Impaired LVEF Research Articles

Cardiac MRI findings in COVID-19 vaccine-related myocarditis: pooled analysis of 435 patients

Abstract Background Myocarditis following COVID-19 vaccination is a rare adverse event that was recently reported. Understanding the pattern and severity of myocardial injury in myocarditis caused by COVID-19 vaccination is imperative for improving care of the patients. Purpose To detect the pattern and severity of myocardial injury in patients with myocarditis following COVID-19 vaccination based on cardiac MRI findings. Study type Systematic review. Method Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically reviewed the literature by screening 2404 databases using boolean operators and the relevant key terms covering COVID-19 vaccine, myocarditis, and Cardiac MRI. We included all observational MRI studies on patients with suspected myocarditis following COVID-19 vaccination. Cardiac MRI findings, including T1, T2, ECV, LGE, and left ventricular ejection fraction, were extracted from included studies. Statistical tests As a single case series, individual-level patient data (IPD) studies were pooled with aggregated–level data (AD) studies through two-stage analyses. For this purpose, first, data from all case series and case reports with IPD were aggregated using one-stage IPD analyses. Results Based on our two-stage pooled analyses of IPD and AD studies, diagnosis of myocarditis using lake luoise criteria was confirmed in 74% (95% confidence interval (CI): 49% to 94%) of patients. Cardiac MRI abnormalities included elevated T2 in 67% (95% CI: 45% to 87%), myocardial LGE in 91% (95% CI: 81% to 99%) [having a subepicardial/midwall pattern: 99.5%], impaired LVEF (<50%) in 4% (95% CI: 0.0% to 9.0%). Also, elevated T1 and ECV (>30), reported only by some IPD studies, was detected in 72.5% (66/91) and 32% (16/50) of patients, respectively. Data conclusion Myocardial injury in COVID-19 vaccine-associated myocarditis may have a similar pattern compared to other forms of acute myocarditis. Despite other myocarditis, Preserved LVEF is a common finding in these patients. Funding Acknowledgement Type of funding sources: None.

Risk factors for intracardiac thrombus in peripartum cardiomyopathy: a retrospective study in China.

Peripartum cardiomyopathy (PPCM) are more vulnerable to intracardiac thrombus than other types of cardiomyopathies, although explicit anticoagulant strategy is not sure. Too aggressive anticoagulation therapy can lead to severe bleeding events. Hence, we want to construct a risk stratification model for intracardiac thrombus in PPCM patients. A total of 159 suspected PPCM cases were initially screened, whereas 123 confirmed cases were enrolled in the final analysis. The study population was randomly assigned as derivation group (N=83) and validation group (N=40). The derivation cohort was utilized to develop the model, and the validation cohort was used to internal validate the discriminatory ability of the model. Formation of intracardiac thrombus was detected in 22 patients. After adjusted by multivariable logistic regression analysis, left ventricle ejection fraction (LVEF, OR 0.772, 95% CI 0.665-0.897, P=0.001), haemoglobin levels (OR 1.050, 95% CI 1.003-1.099, P=0.038), and thrombocyte counts (OR 1.018, 95% CI 1.006-1.029, P=0.003) were identified as risk factors independently associated with intracardiac thrombus and were finally included in the tentative risk stratification model with a C-indexes of 0.916 (95% CI: 0.850-0.982, P<0.001). A score of ≤7 was regarded as low risk, 8-10 defined intermediate risk, and ≥11 defined high risk in our model. Internal validation showed good discriminatory ability of the model with a C-indexes of 0.790 (95% CI: 0.644-0.936, P=0.017). In our retrospective study, impaired LVEF, elevated haemoglobin levels, and high thrombocyte counts were regarded as independent risk factors for intracardiac thrombus in PPCM. A risk stratification model derived from these risk factors, which was economic and easily applicable in clinical practice, could rapidly and accurately identify PPCM patients with higher-risk of intracardiac thrombus.

First-in-human pilot trial of combined intracoronary and intravenous mesenchymal stem cell therapy in acute myocardial infarction.

BackgroundAcute ST-elevation myocardial infarction (STEMI) elicits a robust cardiomyocyte death and inflammatory responses despite timely revascularization.ObjectivesThis phase 1, open-label, single-arm, first-in-human study aimed to assess the safety and efficacy of combined intracoronary (IC) and intravenous (IV) transplantation of umbilical cord-derived mesenchymal stem cells (UMSC01) for heart repair in STEMI patients with impaired left ventricular ejection fraction (LVEF 30-49%) following successful reperfusion by percutaneous coronary intervention.MethodsConsenting patients received the first dose of UMSC01 through IC injection 4-5 days after STEMI followed by the second dose of UMSC01 via IV infusion 2 days later. The primary endpoint was occurrence of any treatment-related adverse events and the secondary endpoint was changes of serum biomarkers and heart function by cardiac magnetic resonance imaging during a 12-month follow-up period.ResultsEight patients gave informed consents, of whom six completed the study. None of the subjects experienced treatment-related serious adverse events or major adverse cardiovascular events during IC or IV infusion of UMSC01 and during the follow-up period. The NT-proBNP level decreased (1362 ± 1801 vs. 109 ± 115 pg/mL, p = 0.0313), the LVEF increased (52.67 ± 12.75% vs. 62.47 ± 17.35%, p = 0.0246), and the wall motion score decreased (26.33 ± 5.57 vs. 22.33 ± 5.85, p = 0.0180) at the 12-month follow-up compared to the baseline values. The serial changes of LVEF were 0.67 ± 3.98, 8.09 ± 6.18, 9.04 ± 10.91, and 9.80 ± 7.56 at 1, 3, 6, and 12 months, respectively as compared to the baseline.ConclusionThis pilot study shows that combined IC and IV transplantation of UMSC01 in STEMI patients with impaired LVEF appears to be safe, feasible, and potentially beneficial in improving heart function. Further phase 2 studies are required to explore the effectiveness of dual-route transplantation of UMSC01 in STEMI patients.

C12 MANAGING CARDIAC ARREST SECONDARY TO SPONTANEOUS CORONARY ARTERY DISSECTION: SHOULD WE ROUTINELY CONSIDER ICD IMPLANTATION? INSIGHTS FROM PARMA SCAD REGISTRY

Abstract Background Cardiac arrest secondary to a spontaneous coronary artery dissection (SCAD) represents a challenging scenario. It deserves specific considerations due to the dramatic presentation and the need for secondary sudden cardiac death prevention. Methods We collected clinical data of four women admitted during the last two years in the Coronary Care Unit of Parma University Hospital, whose presentation of SCAD were cardiac arrest due to ventricular fibrillation (Table1). Results Three patients survived the acute phases. One patient, being considered at high risk of SCAD recurrence, received a subcutaneous implantable cardioverter–defibrillator (S–ICD). Acute management of cardiac arrest related to SCAD deserves specific considerations. Our case series illustrates the importance of prompt resuscitation manoeuvres and early defibrillation. We propose a flow chart of management of cardiac arrest in patient with suspect of SCAD (Figure 2 A). Evaluating risk of SCAD recurrence and sudden cardiac death. The management of SCAD patients complicated by malignant ventricular arrhythmias and cardiac arrest is challenging. Looking at published registries, it appears that SCAD patients are more likely to suffer from ventricular arrythmia or sudden cardiac death than non–SCAD MI patients. The risk–benefit ratio of ICD implantation in these patients remain uncertain . Evaluation of scar burden with CMR can help stratify the global arrhythmic risk, especially as extensive myocardial scar with a residual impaired LVEF increases the risk of future arrhythmic events (Figure 2 B). In our series, only one patient underwent S–ICD implantation, and the decision was mainly driven by the finding of underlying arteriopathy affecting other vascular territories, suggesting a potentially higher rate of SCAD recurrence. For this particular subset of patients, we propose an algorithm that combines predisposing factors and myocardial injury quantification data (Figure 2 B) that could be useful for the estimate of the risk of malignant arrythmias, as well as the risk of recurrence of SCAD, but needs to be validated in larger case studies. Conclusions The acute management of cardiac arrest related to SCAD deserves specific consideration. The residual myocardial damage, predisposing and precipitants factors should be evaluated in order to estimate the SCAD recurrence and sudden cardiac death risks.

Outcomes of primary percutaneous coronary intervention in ST-Segment elevation myocardial infarction in Kurdistan Region of Iraq

Objective: This registry aims to clarify the characteristics and 6-weeks outcomes of patients with STEMI after PPCI in the region.&#x0D; Methods: Data from a total of 151 STEMI patients undergoing PPCI at Duhok heart center, Iraq from 2020 to 2021 was collected. Patient’s demographic, clinical and PPCI profiles were recorded. The major adverse cardiac events (MACE) and left ventricle ejection fraction (LVEF%) outcomes for 6 weeks period was registered. &#x0D; Results: Of the 151 consecutive patients with STEMI who underwent PPCI, 46 (30.4%) were &lt;50 years old. Majority of patients were males and have clusters of cardiometabolic risk factors. 64% of cases attained Cath lab within first hour of initial chest pain. Almost 90% of STEMI cases were treated with stenting with TIMI3 in (94%). 80% of PPCI cases discharged home within 24 hours uneventfully. 6-weeks LVEF was preserved within normal range in 55% of cases. 36% had MACEs including impaired LVEF. All cause-mortality happened in 5%. 4% were Censored from follow up. The predictors of 6-weeks outcomes were depend on type/location of myocardial infarction, the culprit artery, TIMI flow post PCI and length of hospital stay.&#x0D; Conclusions: This registry has shown feasibility in doing PPCI with reasonable outcomes in the Region. Networking of capable centers of PPCI in the country is essential for augmenting the cardiac services and sharing the knowledge among cardiologists and people for better STEMI outcomes.

Myocardial work indices and ventricular dyssynchrony in adults with aortic coarctation

Abstract Funding Acknowledgements Type of funding sources: None. Background Adults with coarctation of the aorta (CoA) may present residual aortic obstruction and develop arterial vasculopathy and subclinical left ventricular (LV) dysfunction. Myocardial work (MW) is a novel non-invasive index of myocardial efficiency calculated from echocardiographic LV pressure-strain loops, which yields incremental information over ejection fraction and global longitudinal strain. (GLS) Purpose Aim of the present study is to analyze LVMW in a cohort of adult patients with operated aortic CoA Methods CoA patients aged &amp;gt; 18 years who underwent transthoracic echocardiography between September 2020 and July 2021 at our tertiary centre were included. Exclusion criteria were significant recoarctation, impaired LVEF, significant valvular disease and suboptimal image quality. A group of healthy individuals with no cardiac abnormalities. GLS and peak strain dispersion(PSD) were measured. MW indices were calculated using the blood pressure measured in the right arm at the time of the exam. Results Sixty patients (26[22-33]years, 66%male) were included. Data on previous medical history, clinical status at last assessment and Coa-related echocardiographic findings are showed in table 1. No significant differences in traditional parameters of LV systolic and diastolic function were found between groups (EF 60[57-64] vs 57[53-61],p = 0.6), however Coa patients had higher LVmass (84[75-97] vs 68[56-75]g). GLS and MW indices in the study population and in the control group are reported in table 2. Coa group showed lower GLS values and higher PSD (p &amp;lt; 0.0001 for both). Global work index(GWI) and global constructive work(GCW) values were not significantly different between groups, whereas CoA group showed significant increase of global wasted work(GWW) and impaired global work efficiency(GWE,p = 0.003 and 0.0005 respectively). Spearman’s linear method illustrated that both GCW and GWI had a moderate positive relation with mean gradient across the descending aorta at continuous wave Doppler. PSD was positively related to GWW and inversely related to GWE(Figure 1). Using linear regression model with the log of GWE values as dependent variable,PSD,age(β:-0.002,p = 0.03) and LVmass(β:-0.06,p = 0.004)were related to GWE. However, only PSD retained a significant relation on multivariable analysis(β:-0.002,p &amp;gt; 0.0001). Conclusion MW indices assessment is feasible in Coa patients may provide a more comprehensive understanding of the overall myocardial mechanics and performance. In particular, MW demonstrated impaired LV efficiency, which was strongly related to increased mechanical dispersion in Coa patients. Abstract Figure. Abstract Figure.

Clinical and Echocardiographic Parameters in Community-Based Individuals Symptomatic Post Pfizer and AstraZeneca COVID-19 Vaccination

Cardiovascular side-effects of the AstraZeneca (AZ) or Pfizer (PZ) COVID-19 vaccines have generated concerns in Australians of all ages, despite the adverse cardiac symptoms mainly reported in younger patients. We assessed 89 consecutive symptomatic patients referred post-AZ (19%), PZ (78%) or combined AZ/PZ vaccination (2%), clinically and with transthoracic echocardiogram (TTE) in an academic practice. Abnormal TTE values were defined as: LVEF <52% (males), LVEF <54% (females), peak GLS <-17%, left atrial volume indexed (LAVI) >34 mL/m2 and the presence of pericardial effusion. Patients with previous TTE were excluded if the above abnormal parameters were pre-existing and/or known prior COVID-19 infection. 51% of the cohort was female, mean age 40 years. Pre-existing cardiac disease was rare in our cohort: including valvular heart disease (7%), pericardial disease (3%), ischaemic heart disease (2%) and hypertrophic cardiomyopathy (1%). Presenting symptoms included: chest pain (69%), palpitations (25%), dyspnoea (19%), and non-specific malaise (13%). 99% of patients at TTE were in sinus rhythm and 1% in atrial fibrillation. The most common abnormalities found were increased LA volume (19%, mean 30 mL/m2) followed by impaired peak GLS (11%, mean -19%), impaired LVEF (4%, mean 59%) and pericardial effusion (1%). In this community cohort of patients with symptoms post COVID-19 vaccination, the incidence of abnormal echocardiographic parameters was reassuringly low. We investigated short-term outcomes in a relatively young population most of whom had not had a pre-vaccination TTE. Future studies focusing on prospective TTE analysis of patients receiving COVID-19 vaccination could further enhance our findings.

Utility of electrophysiologic testing for sudden death risk stratification in cardiac sarcoidosis patients with mildly impaired left ventricular function

BackgroundVentricular arrhythmias (VA) account for at least 25% of deaths caused by cardiac sarcoidosis (CS) and may arise in patients with mildly impaired LVEF (>35%). ObjectiveIn the current study, we examine whether EP study may be used for sudden death risk stratification in CS patients who have mildly impaired LVEF and a diagnosis of highly probable or probable CS according to the World Association of Sarcoidosis and Other Granulomatous Diseases Sarcoidosis Organ Assessment Instrument (WASOGI). MethodsAll patients: (1) exhibited a diagnosis of highly probable or probable CS according to the WASOGI, (2) exhibited cardiac MRI findings consistent with CS, (3) exhibited LVEF >45% and (4) underwent EP study. Device interrogations, transmissions and medical records were reviewed for all patients. ResultsWe identified 46 CS patients with mildly impaired LVEF. VA were induced in 11 patients and 10/11 patients underwent ICD placement. Thirty-five patients had no VA and 24/35 patients underwent placement of an ILR. During the follow-up period, the VA event rate was 6.5%. The negative and positive predictive values of the EP study for the development of VA were 100% and 27.2%, respectively. ConclusionsIn CS patients with mildly impaired LVEF and a diagnosis of highly probable or probable CS, a negative EP study was highly predictive of the absence of VA. The successful execution of future prospective studies is contingent upon enrollment of phenotypically homogenous cardiac sarcoidosis patients.

Abstract 8858: Reduced Left Ventricular Ejection Fraction is Associated with Higher Long-Term Mortality in Patients with Electrical Storm

Introduction: Little is known about the relationship between LV ejection fraction (EF) and mortality in contemporary patients with electrical storm (ES). Objective: EF at the time of admission for ES was organized into subgroups: EF ≤ 22% (A), 23-32% (B), 33-42% (C), 43-52% (D), and &gt;52% (E). EF subgroups were compared to determine differences in 1-year all-cause mortality. Secondary outcomes included cardiogenic shock (CS), multiorgan system failure, acute tubular necrosis (ATN), and cardiac arrest. We hypothesize that patients with reduced EF will have poorer short-term prognosis and more in-hospital complications. Methods: Single center, retrospective study including consecutive patients admitted to the coronary ICU with ES between April 2014 - 2020. ES was defined as ≥ 3 isolated sustained ventricular arrhythmias or ICD therapies within 24 hours. Results: Of 214 patients admitted with ES, 203 had an echocardiogram on admission. 70 (34.5%) were group A, 58 (28.6%) group B, 36 (17.7%) group C, 23 (11.3%) group D, and 16 (7.9%) group E. The mean EF was 30 +/- 13% (Figure 1). The mean age was 64 +/- 13 years, 83.3% male. 1-year all-cause mortality between subgroups was significant by Kaplan-Meier survival estimate and Mantel-Cox log rank (χ 2 11.2; p 0.023; Figure 2). By Cox Regression using Group E as a reference, only Group A had a statistically significant difference in 1-year all-cause mortality (HR A/E 3.71 [95% CI 1.14 - 12.07]; p 0.029). Analysis of in-hospital complications showed a difference only in cardiogenic shock (p &lt; 0.0001) with higher incidence in those with lower EF (Figure 3). Conclusions: In patients with ES, LVEF is significantly associated with all-cause 1-year mortality. Those with significantly impaired LVEF (≤ 22%) had higher 1-year all-cause mortality compared to those with preserved EF (&gt; 52%).

Myocardial injury in stress echocardiography: comparison of dobutamine, dipyridamole and dynamic stress echocardiography – single centre study

Abstract Background Stress echocardiography (SE) plays important role in investigation of the patients with chest pain. Adverse events rate is higher in dobutamine stress echocardiography on comparison to dobutamine stress echocardiography (ExSE) or dipyridamole stress echocardiography (DIP). Dynamic stress (ExSE) is recommended as the first-choice method according to the current guidelines. Purpose Response to the different stressors was studied in several studies with controversial results. This study aimed to investigate myocardial injury during stress echocardiography measured by the serum high sensitivity troponin (hsTnT) in a low risk population and whether there is a difference in hsTnT response between various stressors. Methods 135 patients (DSE n=46, ExsE n=46, Dip n=43) investigated for chest pain with suspicion on angina with negative diagnostic stress echocardiography were enrolled in the study. HsTnT was measured before and at 180 min. after the test was terminated. Patients with baseline elevated hsTnT levels (≥14 pg/ml), impaired LV EF (&amp;lt;50%), regional wall motion abnormalities, previous acute coronary syndrome and/or revascularisation, known epicardial coronary artery stenosis &amp;gt;50%, diabetes, prediabates (fasting glycemia at the day of the test ≥5,6 mmol/l, left ventricle hypertrophy &amp;gt;13 mm, baseline uncontrolled hypertension (BP &amp;gt;160/100 mmHg), estimated systolic pulmonary pressure &amp;gt;45 mmHg, more than moderate valvular disease, and patient who experienced dobutmine side effect (hypotension, atrial fibrillation) were excluded from the study. Results HsTnT increased in DSE and ExSE, but not in DIP group [9,4 (1,5–58,6), 1,1 (−0,9–15,7), −0,1 (−1,4–2,1) ng/L, p&amp;lt;0,001]. Similar result was found In DSE and ExSE subgroups without atropine [5,3 (0,4–45,3) vs 1,1 (−1,1–15,7) ng/L, p&amp;lt;0,001]. Adding atropine during SE triggered much greater hsTnT release in DSE [40,1 (3,7–160,3) vs 5,3 (0,4–45,3) ng/L, p&amp;lt;0,001], but not in ExSE group [0,6 (−0,9–22,7) vs 1,1 (−1,1–15,7) ng/L, p=0,786]. Moderate correlation of hsTnT rise with DSE length was observed (r=0,43). Conclusions DSE leads to significant myocardial injury multiplied when atropine is used. No injury was observed in DIP and only mild was revealed in ExSE. This finding support ExSE as the preferred stress echocardiography method. Whether significant myocardial injury is causative of the higher adverse event rates in DSE remains to be determined. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): University Hospital Hradec Kralove, Czech RepublicFaculty of Medicine Hradec Kralove, Charles University, Czech Republic hsTnT change 0–180 min. the whole grouphsTnT change 0–180 min. w/wo atropine

Short and medium-term impact of a cardiac rehabilitation (CR) program in COVID-19 patients after acute care hospitalization

Abstract Background COVID-19 (C-19) infection can acutely cause organ dysfunctions, especially cardiorespiratory, even with a long recovery period, inducing a significant functional deficit. Aim of the study was to evaluate the impact of a holistic hospital intensive rehabilitation program, based on CR, on C-19 patients (P), after acute care, to improve their fitness, in order to return to their life in the best conditions. Methods In the period april-august 2020, 30 P (mean age 73 years, 60% male) were admitted to the rehabilitation centre at a mean distance of 31±11 days from the onset of C-19; 34% of them had undergone prolonged invasive ventilation, 34% non invasive ventilation and 32% required high flow oxygen. Comorbidities were: hypertension (77%), diabetes (13%) and chronic coronary syndrome (10%); 18 P were unable to stand, and 12 showed impaired trunk control. No P had impaired LVEF or significant valvular disease. Initially, the program focused on training for trunk and sitting control; then on exercises for straightening the upper and lower limbs. From the second week, started a CR training on the cycle ergometer 10–20 minutes a day for 6 days a week, similar protocol to that used in P with heart failure. The aerobic training was of moderate intensity, not exceeding 40–60% of the maximum heart rate, Borg scale 10–12, starting with zero load, gradually increasing by 10–15 watts and up to a minimum target of 25–30 watts. The impact of the protocol on motor functions [MRC Muscle Strenght Scale, Short Physical Performance Battery (SPPB)] on functional capacity [6 Minutes Walking Test (6MWT)] on anxiety (A) and depression (D) [Hamilton Anxiety Rating scale (HAMA) and Hamilton Depression Rating scale (HAMD)] and on basic activities of daily life [Barthel Index (BI)] were evaluated. The assessment was done on the admission (T0), at the discharge (T1, on average after 31 days) and after a follow-up of 55 days (T3). Results The results are shown in the table below. Only 4 P were able to perform the 6MWT at T0. The motor function improves rapidly and then reaches a plateau and its trend is reflected in the BI. Functional capacity, on the other hand, improves significantly even at a distance. A and D decreased rapidly but increased over time. Conclusions A rehabilitation protocol, centered on CR, induces a rapid increase in motor capacity, even in severely compromised subjects such as C-19. The improvement in fitness over time, as demonstrated by the 6MWT, probably is due to the severe muscle deconditioning, for the long stay in acute care. The long-term worsening of A and D may depend on various causes: no longer living in a “protected and safe” place, the fear of relapse, returning home and discovering new deaths and mournings. A program, CR-like, can counteract many of the negative consequences of C-19; however these P deserve an outpatient rehabilitation to maintain and consolidate the positive results over time. Funding Acknowledgement Type of funding sources: None. Table 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.

DMD/BMD – OUTCOME MEASURES: EP.129 Value of global longitudinal strain for identification and monitoring of left ventricular dysfunction in Becker muscular dystrophy

Cardiac involvement is the main cause of death in Becker muscular dystrophy (BMD). Identification of left ventricular (LV) function is crucial, but standard echocardiographic measures such as LV ejection fraction (EF) might not be sensitive enough to detect early myocardial dysfunction. We explored the value of LV global longitudinal strain (GLS) as a more accurate echocardiographic parameter to detect and monitor LV dysfunction in BMD. Furthermore, we studied possible factors associated with LV dysfunction and progression. 40 BMD patients (age 39.0±13.2 years) and 21 matched controls were included. Clinical variables, pulmonary tests, serum biomarkers, and echocardiograms were collected at baseline and after two years. LV systolic function was assessed by LVEF and LV GLS; a significant progression in LV dysfunction was defined as an absolute LV GLS decline ≥15%. Responsiveness to cardiac disease progression was determined using standardized response means (SRM). BMD patients showed impaired LVEF and LV GLS as compared to controls (p<0.001). Of interest, 31 patients (77.5%) showed impaired LV GLS (defined as>-18%) while only 24 patients (60%) had reduced LVEF. LV GLS and LVEF correlated with troponin-I and NT-proBNP (0.52<rho≤0.68), but not with skeletal muscle or pulmonary function. At follow-up (2.0±0.5 years, n=29), LV GLS worsened significantly (-1.3±0.8%, p=0.002, SRM=0.70, annually 0.60%) while LVEF remained stable. No risk factors for LV dysfunction progression were identified. In BMD, LV GLS is frequently impaired and shows deterioration over time as compared to LVEF. LV GLS could be used as a more sensitive parameter to identify and monitor LV dysfunction.

The relationship between myocardial fibrosis and left ventricular remodeling following aortic valve replacement

Aim. Aortic valve diseases are associated with myocardial fibrosis. The relationship between severity of myocardial fibrosis and left ventricular mass reduction (LVMR) after aortic valve replacement (AVR) still needs to be elucidated. Methods. In a single-center, retrospective trial, 130 patients underwent AVR with/without concomitant surgery. The study population was divided by etiology into aortic stenosis (AS) and aortic regurgitation (AR) groups. LV end-diastolic diameter, LV septal and posterior thicknesses, LV mass, and aortic annulus were obtained in all study patients. Left ventricular mass regression index (iLVMR) was found by the difference between preoperative iLVM and follow-up iLVM. iLVMR in months was calculated by divided iLVMR on the number of months before follow-up visit. Myocardial tissue was embedded in paraffin, and sectioned into 4 µm slices for histological staining (picrosirius red) and scanning. The fraction of myocardial volume occupied by collagen tissue was determined. Results. The left ventricular remodeling of AS and AR patients is presented in Table 3. There was significant LV mass reduction in both aortic valve disease groups in the follow-up period (AS group, p < 0.001; AR group, p < 0.05). The number of LVH cases decreased in both groups in the follow-up period (AS group, p < 0.001; AR group, p < 0.05). In Post-AVR period the ejection fraction of LV did not improve in the AS group, compare to AR group (p<0.05). In both groups number of patients with impaired LV EF was increased in Post-AVR period, but not significantly. Moreover, the LV septal thickness, and iLVEDD significantly decreased in the AS group (p<0.001 and p<0.001), compared to the AR group (p=NS, p<0.05). We did not found correlations between MF and LVM in preoperative, and follow-up periods for AS and AR groups. Moreover, MF did not correlate significantly to iLVMR and iLVMR in months. A significant correlation exists in AS patients between MF and preoperative iLVEDD (r = 0.21, p = 0.04). Conclusion. The LVM reduction was observed in both AS and AR groups. LVM of AS group recovered more quickly than that of AR group. In our study MF does not affect LVM regression. Large cohort of patients with myocardial biopsies and long-term follow-up are needed to access the impact of the MF on the LVMR.

Myocardial perfusion after COVID-19 infection: No persisting impaired myocardial blood flow in surviving patients

Funding AcknowledgementsType of funding sources: None.Background Acute myocardial damage is common in hospitalized patients with severe COVID-19, with evidence of myocardial infarction and myocarditis demonstrated on cardiovascular magnetic resonance (CMR). Post-mortem studies have also implicated microvascular thrombosis, which may cause persistent microvascular disease. Purpose To determine the long-term coronary sequelae in recovered COVID-19 using multiparametric CMR including state-of-the-art inline quantitative stress myocardial blood flow (sMBF) mapping to assess global and regional sMBF.Methods Prospective, multicentre observational study of recovered COVID-19 patients scanned at three London CMR units. Results were compared to a propensity-matched, pre-COVID chest pain cohort (104 patients referred for perfusion CMR, with subsequently demonstrated unobstructed coronary arteries) and 27 healthy volunteers (HV). Perfusion image analysis was performed using a novel artificial intelligence approach deriving global and regional stress and rest MBF with a cut-off of >2.25mL/g/min signifying normal sMBF and <1.82mL/g/min abnormal sMBF (Kotecha JCVI 2019). Results 104 recovered, post-COVID patients (median age 62 years, 76% male; 89[87%] hospitalised, 41/89[46%] requiring ICU) underwent adenosine-stress perfusion CMR at a median 131(IQR 43-179) days from COVID-19 diagnosis. Median LVEF was 67% (IQR 60-71%; 12 (11.5%) with impaired LVEF), 51 patients (49%) had late gadolinium enhancement (LGE); 18% infarct-pattern and 33% non-ischaemic LGE. Global stress MBF in post-COVID patients was no different to age-, sex- and co-morbidities-matched controls (2.57 ± 0.77 vs. 2.40 ± 0.75 ml/g/min, p = 0.11, Figure 1), though lower than HV (3.00 ± 0.76 ml/g/min, p = 0.001). Post-COVID, multivariate predictors of low sMBF were male sex (OR 0.57, 95%CI 0.41-0.80, p = 0.001) and hypertension (OR 0.67, 95%CI 0.51-0.88, p = 0.004), but not COVID-19 disease severity (ICU admission) or presence of scar (ischemic/non-ischemic). 21/42 with reduced sMBF (<2.25mL/g/min) had regional perfusion defects consistent with epicardial coronary disease.Conclusions COVID-19 survivors do not demonstrate evidence of reduced global MBF by CMR compared to risk factor matched controls. Stress perfusion CMR identifies etiology of acute myocardial damage (infarction/myocarditis) and presence of occult coronary ischemia. Figure.

Wearable cardioverter-defibrillator: friend or foe in suspected myocarditis?

AimWearable cardioverter defibrillator (WCD, LifeVest, and Zoll) therapy has become a useful tool to bridge a temporarily increased risk for sudden cardiac death. However, despite extensive use, there is a lack of evidence whether patients with myocarditis and impaired LVEF may benefit from treatment with a WCD.Methods and resultsWe conducted a single‐centre retrospective observational study analysing patients with a WCD prescribed between September 2015 and April 2020 at our institution. In total, 135 patients were provided with a WCD, amongst these 76 patients (mean age 48.9 ± 13.7 years; 84.2% male) for clinically suspected myocarditis. Based on the results of the endomyocardial biopsy and, where available cardiac magnetic resonance imaging, 39 patients (51.3%) were diagnosed with myocarditis and impaired LVEF and 37 patients (48.7%) with dilated cardiomyopathy (DCM) without evidence of cardiac inflammation. The main immunohistopathological myocarditis subtype was lymphocytic myocarditis in 36 (92.3%) patients, and four patients (10.3%) of this group had an acute myocarditis. Three patients had cardiac sarcoidosis (7.7%). Ventricular tachycardia occurred in seven myocarditis (in total 41 VTs; 85.4% non‐sustained) and one DCM patients (in total one non‐sustained ventricular tachycardia). Calculated necessary WCD wearing time until ventricular tachycardia occurrence is 86.41 days in myocarditis compared with 6.46 years in DCM patients.ConclusionsOur data suggest that myocarditis patients may benefit from WCD therapy. However, as our study is not powered for outcome, further randomized studies powered for the outcome morbidity and mortality are necessary.

Diastolic dysfunction and mortality in 436 360 men and women: the National Echo Database Australia (NEDA).

Aims To examine the characteristics/prognostic impact of diastolic dysfunction (DD) according to 2016 American Society of Echocardiography (ASE) and European Society of Cardiovascular Imaging (ESCVI) guidelines, and individual parameters of DD.Methods and results Data were derived from a large multicentre mortality-linked echocardiographic registry comprising 436 360 adults with 1 diastolic function measurement linked to 100 597 deaths during 2.2 million person-years follow-up. ASE/European Association of Cardiovascular Imaging (EACVI) algorithms could be applied in 392 009 (89.8%) cases; comprising 11.4% of cases with ‘reduced’ left ventricular ejection fraction (LVEF < 50%) and 88.6% with ‘preserved’ LVEF (≥50%). Diastolic function was indeterminate in 21.5% and 62.2% of ‘preserved’ and ‘reduced’ LVEF cases, respectively. Among preserved LVEF cases, the risk of adjusted 5-year cardiovascular-related mortality was elevated in both DD [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.22–1.42; P < 0.001] and indeterminate status cases (OR 1.11, 95% CI 1.04–1.18; P < 0.001) vs. no DD. Among impaired LVEF cases, the equivalent risk of cardiovascular-related mortality was 1.51 (95% CI 1.15–1.98, P < 0.001) for increased filling pressure vs. 1.25 (95% CI 0.96–1.64, P = 0.06) for indeterminate status. Mitral E velocity, septal e’ velocity, E:e’ ratio, and LAVi all correlated with mortality. On adjusted basis, pivot-points of increased risk for cardiovascular-related mortality occurred at 90 cm/s for E wave velocity, 9 cm/s for septal e’ velocity, an E:e’ ratio of 9, and an LAVi of 32 mL/m2.Conclusion ASE/EACVI-classified DD is correlated with increased mortality. However, many cases remain ‘indeterminate’. Importantly, when analysed individually, mitral E velocity, septal e’ velocity, E:e’ ratio, and LAVi revealed clear pivot-points of increased risk of cardiovascular-related mortality.

Pregnancy outcomes in women with mechanical heart valves

Abstract Background Mechanical heart valves (MHV) and their absolute need for adequate anticoagulation poses a challenge for pregnancy, either due to warfarin fetotoxicity or an increased risk of maternal thromboembolism. This represents a unique patient (P) group where data is scarce and maternal and fetal risks and benefits must be carefully weighed. Purpose To assess maternal and perinatal outcomes in women with MHV on different anticoagulant regimens and compare them with patients with other types of valvular heart disease (VHD). Methods A retrospective analysis of 131 pregnancies in 83 women with VHD (mean age 26.5±5.6 years) was carried out in a tertiary referral centre from 2000 to 2019. 92 pregnancies with VHD, including 11 with biological prosthetic valves, and 39 pregnancies in 22 P with MHV were identified. The main outcome measures were major maternal complications and perinatal outcome. Results MHV implanted were in mitral position (89.7%), aortic (2.6%), or both (7.7%). History of rheumatic heart disease was identified in 16 P (72.7%) and a congenital etiology was present in 2 P (9.1%). 9 P (40.9%) were on warfarine and 13 P (59.1%) on acenocumarol. Regarding anticoagulation strategy, 21 P (65.6%) remained on oral anticoagulation and 10 P (31.3%) had been switched to some form of heparin during part or the entire pregnancy. Mechanical valve thrombosis complicated pregnancy in 4 patients (10.2%), all cases on heparin, and resulted in maternal death in 1 P. MHV P had more hemorrhagic complications (15.4 vs 2.2%, p=0.004) requiring transfusion or surgical revision. MHV P tended to experience more NHYA class worsening demanding initiation or intensification of cardiac medication (17.9 vs 5.4%, p=0.023). Also in the MHV group there was a higher incidence of miscarriage (46.2 vs 12.0%, p≤0.0005), comprising spontaneous abortion (31.6 vs 7.6%, p&amp;lt;0.0005) and fetal malformations (18.4 vs 5.4%, p=0.028), including warfarin embryopathy (10.3 vs 1.1%, p=0.012). The live birth rate was higher in women on heparin compared with those on warfarin (85.9 vs 79.2%, p=0.002). The presence of multivalve disease (p=0.04), mechanical protheses (p&amp;lt;0.001), ACO (p&amp;lt;0.001) and previous impaired LVEF (p=0.02) were related to miscarriage. In multivariate analysis, ACO was the unique independent predictor of unsuccessful pregnancy (p=0.01). Only 29% of the patients with an MHV had a pregnancy free of serious adverse events compared with other types of VHD (81.5%, p&amp;lt;0.0005). Conclusions MHV remains a challenging condition for pregnancy with only 29% chance of experiencing an uncomplicated pregnancy with a live birth. The increased morbimortality warrant extensive prepregnancy counseling with prosthesis type discussion,centralization of care and further larger studies to come up with evidence-based recommendations. Funding Acknowledgement Type of funding source: None

Myocardial 18F-FDG Uptake Pattern for Cardiovascular Risk Stratification in Patients Undergoing Oncologic PET/CT.

Objective: Positron emission tomography/computed tomography with 18F-fluorodeoxy-glucose (18F-FDG-PET/CT) has become the standard staging modality in various tumor entities. Cancer patients frequently receive cardio-toxic therapies. However, routine cardiovascular assessment in oncologic patients is not performed in current clinical practice. Accordingly, this study sought to assess whether myocardial 18F-FDG uptake patterns of patients undergoing oncologic PET/CT can be used for cardiovascular risk stratification. Methods: Myocardial 18F-FDG uptake pattern was assessed in 302 patients undergoing both oncologic whole-body 18F-FDG-PET/CT and myocardial perfusion imaging by single-photon emission computed tomography (SPECT-MPI) within a six-month period. Primary outcomes were myocardial 18F-FDG uptake pattern, impaired myocardial perfusion, ongoing ischemia, myocardial scar, and left ventricular ejection fraction. Results: Among all patients, 109 (36.1%) displayed no myocardial 18F-FDG uptake, 77 (25.5%) showed diffuse myocardial 18F-FDG uptake, 24 (7.9%) showed focal 18F-FDG uptake, and 92 (30.5%) had a focal on diffuse myocardial 18F-FDG uptake pattern. In contrast to the other uptake patterns, focal myocardial 18F-FDG uptake was predominantly observed in patients with myocardial abnormalities (i.e., abnormal perfusion, impaired LVEF, myocardial ischemia, or scar). Accordingly, a multivariate logistic regression identified focal myocardial 18F-FDG uptake as a strong predictor of abnormal myocardial function/perfusion (odds ratio (OR) 5.32, 95% confidence interval (CI) 1.73–16.34, p = 0.003). Similarly, focal myocardial 18F-FDG uptake was an independent predictor of ongoing ischemia and myocardial scar (OR 4.17, 95% CI 1.53–11.4, p = 0.005 and OR 3.78, 95% CI 1.47–9.69, p = 0.006, respectively). Conclusions: Focal myocardial 18F-FDG uptake seen on oncologic PET/CT indicates a significantly increased risk for multiple myocardial abnormalities. Obtaining and taking this information into account will help to stratify patients according to risk and will reduce unnecessary cardiovascular complications in cancer patients.

Association between regional longitudinal strain and left ventricular thrombus formation following acute myocardial infarction.

Left ventricular thrombus (LVT) formation is a dangerous complication to acute myocardial infarction (MI). We hypothesized that regional longitudinal strain impairment is associated with LVT formation. We included 373 prospectively enrolled patients with ST-segment elevation MI. All patients had an echocardiogram performed a median of 2days post-MI. Using logistic regression, we investigated the relation between LVT and left ventricular (LV) speckle tracking, conventional echocardiographic measures and well-known echocardiographic features of LVT formation including LV smoke, aneurysm and valvular regurgitation. Overall, the mean age was 62years of age, 75% were men, 5% had prior MI, and 48% had anterior infarcts. Mean LVEF was 46% and global longitudinal strain (GLS) was - 12%. Of 373 patients, 31 (8%) developed LVT on echocardiograms. Patients with LVT more frequently had anterior infarcts, prior MI, lower LVEF, lower e', lower GLS and regional strain, and these were all associated with LVT formation in univariable analyses. In multivariable analysis (including anterior infarcts, prior MI, LVEF, e'), GLS and regional strain remained independently associated with LVT formation (GLS: OR=1.17 (1.00-1.36), midventricular strain: OR=1.19 (1.03-1.38), apical strain: OR=1.12 (1.00-1.25), per 1% absolute decrease,p < 0.05 for all]. In a combined diagnostic model, including anterior infarct, impaired LVEF (< 42%) and apical strain (> -8%), the sensitivity and negative predictive value was 100%, with a specificity and positive predictive value of 38 and 13%, respectively. In MI patients, non-anterior infarct, preserved LVEF and apical strain can rule out LVT formation. Reduced apical strain indicates a markedly increased LVT risk.