Impaired LV Systolic Function Research Articles

Evaluation of left ventricular systolic function in patients with iron deficiency anemia based on non-invasive left ventricular pressure–strain loops

BackgroundIron deficiency anemia (IDA) is a common health problem worldwide. The objective of this study was to noninvasively and quantitatively evaluate early changes in left ventricular systolic function in patients with IDA using the left ventricular press–strain loop (LV-PSL).MethodsSixty-two patients with IDA were selected and divided into two groups based on hemoglobin (Hb) concentration: Group B with Hb > 9 g/dL and group C with 6 g/dL < Hb < 9 g/dL. Thirty-three healthy individuals were used as the control (Group A). The global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global waste work (GWW), global work efficiency (GWE) were derived using LV-PSL analysis. Receiver operating characteristic (ROC) curves were constructed for MW parameters to detect abnormal left ventricular systolic function in IDA patients.ResultsCompared to group A, GWI and GCW were reduced in group B (both P < 0.01). Compared with groups B and A, GLS, GWI, GCW and GWE, and E/A were all diminished, and GWW, LVEDV, LVESV, and E/mean e’ were all increased in group C (all P < 0.01). GLS was positively correlated with GWI, GCW, and GWE (r = 0.679, 0.681, and 0.447, all P < 0.01), and negatively associated with GWW (r = − 0.411, all P < 0.01). For GWI, area under the ROC curve (AUROC) was 0.783. The optimal GWI threshold for detecting abnormal LV systolic function in IDA was1763 mmHg%, with sensitivity of 0.71 and specificity of 0.78.ConclusionsLV-PSL allows noninvasive quantitative assessment of early impaired LV systolic function in IDA patients with preserved LV ejection fraction, and GWI has high sensitivity and specificity compared with other parameters.

Left ventricular thrombus in patients with heart failure with improved ejection fraction

Abstract Background This study sought to: (1) determine the prevalence of LV thrombus at baseline and at the time of recovered ejection fraction (EF) in patients with heart failure with improved ejection fraction (HF-imp EF), (2) examine clinical and echocardiographic factors associated with the presence of LV thrombus, and (3) determine the prevalence of thromboembolic events when LVEF was improved and oral anticoagulant (OAC) was discontinued. Methods and results Patients with nonischemic HF-imp EF defined as a baseline LVEF of ≤ 40%, a ≥ 10% increase from baseline LVEF, and a second measurement (6 months apart) of LVEF of &amp;gt; 40% were consecutively enrolled in advanced HF clinic in a tertiary center. Patients with recent myocarditis, recent coronary revascularization, active chemotherapy, hypertrophic cardiomyopathy, cardiac amyloidosis, and tachycardia induced cardiomyopathy were excluded. A total of 104 consecutive patients (age 51 ± 15 years; 66% were male) with HF-imp EF were included. Of these, 14 patients (14%) had LV thrombus at baseline. Baseline LVEDD, LVEF, and LV global longitudinal strain (GLS) were 61 ± 10 mm, 23 ± 15%, and -5.9 ± 3.3%, respectively. Younger age, absence of atrial fibrillation, receiving oral diuretics, lower LVEF, reduced LV GLS, and reduced RV free wall (FW) GLS were significantly associated with LV thrombus at baseline (p &amp;lt; 0.05 for all) (Table 1). All patients (100%) with LV thrombus at baseline received oral anticoagulants (OAC). At the median follow-up of 27 months, 14 (100%) had complete resolution of LV thrombus when LVEF &amp;gt; 40%. Of 14 patients, 11 (79%) who were in sinus rhythm discontinued OAC. After a median further follow-up of 27.4 months following OAC discontinuation, there was no thromboembolic event or all-cause mortality in these patients. One of 11 patients developed worsening LVEF and recurrent LV thrombus at 25 months after LVEF improvement (&amp;gt; 40%). Conclusions Approximately 1 in 6 patients with HF-imp EF had LV thrombus at baseline. LV thrombus formation was associated with more impaired LV and RV systolic function and myocardial deformation implicating more thromboembolic milieu. Complete resolution of LV thrombus occurred in all patients who were on OAC therapy at the time of imp-EF. Discontinuation of OAC when LVEF &amp;gt; 40% was safe. However, recurrent thrombus formation can occur when LV systolic function was deteriorated. Annual or bi-annual echocardiographic follow-up may be essential in these patients.

Individualized assessment and optimization of post myocardial infarction care by introducing a hybrid clinic - A DGH experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Optimal secondary prevention remains key in improving cardiovascular outcomes post myocardial infarction. Barriers to achieving timely and individualized medical optimization include unavailability of close follow up’s, compliance to secondary prevention, and more recently, the impact of COVID pandemic on outpatient face to face clinic appointments. With the recent emphasis from the European Society of Cardiology on secondary prevention in addition to optimizing lipid therapy, a dedicated service for post MI patients to address individualized risks can provide a timely opportunity to improve holistic cardiovascular care. Purpose To assess established secondary prevention practices, we initially audited 52 patients who presented with ACS between Jan 2020 and July 2020. These patients were assessed for post MI care optimization at 6 weeks post discharge. Utilizing ESC guidelines as audit targets, in our 6-week post discharge audit, we identified that there was scope of ACE-inhibitor up titration in 55.8% of the patients, beta-blocker optimization in 9.6%, Lipid lowering agents in 15.4%, mineralocorticoid receptor antagonist addition in patients with impaired LV systolic function in 5.8% of the patients. 5% of patients with new diagnosis of diabetes required referral to specialist teams for diabetic medication initiation or optimization. These results provided an opportunity to introduce a structured post MI clinic that will allow individualized risk assessment on an outpatient basis. Method We proposed a one stop hybrid clinic where all patients discharged following a myocardial infarction received a consultation 6 – 8 weeks following a discharge. These patients were sent blood forms 2-3 weeks prior to their appointment for full blood count levels, renal functions, liver profile, HBa1c levels and lipid profile. Focus of this consultation was to assess and educate the patient on risk factors (smoking, diabetes, cardiac rehab program), assess and address compliance to secondary prevention medications and finally titrate medications to maximum tolerated doses whilst achieving ESC defined targets for secondary prevention (post MI target systolic BP&amp;lt;140mmHg in non diabetics and &amp;lt;130mmHg in diabetics, LDLc &amp;lt;1.4, smoking cessation, HBa1c &amp;lt;49). Where appropriately identified, referral to lipid specialist and diabetes specialist teams were made to provide holistic multi-disciplinary management. Results To understand the Impact made by the clinic we obtained patient list through local electronic records to filter those discharged with a primary diagnosis of myocardial infarction in 2022. An audit tool was created and data collection was performed including baseline characteristics as per table 1 and interventions made Table 2. Conclusion(s) By establishing the post MI clinic we were able to demonstrate efficient individualized assessment and optimization of secondary prevention risk factors and pharmacotherapy.

Factors influencing left ventricular thrombus resolution and its significance on clinical outcomes.

A left ventricular thrombus (LVT) is not uncommon in patients with impaired LV systolic function. However, the treatment strategy for LVT has not yet been fully established. We aimed to identify the factors influencing LVT resolution and the significance of LVT resolution on clinical outcomes. We retrospectively investigated patients diagnosed with LVT with left ventricular ejection fraction (LVEF)<50% on transthoracic echocardiography from January 2010 to July 2021 in a single tertiary centre. LVT resolution was monitored through serial follow-up transthoracic echocardiography. The primary clinical outcome was a composite of all-cause death, stroke, transient ischaemic attack, and arterial thromboembolic events. LVT recurrence was also evaluated in patients with LVT resolution. There were 212 patients diagnosed with LVT (mean age, 60.5±14.0years; male, 82.5%). The mean LVEF was 33.1±10.9%, and 71.7% of patients were diagnosed with ischaemic cardiomyopathy. Most patients were treated with vitamin K antagonists (86.7%), and 28 patients (13.2%) were treated with direct oral anticoagulants or low molecular weight heparin. LVT resolution was observed in 179 patients (84.4%). LVEF improvement failure within 6months was a significant factor hindering LVT resolution (hazard ratio, HR: 0.52, 95% confidence interval, CI: 0.31-0.85, P=0.010). During a median 4.0years of follow-up (interquartile range, IQR: 1.9 to 7.3years), 32 patients (15.1%) experienced primary outcomes (18 all-cause deaths, 15 strokes, and 3 arterial thromboembolisms) and 20 patients (11.2%) experienced LVT recurrence after LVT resolution. LVT resolution was independently associated with a lower risk for primary outcomes (HR: 0.45, 95% CI: 0.21-0.98, P=0.045). In the patients with resolved LVT, discontinuation or duration of anticoagulation after resolution were not significant predictors for LVT recurrence, but LVEF improvement failure at LVT resolution was associated with a significantly higher risk of LVT recurrence (HR: 3.10, 95% CI: 1.23-7.78, P=0.016). This study suggests that LVT resolution is an important predictor for favourable clinical outcomes. LVEF improvement failure interfered with LVT resolution and appeared to be a crucial factor for LVT recurrence. After LVT resolution, continuation of anticoagulation did not seem to impact LVT recurrence and the prognosis.

Effectiveness of implantable loop recorder and Holter electrocardiographic monitoring for the detection of arrhythmias in patients with peripartum cardiomyopathy

BackgroundPatients with peripartum cardiomyopathy (PPCM) are at increased risk of sudden cardiac death (SCD). However, the exact underlying mechanisms of SCD in PPCM remain unknown. By means of extended electrocardiographic monitoring, we aimed to systematically characterize the burden of arrhythmias occurring in patients with newly diagnosed PPCM.Methods and resultsTwenty-five consecutive women with PPCM were included in this single-centre, prospective clinical trial and randomised to receiving either 24 h-Holter ECG monitoring followed by implantable loop recorder implantation (ILR; REVEAL XT, Medtronic®) or 24 h-Holter ECG monitoring alone. ILR + 24 h-Holter monitoring had a higher yield of arrhythmic events compared to 24 h-Holter monitoring alone (40% vs 6.7%, p = 0.041). Non-sustained ventricular tachycardia (NSVT) occurred in four patients (16%, in three patients detected by 24 h-Holter, and multiple episodes detected by ILR in one patient). One patient deceased from third-degree AV block with an escape rhythm that failed. All arrhythmic events occurred in patients with a severely impaired LV systolic function.ConclusionsWe found a high prevalence of potentially life-threatening arrhythmic events in patients with newly diagnosed PPCM. These included both brady- and tachyarrhythmias. Our results highlight the importance of extended electrocardiographic monitoring, especially in those with severely impaired LV systolic function. In this regard, ILR in addition to 24 h-Holter monitoring had a higher yield of VAs as compared to 24 h-Holter monitoring alone. In settings where WCDs are not readily available, ILR monitoring should be considered in patients with severely impaired LV systolic dysfunction, especially after uneventful 24 h-Holter monitoring.Trial registrationPan African Clinical Trials Registry: PACTR202104866174807.Graphical abstractExtended electrocardiographic monitoring for the detection of arrhythmias in PPCM. (CHB, complete heart block/third degree AV block; ECG, electrocardiogram; ILR, implantable loop recorder; NSVT, non-sustained ventricular tachycardia; PPCM, peripartum cardiomyopathy)

Short term outcome of distal (ventricular) His bundle pacing and atrioventricular node ablation in patients with symptomatic atrial fibrillation - Refining the concept

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Many patients with atrial fibrillation (AF) do not benefit from rhythm control due to failed catheter ablation, advanced left atrial disease and comorbidities. "Pace and AV node (AVN) ablation" strategy is often adopted for rate control but with a substantial risk of pacing-induced cardiomyopathy. His bundle pacing (HBP) enables physiological biventricular activation through the His Purkinje conduction system. However, the proximity of the HBP lead to the site of AV node ablation may potentially compromise lead integrity in patients who undergo conventional HBP and AVN ablation. Therefore, we have modified HBP by placing the HBP lead distally at the ventricular side of the His bundle (D-HBP) before AVN ablation in patients with symptomatic AF. All patients had a backup RV lead. Method Patients who had D-HBP as part of a "Pace and AVN ablation" strategy were retrospectively analysed. Implant and device clinic follow-up data were collected and analysed. Result Twenty-one patients who had "pace and AVN ablation strategy" with D-HBP between 26th February 2020 and 3rd November 2021 were included. They had a mean age of 75 ± 1.4 years (mean ± SEM), NYHA class of 2.1 ± 0.2, QRS duration of 106 ± 5.3ms and 50% had at least moderately impaired LV systolic function. Seventeen patients (81%) had narrow QRS duration. D-HBP was successful in twenty of twenty-one patients (95%). At D-HBP implant, the mean acute threshold of the HBP lead was 0.96 ± 0.12V at 0.5 ± 0.05ms and the mean HBP lead impedance was 548.1 ± 29.5Ω. Selective HBP pacing was observed in thirteen of twenty patients. The mean QRS duration of HBP paced beats was 104.5 ± 4.7ms. Failure to capture the His bundle was observed in one patient. AVN ablation was performed on the same day after D-HBP in eleven patients and as a subsequent procedure in nine patients. The mean duration of procedure and fluoroscopy for D-HBP were 77.4 ± 4.6 minutes and 11.9 ± 1.4 minutes respectively. There were no acute procedural complications with no lead damage, displacement or lead perforation observed. The median follow-up period was 207 days. The mean D-HBP lead threshold following AVN ablation was 1.1 ± 0.2 V at 0.6 ± 0.07 ms and the mean lead impedance was 433.8 ± 20.7Ω, which were similar to before AVN ablation. One patient was reprogrammed with RV pacing only for elevated HBP lead threshold after AVN ablation to 4.2 V at 1ms. The mean D-HBP percentage was 92.3 ± 6.6% and the mean estimated battery longevity of the pacemaker was 7.9 ± 0.6 years at the last follow up. There was improvement in heart failure symptoms in eight patients from previously symptomatic to NYHA class I following D-HBP and AVN ablation. Conclusion D-HBP appear to be safe with potentially more favourable lead parameters than conventional proximal HBP in patients with symptomatic AF offered "Pace and AVN ablation" strategy.

First signs of reverse cardiac remodeling following one-month, low dose add-on sacubitril-valsartan therapy in patients with advanced systolic heart failure

We investigated the early effects of low dose sacubitril/valsartan (S/V) on cardiac reverse remodeling (CRR). Methods: In 37 patients (45- excluded 8pts,mean age 64.5±17.5 years, five females), 24/26 mg S/V BID was started, and the second evaluation was performed after month. Results: Following CRR parameters improved: LVEDD (-∆2,9±2.6 mm; Student’s t-test: p =0.0098), LVESD (-∆2,4±2.5 mm; Student’s t-test: p=0.0092), LVEDV (-∆14.6±33.1 mL; Wilcoxon test: p = 0.0412), LVESV (-∆13.4±30.6 mL; Wilcoxon test: p =0.0442), LAVI (-∆8.7±37.7 mL/m2; Wilcoxon test: p = 0.0012), and EROA (-∆0.09±0.01 cm2; Student’s t-test: p = 0.0318). In opposite to LVEF, global longitudinal strain (GLS) changed from -6.6% to -7.9% (absolute improvement of 16%, Wilcoxon test: p=0.0013). Other parameters improving: 6-MWT (+∆65.4±75.8 m; Wilcoxon test: p = 0.0013) and the quality of life (MLHFQ 22 vs 16 scores; Student’s t-test: p= 0.0098), NT-pro BNP (-∆1203.1±3121.4 pg/mL; Student’s t-test: p = 0.0348) and troponin T (-∆ 4.7±9.4 pg/mL, Wilcoxon test: p = 0.0041). Correlation between GLS and LVESV (Pearson's correlation coefficient: r = -0,4596, p = 0.0239) was found. ROC curve analysis showed that in the group with severe systolic dysfunction (GLS&lt; -8%) clinical improvement (6MWT: AUC = 0.692, p = 0.0383) and CRR (MRvol: AUC = 0.736, p = 0.0062; LAVI: AUC = 0.710, p = 0.0414) are more likely to occur. Conclusions: Low-dose (24/26 mg BID) S/V therapy initiates CRR. S/V should be started in patients with less impaired LV systolic function (GLS &lt; -8%) because CRR and clinical improvement are more likely to develop.

453 An unexpected finding in an asymptomatic patient planned for non-cardiac surgery

Abstract Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

Accuracy of estimating left ventricular ejection fraction in clinical routine. A SWEDEHEART registry validation study

Abstract Objective Patients admitted to Swedish hospitals with myocardial infarction (MI) are reported to the nationwide Swedish registry for MI (SWEDEHEART). During hospital stay an echocardiography is routinely performed, and left ventricular ejection fraction (LVEF) is assessed according to the clinical praxis. LVEF is categorized as normal (&amp;gt;50%) or mild, moderate or severely impaired (40–49%, 30–39% and &amp;lt;30%, respectively) and reported to the registry by the treating center. The purpose of this study was to validate the reported LVEF assessments against independent echocardiography re-evaluation as this has never previously been done. Methods A random sample of 130 patient from three different hospitals were included. LVEF re-evaluation was performed by two independent reviewers using the modified biplane Simpson method and their mean LVEF was compared to the SWEDEHEART LVEF. Agreement between reported and re-evaluated LVEF was assessed using Gwet's AC2 statistics. Results Analysis showed good agreement between reported and reevaluated LVEF (AC2: 0.76 [95% CI 0.69–0.84]). The LVEF re-evaluations corresponded with registry reported categorized LVEF in 66.0% of cases. In 25.4% of cases the SWEDEHEART LVEF was lower than re-evaluated LVEF. The opposite relation was found in 8.6% of cases (p&amp;lt;0.005). Conclusion Independent validation of SWEDEHEART-reported LVEF shows an overall good agreement with the re-evaluated LVEF. However, a tendency to underestimation of LVEF was observed in patients with impaired LV systolic function, in whom the reported assessment of LVEF should be interpreted more cautiously. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Selanders Stiftelse

Evaluation of global left ventricular systolic function in dipper and newly diagnosed nondipper hypertensive patients

Abstract Objective Nondipper hypertension has been associated with enhanced target organ damage and adverse cardiovascular outcomes. The effect of dipper and non-dipper status on cardiac target organ damage has not been comprehensively investigated by two-dimensional strain echocardiography. We aimed to investigate myocardial deformational strain parameters in dipper and non-dipper untreated hypertensive patients. Material and methods We included 42 newly diagnosed hypertensive patients without previous history of cardiovascular disease and coexisting chronic disease. Study population consisted of two groups of patients, 23 dipper patients and 19 non dipper patients. Global longitudinal strain (GLS), radial strain and circumferential strain analysis were measured by two-dimensional (2-D) speckle tracking method. Results The study population included 42 patients (15 male) with a mean age of 54.5±9 years. The assessment of LV systolic function by GLS showed decreased values in nondippers compared with dippers (−18.13±2.07 vs. −13.7±1.95; p=0.001). But no significant intergroup differences were observed in circumferential and radial strain. The analysis showed that night-time mean arterial pressure (MAP), night-time systolic and diastolic blood pressures (BP), 24-hr SBP, dipping rate and nocturnal reduction rate of MAP were the parameters that correlated with GLS. Only dipping rate was independently associated with left ventricular GLS. Conclusion An isolated non-dipper BP was found to cause impaired LV systolic function detected by myocardial strain. Funding Acknowledgement Type of funding sources: None. Figure 1

COMPARISON BETWEEN DIFFERENT PARAMETERS IN EARLY DETECTION OF LV SYSTOLIC DYSFUNCTION IN PATIENTS WITH CHRONIC STABLE ANGINA

Background: Ischemia plays a pivotal role in the development and progression of both types of HF (HFrEF & HFpEF). Strain echocardiography, performed by using the speckle tracking technique, can identify subclinical left ventricular dysfunction before left ventricular ejection fraction declines. Objective: To assess left ventricular systolic function by different noninvasive imaging modalities in patients with chronic ischemic heart disease. Patients and methods: This study was done at Al Zahra University Hospital from November 2017 till January 2020. It included 80 patients (group I) with chronic ischemic heart disease (IHD), they were 60 males (75%) and 20 females (25%) with mean age 53.5±8.08, and 15 apparently healthy age and sex matched subjects as a control group (group II), they were 11(73.3%) females and 4(26.7%) males with mean age 53.2±7.7. Group I was further sub-classified to impaired and preserved according to their LVEF assessed by 2D echo, speckle tracking echo global longitudinal strain (STE-GLS), tissue Doppler imaging (TDI) strain, TDI Sa and gated SPECT LVEF. Results: The ischemic (group I) showed a statistically significant decrease in the average Sa 5.45±1.69 VS group II 8.7± 0.73 (P value < 0.001), lower LVEF 2D echo in group I 46.3±9.68 compared to group II 58.9±4.68 (P value < 0.001), decrease in gated SPECT LVEF in group I 56.4±13.98 VS group II 67.067±5.66 (P value < 0.001), statistically significant reduction in left ventricular global longitudinal strain (LV-GLS) (-13.89±18.99) in group I vs -21.24±1.23 in group II (P value <0.05). The highest percentage of patients with impaired LV systolic function were those who assessed by STE-GLS (74 patients 92%), 72 patients (90%) impaired LVEF by TDI Sa, 60 patients (75%) impaired LVEF by 2D echo, and by TDI strain, and 22 patients (27.5%) impaired LVEF by gated SPECT. Conclusion: STE is considered the most sensitive method in assessment of subclinical LV systolic dysfunction and is considered superior to other methods.

A machine-learning-based method to predict adverse events in patients with dilated cardiomyopathy and severely reduced ejection fractions.

Patients with dilated cardiomyopathy (DCM) and severely reduced left ventricular ejection fractions (LVEFs) are at very high risks of experiencing adverse cardiac events. A machine learning (ML) method could enable more effective risk stratification for these high-risk patients by incorporating various types of data. The aim of this study was to build an ML model to predict adverse events including all-cause deaths and heart transplantation in DCM patients with severely impaired LV systolic function. One hundred and eighteen patients with DCM and severely reduced LVEFs (<35%) were included. The baseline clinical characteristics, laboratory data, electrocardiographic, and cardiac magnetic resonance (CMR) features were collected. Various feature selection processes and classifiers were performed to select an ML model with the best performance. The predictive performance of tested ML models was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve using 10-fold cross-validation. Twelve patients died, and 17 patients underwent heart transplantation during the median follow-up of 508 days. The ML model included systolic blood pressure, left ventricular end-systolic and end-diastolic volume indices, and late gadolinium enhancement (LGE) extents on CMR imaging, and a support vector machine was selected as a classifier. The model showed excellent performance in predicting adverse events in DCM patients with severely reduced LVEF (the AUC and accuracy values were 0.873 and 0.763, respectively). This ML technique could effectively predict adverse events in DCM patients with severely reduced LVEF. The ML method has superior ability in risk stratification in severe DCM patients.

Heart transplantation from donors with left ventricular ejection fraction under forty percent.

Heart transplantation (HTx) remains the treatment of choice for patients with end-stage advanced heart failure. In 2016, the Shumakov National Medical Research Center commenced performing HTx from donors with abnormal left ventricular systolic function (LVEF<40%). The aim of this study was to evaluate early and late outcomes of recipients after HTx from donors with abnormal LV systolic function. Four hundred eighty seven patients underwent HTx in our institution from January 2016 to December 2018. 27 (5.5%) patients were transplanted using cardiac allografts from donors with LVEF <40%. A total of 47 donors with LVEF <40% were evaluated for potential donation. Most heart donors revealed a left ventricular ejection fraction ranging between 30% and 40%. Twenty-five recipients required urgent HTx. Four recipients presented with early allograft dysfunction. All surviving recipients demonstrated early (85.2%) or delayed (14.8%) recovery of systolic function (LVEF>60%). The use of dysfunctional donor hearts with impaired LV systolic function may be a realistic approach for expanding the donor pool. However, organs from such donors should be used for recipient cohorts requiring an urgent HTx, particularly for those with pretransplant mechanical circulatory support allowing for hemodynamic support in cases of early graft dysfunction in the post-transplant period.

ESSENTIAL HYPERTENSION OR A MISSING CAUSE FOR SECONDAY HYPERTENSION?

Objective: The case highlights the importance of diagnosing secondary hypertension and adequate treatment in the setting of a patient with classical cardiovascular risk factors which would otherwise make primary hypertension the most likely diagnosis. Design and method: Clinical Case Results: A 57 year-old male with cardiovascular risk factors (smoking, dislypidemia), grade 2 essential hypertension (ESC/ESH) and G3a stage chronic kidney disease (CKD) presents to our clinic with fatigue and persistent high blood pressure values despite treatment with ACEi. Clinical exam was unremarkable except for a 10mmHg difference between the arm and foot systolic blood pressure. The 24-hour ambulatory blood pressure monitoring revealed a non-dipping profile, with a mean blood pressure value of 150/100mmHg. TTE was performed and the following were observed: bicuspid aortic valve with tight aortic stenosis (mean AV PG &gt; 40mmHg, AVA = 1.12cm2) and LV systolic dysfunction (LVEF = 35%). TEE was also performed and confirmed the bicuspid aortic valve. Given the context of the patient, computed tomography angiography (CTA) was the investigation of choice in order to visualize the aorta. Postductal coarctation was detected with a hypoplastic thoracic aorta and multiple collateral vessels. The coronary angiogram was normal. The ACEi was stopped and the patient received a dihydropyridine calcium channel blocker in combination with an adolsterone receptor antagonist with a favourable course. Aortic valve replacement surgery with mechanical valve implantation was recommended. Considering the multiple collateral vessels and complex vascular morphology, surgical correction of the coarctation was considered no longer feasible Conclusions: CoA was the actual cause for the persistent high blood pressure values in an adult male with cardiovascular risk factors who was believed to have essential hypertension. In the setting of aortic stenosis with impaired LV systolic function, high blood pressure values are not typical. Taking into account the BAV, the clinical suspicion of CoA was high and prompted further investigations. The CKD is the result of the the underperfusion of the kidneys secondary to the CoA and the use of ACEi.

MITRAL ANNULAR PLANE SYSTOLIC EXCURSION-DERIVED FORMULA TO CALCULATE THE EJECTION FRACTION: A SIMPLE, EASY AND RAPID ECHOCARDIOGRAPHY PARAMETER TO ASSES LEFT VENTRICLE SYSTOLIC DYSFUNCTION

Aims &amp; Objectives - MAPSE DERIVED EJECTION FRACTION CAN BE USED AS AN ALTERNATIVE TO THE CONVENTIONAL ECHOCARDIORAPHIC MEASUREMENTS OF EJECION FRACTION IN EVERY DAY CLINICAL PRACTICE WITH PATIENTS WITH LV SYSTOLIC DYSFUNTION &amp; VALIDATION OF MITRAL ANNULAR PLANE SYSTOLIC EXCURSION DERIVED FORMULA TO CALCULATE THE EJECTION FRACTION IN PATIENTS WITH LV SYSTOLIC DYSFUNCTION EF=4.8XMAPSE(mm)+5.8 in adult male &amp; 4.2X MAPSE(mm)+20 in adult female. Our study is Material and Methodobservational, prospective study with cross sectional data collection done in a period of nov 2018 to nov 2019, The study included 151 adult male and female patients with LV systolic dysfunction fullling all inclusion criteria, LVEF measured by average MAPSE and LVEF measured by visual inspection, M–mode, and modied Simpson's rule was statistically correlated to know the validity of MAPSE derived ejection in case of LVsystolic dysfunction. The current study showed a signicant positive correlation Result - between average MAPSE and EF measured by Mmode (r =0.980, P &lt; 0.001), EF measured by Simpson's rule (r =0.968, P &lt; 0.001), and EF measured by visual inspection(r =0.960, P &lt; 0.001). The mean differences in the EF derived by MAPSE formula between the inter-observer was(-0.14 ± 3.18 ). MAPSE-derived EF using Conclusion - the equation EF = 4.8 × MAPSE (mm) + 5.8 for male and EF = 4.2×MAPSE (mm)+20 for female, is a valid echocardiographic parameter in adult males and females with impaired LV systolic function to asses global LV longitudinal function with minimal interobserver variability.

Left ventricular and left atrial deformation imaging early after pPCI: does diabetes mellitus make any difference?

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf PREDICT-VT More extensive coronary atherosclerosis in diabetes mellitu (DM) induces poorer clinical outcomes after STEMI, but there are data suggesting that impaired myocardial function in DM, even independently from epicardial coronary lesions severity, might have detrimental effect, predominately on heart failure development in DM. Aim the current study is a sub-study of PREDICT-VT study (NCT03263949), aimed to analyse LV and LA function using myocardial deformation imaging based on speckle tracking echocardiography after pPCI in STEMI patients with and without DM. Methods in 307 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done including LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec), LV index of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains and analysis of LV rotation mechanic. Results from 242 patients who completed 1 year follow up, 48 (20%) had DM. Pts with DM were older (60 ± 1,01 vs 57 ± 10; p = 0.067) and had insignificantly higher SYNTAX score (18.5 ± 9.2 vs 15.8 ± 9.8, p = 0.118) . However, diabetics had more severely impaired EF (44.2 ± 8.6 vs 49.2 ± 9.8, p = 0.001), E/A ratio (0.78 ± 0.33 vs 0.90 ± 0.34; p = 0.036) and MAPSE (1.18 ± 0.32 vs 1.32 ± 0.33; p = 0.001). Global LV LS on all layers (endo: -13.6 ± 4.0 vs-16.2 ± 4.7; mid: -11.9 ± 3.5 vs -14.1 ± 4.1; epi: -10.4 ± 3.1 vs -12.3 ± 3.6; p &amp;lt; 0.005 for all) was impaired in DM patients, as well as longitudinal systolic SR (-0.71 ± 0.23 vs -0.84 ± 0.24; p = 0.001) and SR during early diastole (0.65 ± 0.26 vs 0.83 ± 0.33, p &amp;lt; 0.001). Patients with DM had more pronounced longitudinal posts-systolic shortening throughout LV wall (endo: 21.4 ± 16.1 vs 13.7 ± 13.3, p = 0.005; mid: 21.9 ± 16.1 vs 14.3 ± 13.1, p = 0.006; epi: 22.4 ± 16.5 vs 15.3 ± 13.7, p = 0.010) and higher LV mechanical dispersion (MDI: 71.3 ± 38.3 vs 59.0 ± 18.9, p = 0.037). LA strain was significantly impaired in DM patients (18.9 ± 7.7 vs 22.6 ± 10.0, p = 0.011) and even more profoundly LA strain rate during early diastole (-0.73 ± 0.48 vs -1.00 ±0.58, p = 0.002). Patients with DM also had more impaired LV global (15.7 ± 9.1 vs 19.8 ± 10.4, p = 0.013) radial strain, global LV circumferencial strain, especially at the mid-wall level (-13.9 ± 4.2 vs -16.0 ± 4.3, p = 0.005) and impaired circumferential SR E (1.25± 0.44 vs 1.49 ± 0.46, p = 0.003). End-systolic rotation of the LV apex was more impaired in DM (4.7 ± 5.1 vs 6.8 ± 5.5, p= 0.022). During 1 year follow-up heart failure and all-cause mortality tend to be higher among DM pts (46.7% vs 35.2%, p = 0.153). Conclusion STEMI patients with DM have more severely impaired LV systolic and diastolic function estimated both by traditional parameter and advanced echo techniques. These results might, at least partially, explain why outcomes after STEMI in DM might be poorer, even in the absence of more complex angiographic findings, pointing to the significance of impaired myocardial function DM itself.

Prognostic Value of Left Ventricular Global Longitudinal Strain in Patients With Secondary Mitral Regurgitation

BackgroundLeft ventricular (LV) systolic function may be overestimated in patients with secondary mitral regurgitation (MR) when using LV ejection fraction (EF). LV global longitudinal strain (GLS) is a less load-dependent measure of LV function. However, the prognostic value of LV GLS in secondary MR has not been evaluated. ObjectivesThis study sought to demonstrate the prognostic value of LV GLS over LVEF in patients with secondary MR. MethodsA total of 650 patients (mean 66 ± 11 years of age, 68% men) with significant secondary MR were included. The study population was subdivided based on the LV GLS value at which the hazard ratio (HR) for all-cause mortality was >1 using a spline curve analysis (LV GLS <7.0%, impaired LV systolic function vs. LV GLS ≥7.0%, preserved LV systolic function). The primary endpoint was all-cause mortality. ResultsDuring a median follow-up of 56 (interquartile range: 28 to 106 months) months, 334 (51%) patients died. Patients with a more impaired LV GLS showed significantly higher mortality rates at 1-, 2-, and 5-year follow-up (13%, 23%, and 44%, respectively) when compared with patients with more preserved LV systolic function (5%, 14%, and 31%, respectively). On multivariable analysis, LV GLS <7.0% was associated with increased mortality (HR: 1.337; 95% confidence interval: 1.038 to 1.722; p = 0.024), whereas LVEF ≤30% was not (HR: 1.055; 95% confidence interval: 0.794 to 1.403; p = 0.711). ConclusionsIn patients with secondary MR, impaired LV GLS was independently associated with an increased risk for all-cause mortality, whereas LVEF was not. LV GLS may therefore be useful in the risk stratification of patients with secondary MR.

P275 Feasibility and accuracy of the automated quantification of two- and three-dimensional left ventricular ejection fraction and its role in the arrhythmic risk stratification of organic heart disease

Abstract BACKGROUND New automated approaches for left heart chamber quantification based on adaptive analytics algorithms have been introduced for both two- (2DE) and three-dimensional (3DE) echocardiography. These algorithms measure a left ventricular ejection fraction (LVEF) and reduce the intra- and inter-observer variability associated with the conventional manual tracing of LV endocardial borders. However, the clinical utility of these algorithms in the sudden cardiac death (SCD) risk stratification of patients with organic heart disease remains to be clarified. PURPOSE We sought to test the feasibility and the accuracy of two automated algorithms that measure 2DE and 3DE LVEF in patients with impaired LV systolic function and to define the cut-off values for fully automated 2DE and 3DE LVEF that could predict major arrhythmic events (MAE). We wanted also to assess the feasibility of replacing manual 2DE and semi-automated (SA) 3DE LVEF with fully-automated (FA) 2DE and 3DE LVEF respectively, in the stratification of high arrhythmic risk patients. METHODS We prospectively enrolled 240 patients (63 ± 13 years, 81% men) with both ischemic and non-ischemic cardiomyopathy with 2DE LVEF &amp;lt; 50%, no previous MAE or coronary artery revascularization &amp;lt; 90 days, after at least 3 months of optimal medical therapy for heart failure. MAE were defined as SCD, resuscitated cardiac arrest (CA), ventricular fibrillation, sustained ventricular tachycardia and appropriate ICD shocks. The risk detection cut-off values for 2DE and 3DE FA LVEF were computed using the maximally selected rank statistics method. In order to predict the risk of MAE we created four different risk models, including both clinical characteristics (age, NYHA class, aetiology of the LV dysfunction) and imaging-derived data (2DE manual LVEF, 2DE FA LVEF, 3DE SA LVEF and 3DE FA LVEF), analyzed by a ROC curve. RESULTS During a 27 ± 25months follow-up period, 31 patients (13%) presented MAE including SCD (n= 22; 9%), resuscitated CA (n = 3; 1%) and appropriate ICD shocks (n = 6; 2%). Both 2DE and 3DE FA LVEF showed high feasibility (92% and 95%, respectively), and good agreement with conventional LVEF (2DE mean difference 4 ± 7%, and 3DE mean difference 4 ± 7%). We identified two FA LVEF cut-offs for the MAE detection: 2DE &amp;lt;39% (p = 0.006) and 3DE &amp;lt;37% (p = 0.005). The model including the 2DE FA LVEF showed an area under the curve (AUC) larger than the one including conventional 2DE LVEF (0.83 vs 0.80). Conversely, the AUC obtained with FA 3DE LVEF model was slightly lower than the one obtained using SA 3DE LVEF model (0.80 vs 0.84). CONCLUSIONS Both 2DE and 3DE FA LVEF are feasible and accurate alternative to the conventional (manual) or SA endocardial border tracing. The use of specific FA 2DE LVEF cut-off values showed a comparable predictive power in the MAE risk stratification compared to the conventional one with the advantage of very low intra- and inter-observer variability.

Haemodynamic effects of pharmacologic stress with adenosine in patients with left ventricular systolic dysfunction

BackgroundIn patients with heart failure, downregulation of adenosine receptor gene expression and impaired adenosine-related signal transduction may result in a diminished response to adenosine. This may have implications for cardiac stress testing. We evaluated the haemodynamic response to intravenous adenosine in patients with left ventricular systolic dysfunction (LVSD) undergoing stress cardiovascular magnetic resonance imaging (CMR). Methods and resultsWe retrospectively examined 497 consecutive patients referred for clinical stress CMR. Blood pressure and heart rate responses with intravenous adenosine were compared in patients with normal, mild-moderately impaired and severely impaired LV systolic function (ejection fraction [EF] > 55%, 36–55% and < 35%, respectively).Following 2 min of adenosine infusion, there was a significant difference between the groups in the heart rate change from baseline, with a diminished heart rate response in patients with LVSD (p < 0.001). An increase in the dose of adenosine (up to 210 μg/kg/min) was required to achieve a sufficient haemodynamic response in more patients with severe LVSD (41%) than those with mild-moderately impaired and normal LV systolic function (24% and 19%, respectively, p < 0.001). Even with increased doses of adenosine in subjects with severe LVSD, peak haemodynamic response remained blunted. With multivariate analysis age (p < 0.001) and LVEF (p = 0.031) were independent predictors of heart rate response to adenosine. ConclusionPatients with reduced LVEF referred for stress CMR may have a blunted heart rate response to adenosine. Further study is warranted to determine whether this may be associated with reduced diagnostic accuracy and also the potential utility of further dose increases or alternative stressors.

Effect of high flow arteriovenous fistula on cardiac function in hemodialysis patients.

BackgroundVascular access for hemodialysis (HD) with an inappropriately high flow may underlie the onset of high output heart failure (HOHF).The aim of this study was to determine the prevalence of high flow access (HFA) in chronic HD patients, and to determine its effects on cardiac functions.MethodsThis cross sectional study was conducted on 100 chronic hemodialysis patients through arteriovenous fistula (AVF). The study cohort was subdivided into 2 groups based on AVF flow: Group A (Non-HFA group with Qa < 2000 ml/min), and Group B (HFA group with Qa ≥ 2000 ml/min). AVF flow (Qa) was assessed using Color Doppler ultrasonography. Transthoracic echocardiography was performed for all patients to assess cardiac dimensions and functions.ResultsPrevalence of HFA among study population was 24%. Mean AVF Qa was 958.63 ± 487.35 and 3430.13 ± 1256.28 ml/min, for group A and B respectively. The HFA group demonstrated a significant dilatation in LV dimensions and volumes and significantly larger LA volume as compared to non-HFA group. A significantly lower LV ejection fraction [EF] was also observed in group B with a mean value of 57.32 ± 6.19% versus 62.90 ± 5.76%. A significant association between HFA group and high Qa/cardiac output (CO) ratio (≥20%) was also observed.ConclusionHFA is a prevalent hemodialysis vascular access problem. HFA was associated with dilated LV dimensions, impaired LV systolic function. High Qa/CO ratio (≥20%) was an independent predictor of high output heart failure (HOHF) in our study population.