be a clinical indicator of reinnervation, as many transplant patients present with CAV in the absence of chest pain.

Cardiac Magnetic Resonance Imaging Based Ischemic Injury Pattern in Patients with Acute Myocardial Infarction Sensu Left Ventricular Global Systolic Function.

The purpose of the study was to identify factors characterizing a decrease in LV global systolic function in patients with ST-segment elevation myocardial infarction (STEMI) after revascularization using cardiac magnetic resonance imaging (MRI)-based ischemic injury pattern and laboratory parameters sensu left ventricular global systolic function. A total of 109 STEMI patients were examined. The patients underwent contrast-enhanced cardiac MRI with a 1.5 Tesla GE SIGNA Voyager (GE HealthCare, Chicago, IL, USA) on the 7th-10th days from the onset of the disease. According to cardiac MRI analysis, the patients were divided into the following groups with regard to left ventricular ejection fraction (LVEF) values: Group 1-patients with LVEF ≥ 50%; group 2-patients with mildly reduced LVEF 40-49%; group 3-patients with low LVEF < 40%. A predominance of most parameters of the ischemic injury pattern was noted in patients with mildly reduced and low LVEF versus patient group with LVEF ≥ 50%. Some risk factors for a decrease in LVEF < 50% systolic function in STEMI patients after revascularization were revealed: male gender; time from the onset of the anginal attack to revascularization; coronary artery status; several LV parameters; ischemic injury characteristics; natriuretic peptide and troponin I levels.

From ejection fraction, to myocardial strain, and myocardial work in echocardiography: Clinical impact and controversies.

Enhancing an echocardiographic tool, aimed to detect even subtle left ventricular (LV) systolic function abnormalities, capable of obtaining both early diagnosis and risk prediction of heart disease, represents an ambitious, attractive, and arduous purpose in the modern era of cardiovascular imaging. Ideally, that tool should be simple, reliable, and reproducible, in order to be concretely applied in routine clinical practice. Importantly, that technique should be physiologically plausible and useful both at the population-level, as well as in the individual subject. For a long time, LV ejection fraction (EF) has been considered the first-line parameter for assessing LV global systolic function, strictly related to the prognosis, at least in some settings. However, LV EF limitations are well-known, even though frequently overemphasized, including its load-dependency. Therefore, myocardial strain techniques have been proposed, deemed able to disclose even subtle early LV function anomalies. Nevertheless, many disadvantages of myocardial strain have been reported as well. More recently, myocardial work (MW) analysis has been introduced as a new echocardiographic tool for the evaluation of LV global systolic function, attempting to overcome EF and strain disadvantages. However, MW has shown many limits as well. Notwithstanding, LV EF still remains a landmark functional classification marker for heart failure and cardiac oncology, allowing reliable fast reassessment of LV function changes during patient management, in order to guide treatment in individual cases as well. Notably, global longitudinal strain and MW parameters seem to show better meaningful results at the population-level, but controversial clinical impact, major limitations, wide cut-offs spread and overlap, when the single value needs to be applied to the single case. Taking into account the recent literature-based evidence, the scope of the present narrative critical review is trying to delineate the different types of information given by the described LV global systolic function parameters, both at the population-level and in the individual case, in order to trace a comparative analysis of advantages and limitations in clinical practice.

Application of Global Longitudinal Strain as a Parameter of Left Ventricular Systolic Function in Echocardiography

Global longitudinal strain (GLS) derived from speckle tracking has emerged as an important tool in assessing myocardial function, offering sensitive insights into cardiac performance. This review highlights GLS as a valuable technique for early detection and monitoring of various cardiac conditions, including heart failure, ischemic heart disease, and valvular heart disease. GLS is a measure of deformation along the longitudinal axis of the heart, providing a quantitative assessment of global left ventricular systolic function. It surpasses traditional parameters like ejection fraction in sensitivity, detecting abnormalities at earlier stages. Additionally, GLS is a robust predictor of adverse events in a wide spectrum of cardiac diseases. While GLS shows promise, it does have some drawbacks like relying on image quality and standardized guidelines. However, its high consistency and lower reliance on the operator make it more reliable in real-world clinical settings. Overall, GLS is an indispensable tool in cardiovascular imaging, empowering clinicians to detect subtle changes in cardiac function, predict adverse events, and optimize patient care and outcomes.

Point of care ultrasonography in the evaluation of myocardial dysfunction due to sepsis.

Background: Septic shock is commonly diagnosed in critically ill patients and is an important cause of mortality. Techniques used to assess fluid responsiveness and hemodynamic profile with physical examination and central venous pressure have been shown to be insufficient. Thus, the importance of other methods, such as bedside ultrasound (POCUS), is evident. The aim of this study was to analyze patients with septic shock who developed left ventricular dysfunction by POCUS. Methods: Prospective study involving 14 patients diagnosed with septic shock, over 18 years old, without previous cardiac pathologies. Clinical, laboratory and imaging data were collected. POCUS was applied by a cardiology resident; the results were compared with those found by an echocardiographer. Results: Variables were compared between patients with normal and depressed ventricular function (VF). Mean arterial pressure was significantly lower in patients with depressed VF (p = 0.01). Vasopressor drug dose and Pro-BNP value were significantly higher in patients with depressed VF (p = 0.01). Regarding the POCUS inter-rater comparison, the variables of left ventricular global systolic function, vena cava index and presence of B line were significantly concordant (p= 0.02; 0.003; 0.002). Conclusions: Patients with depressed VF had a greater severity of shock, suggesting refractoriness, with cardiac dysfunction as a possible aggravating factor, which was visualized only by POCUS and corroborated by higher Pro-BNP values. A short POCUS training is enough for the non-specialist physician to be able to use this resource in the management of these patients.

Effect of ischemic injury characteristics on left ventricular systolic function in patients with acute myocardial infarction

Aim. To study laboratory and magnetic resonance imaging (MRI) characteristics of infarction area depending on left ventricular (LV) global systolic function in patients with acute myocardial infarction (AMI) after revascularization.Material and methods. A total of 78 patients with primary AMI were included. On days 7-10, contrast-enhanced cardiac MRI was performed. Blood brain natriuretic peptide (BNP) was analyzed. Cardiac MRI was used to determine the characteristics of scar tissue, peri-infarct zone (PIZ), microvascular obstruction (MVO), intramyocardial hemorrhage (IMH) and the global contrast index.Results. According to the MRI, patients were divided into following groups: group 1 — LV ejection fraction (LVEF) ≥50% (n=50), group 2 — LVEF 40-49% (n=21), group 3 — LVEF &lt;40% (n=7).The BNP in groups 1, 2, 3 was 106,8 (37,5; 248), 232,6 (170,1; 337,7) and 548,5±236,4 ng/ml, respectively (p1-3&lt;0,05). The scar tissue mass in groups 1, 2, 3 was 10,3 (2,4; 20,0), 34,7±21,3, 59,4±37,6 g, respectively (p1-2, 3&lt;0,01). PIZ differences were found only between patients with preserved and mildly reduced EF. MVO was diagnosed in 26% of patients with LVEF ≥50%, in 47,6% of patients with LVEF of 40-49% and 85,7% with LVEF &lt;40% (p1-3&lt;0,01). The detection rate of IMH prevailed in the 2nd group (33,3%) compared with the 1st group (12%) (p1-2&lt;0,05). The global contrast index was the lowest in the 1st group (14,7 (8,8; 27,9)%), intermediate in the 2nd group (33,3±12,6%), the highest in the 3th group (54,2±19,5%) (р1-2, 3; 2-3&lt;0,05).Conclusion. The following risk factors for a decrease in LV systolic function in patients with AMI after revascularization were identified: the size of scar tissue, PIZ, MVO and IMH characteristics, global contrast index, BNP level.

Study on the correlation between cardiac function indices measured by velocity vector imaging and disease severity in patients with Parkinson disease.

This study aimed to evaluate cardiac function, particularly left ventricular systolic function, in patients with Parkinson disease (PD) using velocity vector imaging (VVI), and to determine whether a correlation exists between left ventricular global systolic function and PD severity. A case-control study design was used to select 56 PD patients and 30 healthy controls from January 2019 to December 2019. The characteristics of age, sex, BMI and course of disease were collected. The Hoehn-Yahr (H-Y) score was collected to record the grading of PD. The left ventricular systolic function of all patients was evaluated by variable vapor injection (VVI). The left ventricular systolic function was compared between the case group and the control group, and the correlation between cardiac dysfunction and the severity of PD symptoms was assessed using the modified H-Y scale. Compared with control group, left ventricular global systolic function18.22 (17.08, 19.12) vs 18.88 (18.12, 20.01) was lower in PD patients as indicated by left ventricular global longitudinal strain (GLS), and the difference was statistically significant (P = 0.039). Additionally, H-Y scores (r = -0.404) and PD duration(r = -0.323) were significantly correlated with reduced left ventricular ejection fraction (P < 0.01), GLS (P < 0.001), left ventricular global radial strain (GRS; P < 0.001), and left ventricular global circumferential strain (GCS; P < 0.001), along with their associated peak strain rates (GLSr, GRSr, and GCSr; P < 0.001). Subclinical left ventricular global systolic dysfunction in patients with PD can be detected using VVI, and reduced left ventricular systolic function correlates with the modified H-Y score and duration of the disease.

Evaluation of Subclinical Left Ventricular Systolic Dysfunction By Global Longitudinal Strain Using 2D Speckle Tracking Echocardiography in Angina With Normal Epicardial Coronary Arteries

Background: Global longitudinal strain (GLS), assessed by 2D speckle tracking echocardiography (2D-STE), may offer a valuable non-invasive method to assess subclinical left ventricular (LV) systolic dysfunction in patients with chest pain but normal epicardial coronary arteries. The primary objective of the study was to detect subclinical LV systolic dysfunction by GLS using 2D-STE in patients with angina with normal coronary arteries and conventional echocardiograms at baseline. Methods: This was a comparative case–control study that included patients with complaints of an ischaemic pattern of chest pain despite normal coronary arteries (cases) and healthy individuals (controls). Resting LV systolic function was assessed by transthoracic echocardiography and GLS using 2D-STE analysis. The results of all three planes in GLS (the apical four-chamber, two-chamber, and three-chamber views) were combined in a single ‘bull’s eye’ summary (agreeing with the standard 17-segment model), which presented the analysis of each segment along with a global peak systolic strain value for the LV. Results: The study included 120 participants (60 cases and 60 controls). The normal reference value of the mean GLS in the control group was −19.7 ± 1.84%. GLS assessed by 2D-STE was significantly impaired in patients with angina-like syndrome with normal epicardial coronary arteries (−18.78 ± 1.87 versus −19.7 ± 1.84%; p&lt;0.007) compared with the control group despite preserved LV ejection fraction. In the case group, GLS reduced significantly in eight patients (13.3%) than control group. Conclusion: Patients with angina with normal epicardial coronary arteries are likely to have microvascular disease. GLS assessed by 2D-STE has the potential to improve the value of echocardiography in coronary microvascular disease detection. Despite normal LV ejection fraction, significant impairment of LV global longitudinal systolic function can differentiate a microvascular group of patients from others who have angina with normal coronaries.

P168 FOLLOW–UP IN A PATIENT WITH LYMPHOMA UNDERGOING CHEMOTHERAPY TREATMENT

Abstract We present the case of a 55–year–old hypertensive patient, with no other cardiovascular risk factors and no noteworthy cardiovascular history. Suffering from lymphoma, derived from grade I/II peripheral B lymphocytes, diagnosed in January 2018, underwent chemotherapy according to the R–CHOP scheme and continued until September 2021 with immunotherapy (Rituximab). The follow–up cardiological evaluation in September 2022 refers to dyspnoea for moderate exertion and some episodes of stinging chest pain, of short duration, not associated with neurovegetative symptoms. The Echocardiogram documented a left ventricular global systolic function at the lower limits of the norm evaluated with Eco3D (FE 53%). GLS –17.6%. ECG normal. A Coro–Tc was recommended and scheduled which documented the presence on the middle part of the anterior descending artery of partially calcified atheromatous plaque which extends for about 5 mm and which determines the reduction of the area by 67% and of the diameter of 70% therefore the patient underwent a coronary angiography with angioplasty with implantation of a medicated stent on IVA. This case demonstrates how important it is to perform a careful follow–up in cancer patients and how properly used imaging methods can help us in diagnosis and treatment.

Lifetime Evaluation of Left Ventricular Structure and Function in Male C57BL/6J Mice after Gamma and Space-Type Radiation Exposure

The lifetime effects of space irradiation (IR) on left ventricular (LV) function are unknown. The cardiac effects induced by space-type IR, specifically 5-ion simplified galactic cosmic ray simulation (simGCRsim), are yet to be discovered. Three-month-old, age-matched, male C57BL/6J mice were irradiated with 137Cs gamma (γ; 100, 200 cGy) and simGCRsim (50 and 100 cGy). LV function was assessed via transthoracic echocardiography at 14 and 28 days (early), and at 365, 440, and 660 (late) days post IR. We measured the endothelial function marker brain natriuretic peptide in plasma at three late timepoints. We assessed the mRNA expression of the genes involved in cardiac remodeling, fibrosis, inflammation, and calcium handling in LVs harvested at 660 days post IR. All IR groups had impaired global LV systolic function at 14, 28, and 365 days. At 660 days, 50 cGy simGCRsim-IR mice exhibited preserved LV systolic function with altered LV size and mass. At this timepoint, the simGCRsim-IR mice had elevated levels of cardiac fibrosis, inflammation, and hypertrophy markers Tgfβ1, Mcp1, Mmp9, and βmhc, suggesting that space-type IR may induce the cardiac remodeling processes that are commonly associated with diastolic dysfunction. IR groups showing statistical significance were modeled to calculate the Relative Biological Effectiveness (RBE) and Radiation Effects Ratio (RER). The observed dose-response shape did not indicate a lower threshold at these IR doses. A single full-body IR at doses of 100-200 cGy for γ-IR, and 50-100 cGy for simGCRsim-IR decreases the global LV systolic function in WT mice as early as 14 and 28 days after exposure, and at 660 days post IR. Interestingly, there is an intermediate time point (365 days) where the impairment in LV function is observed. These findings do not exclude the possibility of increased acute or degenerative cardiovascular disease risks at lower doses of space-type IR, and/or when combined with other space travel-associated stressors such as microgravity.

Global Longitudinal Strain in Cardio-Oncology: A Review.

Several therapies used in cancer treatment are potentially cardiotoxic and may cause left ventricular (LV) dysfunction and heart failure. For decades, echocardiography has been the main modality for cardiac assessment in cancer patients, and the parameter examined in the context of cardiotoxicity was the left ventricular ejection fraction (LVEF). The assessment of the global longitudinal strain (GLS) using speckle tracking echocardiography (STE) is an emerging method for detecting and quantifying subtle disturbances in the global long-axis LV systolic function. In the latest ESC guidelines on cardio-oncology, GLS is an important element in diagnosing the cardiotoxicity of oncological therapy. A relative decrease in GLS of >15% during cancer treatment is the recommended cut-off point for suspecting subclinical cardiac dysfunction. An early diagnosis of asymptomatic cardiotoxicity allows the initiation of a cardioprotective treatment and reduces the risk of interruptions or changes in the oncological treatment in the event of LVEF deterioration, which may affect survival.

Left Ventricular Global Longitudinal Strain Following Acute ST-Elevation Myocardial Infarction - A Comparison of Primary Coronary Angioplasty and Tenecteplase-Based Pharmacological Reperfusion Strategy.

In the setting of acute ST-elevation myocardial infarction (STEMI), reperfusion therapy with primary percutaneous coronary intervention (PCI) performed by an experienced team or pharmacological reperfusion with thrombolytic therapy is highly recommended. Standard echocardiographic measurement of the left ventricular ejection fraction (LVEF) is widely used to assess left ventricular global systolic function. This study was designed to compare the assessment of global left ventricular function by standard LVEF and global longitudinal strain (GLS) in the two well-known reperfusion strategies. We conducted a retrospective single-center observational study in 50 patients with acute STEMI who underwent primary PCI (n = 25) and Tenecteplase (TNK)-based pharmacological reperfusion therapy (n = 25). The primary outcome was left ventricle (LV) systolic function after primary PCI, as assessed by two-dimensional (2D) GLS using speckle-tracking echocardiography (STE), as well as LVEF using standard 2D echocardiogram using Simpson's biplane method. Overall mean age was 53.7 ± 6.9 years with 88% male gender. The mean door-to-needle time was 29.8 ± 4.2 min in the TNK-based pharmacological reperfusion therapy arm, and the mean door-to-balloon time was 72.9 ± 15.4 min in the primary PCI arm. LV systolic function was significantly better in the primary PCI arm as compared to the TNK-based pharmacological reperfusion therapy, both by 2D STE (mean GLS: -13.6 ± 1.4 vs. -10.3 ± 1.2, P ≤ 0.001) and LVEF (mean LVEF: 42.2 ± 2.9 vs. 39.9 ± 2.7, P = 0.006). There were no significant differences in mortality and inhospital complications in both groups. Global LV systolic function is significantly better after primary coronary angioplasty as compared to TNK-based pharmacological reperfusion therapy when assessed by routine LVEF and 2D GLS in the setting of acute STEMI.

Strain Imaging in Aortic Stenosis

Although aortic stenosis (AS) is a disease of poor outcomes, timely aortic valve replacement [AVR -surgical AVR (SAVR) or transcatheter AVR (TAVR)] improves the outlook with acceptable procedural risk. Survivors of AVR enjoy life expectancy that is like that of age matched controls. AVR receives a class I indication from the American and European Guidelines, in the presence of symptoms attributable to AS or when left ventricular (LV) systolic dysfunction manifests. However, there are fallacies in timing the intervention based on symptoms or LV ejection fraction. If surgery is delayed till symptoms manifest or LV dysfunction occurs, surgical risks are increased, long term outcomes are poor and in half of the patients, LV function never normalizes. Because of these reasons, pre-emptive intervention based on non-conventional parameters is expected to save more lives and prevent LV dysfunction. Data are emerging towards this approach and researchers have started focussing their attention on biomarkers like brain natriuretic peptide, multimodality imaging like estimation of extracellular volume by cardiac magnetic resonance for choosing the appropriate time for intervention in asymptomatic individuals. A relatively inexpensive way of identifying such high-risk individuals is speckle tracking imaging and in the last decade sufficient data have accumulated in favour of this modality to identify patients who may be benefited by early intervention. Speckle tracking echocardiography is a well validated technique which enables highly reproducible, angle-independent assessment of regional and global LV systolic function in longitudinal, circumferential and radial planes. Longitudinal strain, which is predominantly governed by the subendocardial layer, is most sensitive in the presence of myocardial disease and well-studied. Moreover, when discrepancies occur between gradient and valve area leading to uncertainties about the severity of AS, strain imaging would be of value in predicting outcomes particularly in those with low flow low gradient AS with normal LV ejection fraction.

Global Left Ventricular Myocardial Work Efficiency in Patients With Severe Rheumatic Mitral Stenosis and Preserved Left Ventricular Ejection Fraction.

Assessment of left ventricular (LV) function plays a pivotal role in the management of patients with valvular heart disease, including those caused by rheumatic heart disease. Noninvasive LV pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate global LV systolic function, integrating longitudinal strain by speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work. The aim of this study was to characterize global LV myocardial work efficiency in patients with severe rheumatic mitral stenosis (MS) with preserved ejection fraction (EF). We retrospectively included adult patients with severe rheumatic MS with preserved EF (> 50%) and sinus rhythm. Healthy individuals without structural heart disease were included as a control group. Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. A total of 45 individuals with isolated severe rheumatic MS with sinus rhythm and 45 healthy individuals were included. In healthy individuals without structural heart disease, the mean global LV myocardial work efficiency was 96% (standard deviation [SD], 2), Compared with healthy individuals, median global LV myocardial work efficiency was significantly worse in MS patients (89%; SD, 4; p < 0.001) although the LVEF was similar. Individuals with isolated severe rheumatic MS and preserved EF, had global LV myocardial work efficiencies lower than normal controls.

Myocardial strain indices and coronary flow reserve are only mildly affected in healthy hypertensive patients

Abstract Hypertension is a major risk factor for cardiovascular disease and is associated with functional and structural changes in the heart and the vessels. Left ventricular deformation imaging with 2D Strain Echocardiography (2DSTE) and stress echocardiography with a vasodilator,such as dipyridamole (DIPSE), are useful tools for the detection of early myocardial abnormalities in hypertensive patients The aim of the current study was to investigate whether early (relatively healthy) hypertensive patients with normal left ventricular (LV) ejection fraction may differ in 2D Strain indices at baseline and in response to a stress test such as dipyridamole, compared to healthy controls. In the current study, the associations of 2DSTE indices and their changes following DIPSE with other studied parameters were also assessed. Forty-seven male hypertensive patients (aged 57±9 years) with normal ejection fraction and without left ventricular hypertrophy and 20 healthy male subjects were studied with conventional and 2D Strain echocardiography at rest and post DIPSE. Coronary flow reserve (CFR) in the left anterior descending artery following DIPSE was also evaluated. Global longitudinal strain (GLS) and TWIST were higher while UNTWIST rate was lower in hypertensives versus controls (p&amp;lt;0.05 for all). TWIST remained higher in hypertensives (p=0.021) after adjustment for differences in age and body mass index (BMI) between the groups. CFR was higher in controls compared to hypertensives even after adjustment for confounders (4.14 vs. 2.53, p=0.001). DIPSE-induced changes did not differ between the groups after adjustment for age and BMI (p&amp;gt;0.05 for all). DIPSE-induced improvement in GLS was associated with higher CFR only in hypertensive patients (r −0.372, p=0.010). The current study showed that well controlled hypertensive patients have mild echocardiographic differences compared to controls. Some of these differences appear to depend on age and Body mass index. A “hyper-rotation” phenomenon (higher TWIST) early in hypertension may be a compensatory mechanism to preserve global systolic LV function. Coronary microcirculatory function was impaired in hypertensive patients, albeit within normal range, and was associated with DIPSE-induced changes in myocardial long-axis systolic function. Funding Acknowledgement Type of funding sources: None.

Severe Impairment of Left Ventricular Regional Strain in STEMI Patients Is Associated with Post-Infarct Remodeling.

Background: Measures of global left ventricular (LV) systolic function have limitations for the prediction of post-infarct LV remodeling (LVR). Therefore, we tested the association between a new measure of regional LV systolic function—the percentage of severely altered strain (%SAS)- and LVR after acute ST-elevation myocardial infarction (STEMI). As a secondary objective, we also evaluated the association between %SAS and clinical events during follow-up. Methods: Of 177 patients undergoing echocardiography within 24 h from primary percutaneous coronary angioplasty, 172 were studied for 3 months, 167 for 12 months, and 10 died. The %SAS was calculated by dividing the number of LV myocardial segments with ≥−5% peak systolic longitudinal strain by the total number of segments. LVR was defined as the increase in end-diastolic volume >20% at its first occurrence compared to baseline. Results: LVR percentage was 10.2% and 15.8% at 3 and 12 months, respectively. Based on univariable analysis, a number of clinical, laboratory, electrocardiographic and echocardiographic variables were associated with LVR. Based on multivariable analysis, %SAS and TnI peak remained associated with LVR (for %SAS 5% increase, OR 1.226, 95% CI 1.098–1.369, p < 0.0005; for TnI peak, OR 1.025, 95% CI 1.004–1.047, p = 0.022). %SAS and LVR were also associated with occurrence of clinical events at a median follow-up of 43 months (HR 1.02, 95% CI 1.0–1.04, p = 0.0165). Conclusions: In patients treated for acute STEMI, acute %SAS is associated with post-infarct LVR. Therefore, we suggest performing such evaluations on a routine basis to identify, as early as possible, STEMI patients at higher risk.

LEFT VENTRICULAR REMODELING IN HEART FAILURE (PART I): CURRENT UNDERSTANDING OF PATHOMECHANISMS AND RELATED MYOCARDIAL DYSFUNCTION

Aim: to provide a literature review of the current data on various pathomechanisms of left ventricular (LV) remodeling in heart failure (HF) patients and their role in the development and progression of myocardial dysfunction. This paper is a first part of the review, devoted to the current state of pathophysiology of LV remodeling in HF.&#x0D; Material and methods. The thematic scientific papers, published during the last decade, constituted the study material. The research methodology involved bibliosemantic method and structural and logical analysis.&#x0D; Results and discussion. LV remodeling is the result of complex changes at the molecular, cellular and tissue levels, affecting the myocardial mass, geometry and performance, and ultimately leading to HF development and progression. LV systolic dysfunction occurs through the numerous mechanisms, including the defects in sarcomere function, abnormal excitation-contraction coupling and calcium homeostasis, ion channel dysfunction, mitochondrial and metabolic abnormalities, depressed cardiomyocytes survival signaling, redox pathobiology, inflammation and inadequate vasculogenesis. The term «LV diastolic dysfunction» covers the alterations in diastolic distensibility, filling or relaxation of the LV, regardless of whether LV (global) systolic function is normal or abnormal, and regardless of whether the patient has clinical manifestations of HF. The up-to-date pathophysiological paradigm of the development and progression of HF with LV diastolic dysfunction and preserved LV (global) systolic function considers systemic inflammation as a key pathomechanism of structural and functional changes of the myocardium, promoted by various cardiovascular and extracardiac conditions. In its turn, the systemic inflammation promotes endothelial dysfunction, contributing to multiple end-organ damage.&#x0D; Conclusion. The deepening one`s knowledge of various pathomechanisms of LV remodeling and related myocardial dysfunction in HF patients is an important prerequisite for identifying new perspectives on further fundamental research аnd more rational designing of future clinical trials.

Specific deformation pattern in hypertensive patients with septal bulge and preserved systolic function.

A wide range of subclinical changes in left ventricular (LV) geometry and function can be observed, even in the early course of arterial hypertension (HTN). Aim of the study was to investigate if the appearance of isolated basal septal hypertrophy (BSH, septal bulge) in asymptomatic young and middle-aged adults with HTN could be a marker of incipient LV systolic dysfunction when other measures of global LV function are still normal. A total of 138 patients with primary arterial hypertension, aged less than 65years, with no comorbidities and with preserved LV ejection fraction (EF) were included. Complete 2D transthoracic echocardiography study was preformed according to standardized protocol, as well as deformation study using speckle tracking echocardiography. Global and regional longitudinal strain was measured in apical 4-, 2- and 3-chamber views according to 18-segments model. Global and regional circumferential and radial strains were measured in short axis view. Average was taken from each of the six basal, middle and apical LV segments. Patients were divided into two groups according to BSH presence and values were compared. Basal septal hypertrophy was found in half of the patients (53.6%). The whole cohort had altogether normal LV global systolic function, as well as global indices of radial strain (GRS 43.86 ± 10.75%) and longitudinal strain (GLS - 19.73 ± 2.19%), while global circumferential strain (GCS) was mildly reduced (GCS - 19.5 ± 2.81%). BSH patients had more expressed LV geometry changes (LV mass: 89.19 ± 24.59g/m2 vs 109.15 ± 25.33g/m2, p < 0.001; relative wall thickness: 0.3 ± 0.08 vs 0.38 ± 0.11, p < 0.001) and also revealed a specific pattern of longitudinal deformation impairment in three LV segments (basal and mid interventricular septum, basal anteroseptum). "Strain gradient" from LV base to apex (basal < mid < apical) was observed in the whole population for longitudinal and circumferential strain, and it was more pronounced in the BSH group. This group had more impaired basal LS, while apical CS was improved. Subendocardial longitudinal strain was also more impaired in the BSH group. This study brings new meaning to basal septal hypertrophy (BSH) occurrence in hypertensive patients with discrete global concentric remodeling. Regional systolic dysfunction of the basal and mid LV segments is found, while apical segments increase in deformation. This specific "strain gradient" pattern was found to be more pronounced in patients with BSH. The recognition of BHS in apparently healthy hypertensive patients with no impairment in global systolic function may suggest latent target organ damage with regional impairment of systolic function and the need to imply more aggressive treatment approach.

P169 LEFT–DOMINANT ARRHYTHMOGENIC CARDIOMYOPATHY (LDAC)

Abstract Arrhythmogenic cardiomyopathy (ACM) is characterised by myocardial structural alterations with fibro–adipose replacement/infiltration, most frequently affecting the right ventricle. Malignant arrhythmias represent the most dangerous clinical manifestation. We describe the case of a 38–year–old man who came to the Emergency Room of our hospital due to polytrauma. Following the unexpected ECG finding of signs of necrosis in the infero–lateral area and negative T waves in the antero–lateral area, a cardiological examination was performed. The patient, a smoker, had non–contributory family and personal history of cardiovascular diseases and sudden cardiac death. However, he reported several unspecified episodes of “absence seizures”. The transthoracic echocardiogram showed mild reduction in global left ventricular systolic function (EF 45–50%) due to regional changes in motion extending beyond the territory distribution of one single coronary vessel. Holter–ECG showed a Sustained Ventricular Tachycardia (SVT) symptomatic for syncope. A coronary angiography was therefore performed, which excluded any significant coronary stenosis and a cardiac MRI revealed the presence of fibro–adipose replacement of the left ventricle and, to a lesser extent, of the right side of the interventricular septum. Medical therapy with Bisoprolol, Ramipril, Spironolactone was initiated and an ICD was implanted as secondary prevention. No endomyocardial biopsy was carried out due to the high risk of the procedure; genetic testing proved to be negative. A diagnosis of borderline arrhythmogenic cardiomyopathy was therefore made. This case is of special interest as ACM with predominant left ventricular involvement (LDAC) is a rare cardiomyopathy. Diagnosis is made difficult by the presence of phenocopies and by the fact that the diagnostic criteria in use mostly focus on the forms with predominantly right–sided involvement. In the case of suspicious ECG changes, SVT or resuscitated cardiac death with imaging compatible with cardiomyopathy, it is important to raise the diagnostic suspicion of LDAC.

Effects of late, repetitive remote ischaemic conditioning on myocardial strain in patients with acute myocardial infarction

Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks’ daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5–7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from − 16.2 ± 5.2 at baseline to − 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from − 15.5 ± 4.0 to − 15.2 ± 4.7, p = 0.81; for change: − 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (− 1.2 ± 4.4 versus − 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611.