Global Systolic Function Research Articles

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.

Cardiac structure, function, and coronary anatomy 10 years after isolated contemporary adjuvant radiotherapy in breast cancer patients with low cardiovascular baseline risk.

The effects of isolated contemporary low-dose breast cancer (BC) radiotherapy (RT) on the heart remain poorly understood. This study aims to assess the long-term impacts of BC-RT on cardiac structure and function. Seventy-six women (62 ± 7 years) without history of prior heart disease, who had undergone RT for either first left (n = 36) or right (n = 40) BC, without additional medical oncology therapy apart from hormonal treatment 11 ± 1 years earlier, underwent transthoracic echocardiography, cardiac magnetic resonance imaging (CMR), computed tomography coronary angiography (CTCA), NT-proBNP, and a 6-min walk test (6MWT). They were compared with 54 age-matched healthy female controls. By CTCA, 68% of BC patients exhibited no or very mild coronary disease, while only 11% had moderate stenosis (50-69%) and 3% had significant stenosis (>70%). Despite slightly reduced regional echocardiographic midventricular strains, BC patients exhibited similar global left and right ventricular volumes, ejection fractions, and global strains by echocardiography and CMR as controls. Mitral E/e' ratios were slightly higher, and mitral deceleration times were slightly lower, but NT-proBNP was similar to controls. Also, 6MWT was normal. None had late gadolinium enhancement, and extracellular volume fraction was similar in BC (28 ± 3 vs. 29 ± 3, P = 0.15) and controls. No differences were observed relative to dose or side of RT. Aside from minor alterations of regional strains and diastolic parameters, women who received isolated RT for BC had low prevalence of coronary disease, normal global systolic function, NT-proBNP, and exercise capacity and showed no structural changes by CMR, refuting significant long-term cardiotoxicity in such low-risk patients.

The effect of iron deficiency anemia on myocardial function in pediatrics

BackgroundIron deficiency is one of the most common types of anemia in children. Anemia leads to tissue hypoxia, which activates compensatory mechanisms such as increased cardiac output. Tissue Doppler imaging (TDI) is a useful echocardiographic technique for evaluation of regional and global myocardial systolic and diastolic function. ObjectivesThis study aimed to determine whether iron deficiency anemia (IDA) affects myocardial function in pediatric patients using conventional echocardiography and TDI. MethodsThis case-control study was conducted at an outpatient general pediatric clinic in cooperation with the Cardiology Unit of the Pediatric Department of Fayoum University Hospital from May 2021 to February 2022. The study included 30 cases with IDA and 30 apparently healthy children. The two study groups were matched for age and sex. ResultsThere was an increase in left ventricular end-diastolic diameter (LVEDD), while the control group showed increased ejection time (ET). There was a statistically significant lower mean E/A ratio among cases. There was a positive correlation between serum iron levels, ET, and isovolumetric contraction time (IVCT) among the cases. Additionally, there was a negative correlation between hemoglobin levels and LVEDD in the entire study group. No significant difference was found between the two study groups regarding the Tei index. ConclusionMinimal alterations in LV function parameters may occur due to IDA. A decrease in serum iron levels was significantly associated with further decreases in ET and IVCT. Additionally, there was a statistically significant lower mean E/A ratio among cases.

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.

Abstract 14672: Exercise Hemodynamic Profiles of Resting and Exercise-Based Definitions of Cancer Therapy-Related Cardiac Dysfunction in Anthracycline-Treated Breast Cancer Survivors

Introduction: Detection of cancer therapy-related cardiac dysfunction (CTRCD) is a cornerstone of heart failure (HF) risk assessment. However, it is unclear how closely CTRCD definitions reflect typical HF features of reduced exercise tolerance (VO 2 peak) and blunted cardiac reserve. Hypothesis: Standard CTRCD metrics (resting LVEF and GLS) will show poor agreement with reduced VO 2 peak and changes in cardiac reserve following anthracycline chemotherapy (AC). Methods: This analysis used baseline (pre-AC) and 12-month assessments from a randomized trial of exercise training in breast cancer patients (n=104) undergoing AC ± anti-HER2 therapy. Assessments included resting echocardiography (LVEF and GLS), cardiopulmonary exercise testing (VO 2 peak) and exercise cardiac magnetic resonance (peak cardiac output [CO], stroke volume [SV] and LVEF [LVEF peak ]). CTRCD was defined as ≥10% absolute decline in LVEF to a value <50%, >15% decline in GLS, and a ≥10% decline in VO 2 peak from pre-AC. Results: Seventy-nine participants (76%) completed pre-AC and 12-month assessments, 14 of whom (18%) met LVEF and 30 (38%) met GLS CTRCD criteria (10% met both criteria). In addition to declines in resting LVEF and GLS, these participants showed a reduction in LVEF peak , but no change in peak SV, CO or VO 2 peak (Figure 1A-B). In contrast, 19 participants (24%) had a ≥10% VO 2 peak decline (-17% vs Pre-AC, P<0.001) that coincided with a decline in peak SV (-6%, P=0.03), and LVEF peak (-11%, P=0.02), with no significant change in resting LVEF or GLS (Figure 1C). Of those who met VO 2 peak criteria, only three (16%) and five (26%) met LVEF or GLS criteria, respectively, and only one met all three criteria. Conclusions: Whilst capturing reduced global LV systolic function, CTRCD definitions are insensitive to meaningful declines in VO 2 peak and cardiac reserve. Incorporating measures of VO 2 peak into CTRCD surveillance may improve HF risk stratification in breast cancer survivors.

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 <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<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<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 <40% (p1-3<0,01). The detection rate of IMH prevailed in the 2nd group (33,3%) compared with the 1st group (12%) (p1-2<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<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.

Acute Changes in Right Ventricular Function in Pediatric Patients with Pulmonary Valve Stenosis Undergoing Percutaneous Valvuloplasty: A Speckle-Tracking Study.

Pulmonary valve stenosis determines multiple effects on the right ventricular dimension and function. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages. However, little is known regarding right ventricular function immediate changes after percutaneous balloon dilation. Pediatric patients with isolated pulmonary valve stenosis represent a pure clinical model of chronic RV pressure overload not affected by other confounders or comorbidities. This study seeks to explore right ventricle (RV) mechanics in pediatric patients early after percutaneous balloon pulmonary valvuloplasty (BPV) for valvar pulmonary stenosis (PS). Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years old, with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent standard transthoracic echocardiography (TTE), and speckle-tracking echocardiography (STE) with an analysis of right ventricle free-wall longitudinal strain (RVFWLS) one day before and one day after the procedure. For each patient, we collected invasive parameters during the interventional procedure before and after BPV. After the procedure, there was an immediate significant reduction in both peak-to-peak transpulmonary gradient (peak-to-peak PG) and ratio between the right ventricle and aortic systolic pressure (RV/AoP) with a drop of ∆29.3 ± 14.67 mmHg and ∆0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (∆50 ± 32.23 and ∆31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, affecting 29% of our patients post-BPV (p = 0.007). The analysis of right ventricular mechanics showed a significant improvement of fractional area change (FAC) immediately after BPV (40.11% vs. 44.42%, p = 0.01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE and global RVFWLS, did not improve significantly after intervention. The segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments. Percutaneous BPV represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. The analysis of the right ventricular function on echocardiography demonstrated an immediate global systolic function improvement, while longitudinal systolic function was persistently impaired 24 h after intervention, possibly due to the necessity of a longer recovery time.

Sudden cardiac death in myocarditis

According to statistics, myocarditis is one of the leading causes of sudden cardiac death (SCD) in children and young adults. The etiology of myocarditis includes infectious and non-infectious, including autoimmune diseases, as well as toxicities and hypersensitivity to various drugs or bites of insects, spiders, snakes, etc. The risk of myocarditis among patients with COVID-19 is 15.7-fold higher than that in the general population. The most common cause of death in myocarditis is heart arrhythmia, such as ventricular tachyarrhythmia, ventricular fibrillation, or severe bradycardia. Genetic predisposition, ion and metabolic disorders, mechanisms of autoimmune response, and direct cardiotoxic action in viral diseases play a role in the pathophysiology of inflammatory myocardial damage. While the majority of patients with myocarditis, who died suddenly, was asymptomatic or had few symptoms, a timely and accurate diagnosis of myocarditis seems to be an important challenge for prevention or minimization of SCD risk. Nonetheless, at present there is no convincing evidence of an association between laboratory and instrumental parameters and the SCD risk in such patients. Endomyocardial biopsy remains the "golden standard" in the diagnosis of myocarditis. Biomarkers (troponins or creatine phosphokinase) are not highly specific. The most common electrocardiographic findings in myocarditis are sinus tachycardia and nonspecific changes in the ST-T segment. The presence of Q wave, bundle branch block, Brugada syndrome, shortened or prolonged QT interval, and early ventricular repolarization are associated with an increased risk of SCD in myocarditis. Given the absence of specific echocardiographic signs of myocarditis, special attention is paid to the assessment of the size of the cardiac chambers, wall thicknesses, global and regional systolic and diastolic function of both the left and right ventricles, visualization of pericardial effusion and intracardiac thrombi. A combined cardiac magnetic resonance imaging using T2-weighted imaging and early and late gadolinium enhancement provides high diagnostic accuracy and seems to be a useful tool in the stratification of patients with suspected acute myocarditis. With the established etiology of myocarditis, specific therapy is necessary to eliminate the pathogen. It is necessary to take into account the likely arrhythmogenic effects of the drugs used in treatment. Non-steroidal anti-inflammatory drugs are generally not indicated in patients with myocarditis because they cause renal impairment and sodium retention, which can exacerbate left ventricular dysfunction and increase the risk of SCD. In the case of severe conduction disturbances and ventricular tachyarrhythmias, implantation of a pacemaker or cardioverter-defibrillator is necessary.

Evaluation of myocardial work index in predicting in-hospital complication in patients with Takotsubo syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Backgrounds Tako-tsubo syndrome (TTS) is a reversible heart failure pathology characterized by transient myocardial left ventricular (LV) dysfunction. Although traditionally considered a benign condition, in-hospital complications are frequent in this cohort of patients. Non-invasive myocardial work (MW) parameters are considered as emerging indexes in evaluating global and regional myocardial systolic function. Aim The aim of this TTS study was to investigate the potential association of MW with in-hospital complications, and to compare MW with standard (LVEF) and advanced (GLS) echocardiographic parameters of LV systolic function Methods thirty-eight patients (mean age, 68 ± 12 years, 35 women) with TTS diagnosed with Takotsubo Italian Network criteria were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours from hospital admission. Clinical and echocardiographic characteristics during the index event were reported in table 1. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating into its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted myocardial work (WMW) were measured. LV GLS and LV EF were also measured. In hospital complications were defined as a composite of apical LV thrombosis, hypokinetic arrhythmias (HA), supraventricular tachycardia (SVT), acute heart failure (AHF), ventricular tachycardia/fibrillation (VT/VF), cardiogenic shock (CS), respiratory arrest (RA), stroke and cardiac death (CD). Results Hospital complications occurred in 16 TTS patients (26% with AHF; 10% with SVT; 8% with CS; 5% with apical LV thrombosis; 5% with HA; 2,6 % with RA; 2,6% with stroke; 2% with VT/VF). The WMW parameter appear to have the best performance in predicting in-hospital complications (odds ratio for having HC: 8.4 (95% confidence interval: 1.5 to 46.1), figure 2). Conclusion global and regional myocardial performance is transiently impaired in TTS and significantly associated with hospital complication. Although limited by the low number of patients, these results suggest that myocardial work parameters may have a better performance than the EF value in predicting intra-hospital complications. Larger studies will be necessary to confirm these preliminary results.

Relative dilatation of left ventricle and left atrium in patients with Parkinson disease

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This study was supported by Czech Health Research Council AZV NU21-04-00445 and by the European Regional Development Fund - project ENOCH (No. CZ.02.1.01/0.0/0.0/16_019/0000868) Introduction Morbus Parkinson (MP) is the second most common neurodegenerative disease that progressively affects the nervous system. Accompanying heart problems may include mainly cardiovascular autonomic dysfunction. So far, very little is known about structural and functional cardiac changes in patients with MP. Purpose This pilot study aimed to analyse left ventricular (LV) and left atrial (LA) function and volumes using cardiovascular magnetic resonance (CMR). Methods In this study, 37 patients with MP (mean age 59,0 ± 8,0 years) without a history of cardiac disease or symptoms were compared to 37 sex- and age-matched control subjects without any heart disease history (mean age 54,5 ± 11,4 years). All patients underwent CMR examination at 1,5 MR scanner, including cine images for assessment of LV and LA volumetric and functional parameters. LA volumes (LAV) were measured at LV end-systole (maximum LAV - LAVmax), before the atrial contraction (pre-atrial contraction volume - LAVpac), and at late LV diastole (minimum LAV - LAVmin) and indexed (I) to the body surface area. LA strains were analysed for all LA phases: reservoir strain (LSr), conduit strain (LScd), and contractile strain (LSct). Descriptive statistics are reported as the mean (SD) or median (IQR) for normally and non-normally distributed continuous variables. All the p-values were adjusted using a false discovery rate for multiple comparisons. Results MP patients had normal global and regional systolic LV function – LV ejection fraction (EF) 65,9 ± 6,8% vs 68,9 ± 7,0% (p = NS). On the contrary, all indexed LV volumes were significantly higher in comparison to controls: LV end-diastolic volume index was 67,3 ± 12,1 ml/m2 vs 58,3 ± 11,7 ml/m2 (p = 0,013), LV end-systolic volume index was 22,0 (17,8 to 27,5) ml/m2 vs 18,9 (13,2 to 21,9) ml/m2 (p = 0,027), and LV stroke volume index was 43,8 ± 7,2 ml/m2 vs 39,8 ± 6,3 ml/m2 (p = 0,035). Similarly, indexed LAVmax and LAVpac were also relatively increased: LAVImax 42,7 ± 9,0 ml/m2 vs 35,7 ± 10,3 ml/m2 (p = 0,014), LAVIpac 29,8 ± 7,1 vs 23,8 ± 7,6 ml/m2 (p = 0,012). LAVImin was similar in both groups: 17,3 ± 5,5 ml/m2 vs 14,3 ± 6,7 ml/m2 (p = NS). LA strains were slightly lower in the MP cohort during the reservoir and conduit phase, and slightly higher in the contractile one. However, the difference did not reach statistical significance in any phase. Conclusion Patients with Parkinson´s disease have enlarged LV and LA compared to controls.

#5221 PULMONARY HYPERTENSION: AN IMPORTANT RISK FACTOR IN CARDIOVASCULAR MORTALITY IN DIALYSIS PATIENTS

Abstract Background and Aims It is widely known that chronic dialysis patients experience significantly higher cardiovascular (CV) death rates than the overall population. Among other CV risk factors, recent research has shown pulmonary hypertension (PH) as a consequence of chronic kidney disease and end-stage renal failure. The present study aimed to determine the risk factors that impact survival in chronic haemodialysis and peritoneal dialysis patients and to analyse the correlation of these factors with pulmonary hypertension. Method We studied 125 stable haemodialysis and peritoneal patients (females 40%, mean age 52.42 ±11.88 years) on RRT for more than three months with a two-year follow-up. Demographic information, clinical characteristics, blood tests, and a thorough echocardiographic evaluation were collected at the optimal dry weight. After conventional echocardiographic examination, a tissue Doppler echocardiographic (TDE) examination was performed to evaluate the global and regional myocardial systolic and diastolic functions and pulmonary hypertension. Systolic pulmonary artery pressure (sPAP) of 35 mmHg was used to define PH. Results The cardiovascular mortality rate was 15.5%. In ROC analysis for CV mortality, the area under the curve (AUC) for PH and CRP was found 0.8; for LVM-I, E/E', and PP, the AUC was 0.76, 0.75, 0.72, respectively, while the inverse relationship was found with MASa and TASa with AUC = 0.66 and 0.95 respectively. According to the echocardiographic findings, PH was found in 28% (35 patients) of all patients. The mean PH was 33.46±5.38 mmHg. The higher level of higher parathormone (PTH), C-reactive protein (CRP), and E/E’ average, the lower left ventricular ejection fraction (EF), the peak systolic velocity at the lateral mitral annulus (MASa), and the peak systolic velocity at the lateral tricuspid annulus (TASa) were found to be predictors of PH. Patients evaluated with PH have a significantly lower cardiovascular survival rate [Long Rank (Mantel-Cox) p = 0.0001. Conclusion Our research demonstrates that cardiovascular morbidity and death in dialysis patients are mainly attributed to pulmonary hypertension, inflammation, vascular stiffness, and left ventricular hypertrophy. PH is common among dialysis patients. Inflammation, CKD-MBD biomarkers linked to systolic and diastolic left and right ventricular dysfunction, and inflammation all influence it. These conditions are all connected. Cardiovascular imaging is simple to use, offers a favourable viewpoint in the early identification of cardiac abnormalities and quick treatment of this disease, and is thus strongly advised in the dialysis population.

P456 SUBACUTE STEMI AND ISCHEMIC STROKE DURING SARS–COV2 INFECTION: A CASE REPORT

Abstract A 71–year–old woman arrived in the ER for left hemiparesis and dysarthria. The Patient was oriented, collaborative. Stable hemodynamics. Left hemiparesis. Dysarthria. NIHSS 8, Ranking 2. Blood tests, EGA, swab for SARS–Cov2 were performed (hsTnI 9433 ng, PCR 15.6 mg/dl, Sars–Cov2 positive test). ECG showed evidence of inferolateral ST–segment elevation with Q waves in the inferior site and negative T waves in the inferolateral leads. An episode of chest pain radiating to the left upper limb two days ago was reported. The echocardiography showed non–dilated left ventricle with global systolic function at the lower limits. Inferior, infero–lateral and medio–basal akinesia with hyper–refractive wall and preserved thicknesses were found. Moreover, a slight layer of circumferential pericardial effusion, without any hemodynamic importance was showed. In order to exclude an aortic syndrome, a CT angiography of the brain, neck and chest was performed for recent lesions, with negative result. Angiography showed the left vertebral artery up to the V3 segment, suspected by dissection. Recommendations on performing fibrinolysis in adults, with concurrent ischemic stroke and subacute STEMI, are conflicting: according to ASA/AHA guidelines in recent 3–month infarction, treatment is reasonable if the inferior or right wall is involved. According to ESO guidelines, fibrinolysis is not recommended if the subacute STEMI is seven days old. The Italian guidelines consider the treatment of acute stroke with r–TPA with subsequent PTCA, with possible stent, and recognize a very low risk of consequent hemopericardium. Depending on the timing of the anginal symptoms, the presence of Q waves on the ECG and the echocardiographic alterations, the AMI was considered subacute with no indication for urgent coronary angiography. For the patient of this case report, a conservative attitude for both pathologies was decided, performing an antiplatelet therapy with ASA and continuous ECG monitoring. Despite the treatment, the patient suffered heart failure and exitus after 10 days hospitalization. The lack of unequivocal guidelines on the treatment of patients with simultaneous ischemic stroke and subacute STEMI, require careful evaluation of the individual case, searching for possible predisposing factors of a poor prognosis.

P333 A RARE CAUSE OF SHOCK: AORTO–PULMONARY FISTULA AS AORTIC ANEURYSM COMPLICATION

Abstract Clinical case A 69–year–old man with right shoulder discomfort, malaise for one hour and hemodynamic instability was admitted to our Emergency Department (ED). The patient had a history of arterial hypertension, diabetes, renal failure on peritoneal dialysis and ischemic cardiomyopathy with preserved ejection fraction treated by angioplasty and stent implantation on right coronary. At first medical contact out of hospital the patient appeared confused with severe hypotension (BP 70/40 mmHg). ECG transmitted to our Cardiology Unit showed sinus tachycardia with repolarization abnormalities consistent with diffuse ischemia. The patient was centralized with clinical suspicion of acute coronary syndrome complicated by cardiogenic shock. In ED, BP was 65/35 mmHg. On physical examination extremities were cold and mottled, crackles in the lower lung zones and turgid jugulars were present. Pulses were weak but present. ECG was repeated and no evolutive signs were detected. Echocardiography finding were: not dilated left ventricle with global systolic function at the lower limits, moderate aortic insufficiency, right ventricle with dimensions at the upper limits and hypocontractile, moderate tricuspid regurgitation, inferior vena cava dilated with preserved inspiratory collapse. Aortic root was non dilatated but aortic arch was 55 mm with no images of dissection flap. At blood test lactates were 4,2 with metabolic acidosis, troponin was just above the upper limit, inflammation indices were negative and electrolytes were in range. Vasopressor support with norepinephrine was started. With the high suspicion of acute aortic disease, CT angiography was performed showing a voluminous aneurysm of the aortic arch of 70x56 mm rupturing into the left pulmonary artery (Figure 1,2). Concomitant bilateral iliac artery dissection was detected. Cardiac and Vascular Surgeons were promptly alerted to plan tan emergent surgical intervention whose complexity was increased by the difficult vascular cannulation for iliac dissection. However, the patient‘s hemodynamic rapidly deteriorated requiring intubation and, after subsequent episodes of cardiac arrest in pulseless electrical activity (PEA), his death was assessed.

P436 ASSOCIATION BETWEEN REVERSE–TAKO–TSUBO E NEUROLOGICAL DISORDER

Abstract Reverse–Tako–tsubo (r–TTC) is a rare variant of Tako–tsubo syndrome (TTC). TTC is characterized by transient and reversible left ventricular systolic dysfunction, for which an emotional or physical stressful trigger can usually be identified. Clinically, it mimics an acute myocardial infarction, with elevation of myocardial cytonecrosis enzymes and no obstractive coronary artery stenosis. On imaging, r–TTC is characterized by hypokinesia of the mid–basal regions associated with hyperkinesia of the apical region that resolves spontaneously. Case report: 78–year–old female affected by cerebral atrophy, leukoencephalopathy, cognitive impairment, behavior disorders. Reported episode of loss of consciousness lasting several minutes, associated with spontaneously resolving tremors and left hemisome hyposthenia. When she arrived in the emergency room, the haematological tests found high troponin values. On CT brain without contrast, no evidence of alterations of the encephalic tissues referable to acute lesions, but it showed of diffuse supratentorial leukoaraiosis and widening of the cerebrospinal fluid spaces on an atrophic basis. The neurological evaluation excludes the presence of a seizure. The electrocardiogram showed diffuse negative T waves and QTc 636 ms. The coronary angiography didn’t show significant coronary arteries stenosis and the ventriculography showed normal ventricular dimensions with total akinesia of the mid segments and normokinesia of the apical region with an ejection fraction of 50%. With these findings a diagnosis of mid left ventricular Tako–tsubo (r–TTC) was made. Transthoracic color Doppler echocardiography confirmed the alterations of the left ventricular kinetics observed by ventriculography. Conclusions compared to CTT, r–TTC is associated with a lower decline in global systolic function and, as reported in the literature, there is a greater connection to neurological insults as triggering factors, such as episodes of aneurysmal subarachnoid hemorrhage, brain surgery, ischemic stroke seizures and traumatic brain injury. The underlying mechanisms are still unknown, a crucial role in catecholamine–induced cardiotoxicity, coronary microvascular dysfunction or coronary vasospasm and/or estrogen deficiency is hypothesized.

P379 A BIG MASS AROUND THE HEART: SHOULD I BE WORRIED?

Abstract Lipomas account for about 10% of all cardiac tumors and symptoms are often secondary to the compression of cardiac chambers and the consequent hemodynamic impact. We report the case of a 76–year–old woman with no cardiological history, undergoing oncological follow–up for breast cancer underwent a left radical mastectomy in 2014, not followed by radiotherapy or chemotherapy, who came to our attention due to the identification at the total–body CT scan of a mediastinal mass. A voluminous intrapericardial formation was detected, with a maximum size of 5.4 x 8.6 cm, characterized by adipose attenuation values at baseline. On examination, the patient was asymptomatic and eupneic, in good hemodynamic compensation, in functional class NYHA I. The ECG showed sinus rhythm with regular atrioventricular and intraventricular conduction without significant alterations in repolarization. On the echocardiogram, the left ventricle appeared of normal size and thickness without alterations in the global and segmental systolic function, EF 65%; the right ventricle was regular in size and contractility; a voluminous pericardial mass of about 8 x 4.5 cm was observed in the inferior, posterior and lateral site, homogeneous, not vascularized, not compressing the cardiac cavities and not determining hemodynamic impact. The patient was then submitted to cardiac MRI which confirmed the suspicion of intrapericardial lipoma. Considering the absence of symptoms, the benign nature of the lesion and the absence of compression on the cardiac structures, we decided not to remove the mass and to continue clinical and radiological follow–up, thus monitoring size and symptoms.

P435 THE IMPORTANCE OF CORRELATION BETWEEN HEART FAILURE AND THYROID: A CASE REPORT

Abstract A 39–year–old African man was admitted to our department within a four days symptoms of short of breath, cough, tachycardia and lower limb edema. He also complained headache for about a month. He denied fever, chest pain and loss of consciousness. Clinical and family history were unremarkable. Blood tests showed moderate microcytic anemia ( Hb 9.6 g/dl, MCV 93.3 fL), hypoalbuminemia ( Albumin: 3.20 g/dl), elevated levels of LDH ( LDH: 246 U/L), mild C–reactive protein (CRP) and pro–Brain Natriuretic Peptide (pro–BNP) increase (CRP: 1.14 mg/dl); (PRO–BNP: 1133 pg/mL) and negative troponin. Given the clinical picture suggestive of heart failure, we immediately started diuretic therapy with benefit. Chest–x ray revealed a modest thickening of the pulmonary interstitium, electrocardiogram (ECG) a sinus rhythm and early repolarization changes. Chest CT highlighted a bilateral apical–basal pleural effusion, a bilateral hilar ectasia and interstitial markings due to stasis. He underwent an ultrasound of the abdomen that was normal. Thyroid function tests showed high levels of thyroid hormones with suppressed TSH and elevated levels of Ab anti–receptor TSH ( FT3: 8.73 pg/mL; FT4: 2.35 ng/dL; TSH&amp;lt;0.01 mUI/ml; TRAB: 3.62 UI/L). Thyroid ultrasound showed a multinodular goiter. The patient began therapy with Tapazole. Echocardiogram didn’t show any evidence of acute heart disease and systolic function was normal. After discharge he performed a heart MRI with evidence of no alteration of global systolic function, of regional left and right ventricular kinetics or of pathological areas of delayed enhancement in relation to myocardial edema/fibrosis/necrosis. Hyperthyroid patients can show signs and symptoms of heart failure that are due to the hyperdynamic circulatory state and/or to the frequent pulmonary arterial hypertension and our case report demonstrates that this clinical status tends to improve with the restoration of euthyroidism, but if left untreated, can worsen over the time leading to heart failure.

P316 CHEST PAIN: ONE, NONE AND A HUNDRED THOUSAND DIAGNOSES. A CASE REPORT

Abstract A 62–year–old woman, with a history of systemic hypertension, smoking habit and paroxysmal atrial fibrillation treated with Flecainide, was admitted to the ER of our Hospital for chest pain. She reported that the symptoms appeared after an emotional stress at work. Troponin I was of 895 pg/mL. The electrocardiogram showed: negative T waves in the inferior leads and an early repolarization pattern/ ST elevated in the antero–lateral leads. The patient underwent transthoracic echocardiography which showed: EF 45%, akinesia of the posterior and inferior segments of the septum. Invasive coronary angiography showed absence of lesions. CMR presented: EF 51% and mild hypokinesia of the mid septum and inferior segment; signs of oedema affecting the left ventricular myocardium in the apex, the mid inferior segment and in the lower apical wall, with subendocardial hypoperfusion layer in the mid inferior septum (microvascular dysfunction?). The patient was dismissed with the diagnosis of M.I.N.O.C.A. A month later, she was admitted again to our ER suffering from a new episode of acute chest pain; she also reported a short episode of atrial fibrillation (documented by an EKG) lasting about 10 minutes occurred the day before. The EKG showed: negative T waves in anterolateral leads. TnI was of 2052,5 pg/ml. The patient underwent a transthoracic echocardiogram which demonstrated: reduced global systolic function (EF 35%), akinesia of the apex, mid–anterior septum and mid– anterior wall. The day after the echo was repeated and it demonstrated a gaining of Vsx EF which was of approximately of 50%. Invasive coronary angiography showed absence of lesions. A methylergometrine test was negative for vasospasm on anterior descending artery. The CMR showed: EF 58%, signs of oedema in the basal and mid anterior wall, mid–anterior septum. LGE intra wall of the apical septum and of the basal part of the anterior wall (coronary spasm? Vasculitis?) Absence of edema. The final diagnosis was of Tako Tsubo. Discussion and conclusions This case offers the inspiration to reflect on differential diagnosis of chest pain with undamaged coronary arteries. In addition to this, it should be considered coronary emboli arisen through various mechanisms including left atrial appendage thrombi due to atrial fibrillation, so that also anticoagulation therapy is suggested as discharge treatment.