Improvement In Global Longitudinal Strain Research Articles

Influence of mitral transcatheter edge-to-edge repair in patients with severe mitral regurgitation on left ventricle function

Aim. To study the changes of left ventricular (LV) contractile function in patients with severe mitral valve (MV) insufficiency with assessment of global longitudinal strain (GLS) indicators and LV myocardial function after the mitral transcatheter edge-to-edge repair (TEER) within 12-month follow-up.Material and methods. The study consisted of 43 patients with severe mitral regurgitation (MR) as follows: 23 patients with functional MR (FMR), 20 patients with degenerative MR (DMR). A comprehensive echocardiographic study, including speckle tracking echocardiography, was performed at baseline, 4-5 days, 6 and 12 months after TEER. Standard structural and functional indicators of the LV, LV GLS and myocardial performance parameters were assessed.Results. The early postoperative period (4-5 days) was characterized by a decrease in global constructive work (GCW) (FMR group — from 977 [684; 1253] to 857 [736; 1488] mm Hg%, (p=0,038); DMR group — from 1458 [1283; 1848] to 1350 [1010; 1488] mm Hg% (p=0,011)), an increase in global wasted work (GWW) (FMR group — from 177 [130; 280] to 336 [242; 388] mm Hg% (p=0,004); DMR group — from 128 [81; 172] to 216 [164; 279] mm Hg% (p=0,043)), which was accompanied by a decrease in myocardial efficiency (FMR group — from 81,5 [77; 87] to 76 [73; 79]%, (p=0,021); DMR group — from 90 [85; 93] to 82 [79; 85]% (p=0,018)). After 12-month follow-up, there was a significant increase in GCW relative to the initial values in both cohorts of patients as follows: FMR group — to 1128 [890; 1711] mm Hg% (p=0,048); DMR group — to 1818 [1478; 2034] mm Hg% (p<0,001). There was also an increase in GWW in the FMR group to 255 [214; 363] mm Hg% (p=0,024) and in the DMR group to 230 [140; 270] mm Hg% (p=0,043). There were no significant improvement of LV GLS in both groups.Conclusion. The early postoperative period after TEER was characterized by a temporary deterioration in all LV performance parameters, which recovered by 6 and 12 months of follow-up. Myocardial function restoration by one year of follow-up was noted due to an increase in GCW. LV GLS and ejection fraction did not change significantly by 1 year of follow-up compared to baseline values.

Assessment of left ventricular dysfunction by strain echo in primary hyperparathyroidism and its reversal after parathyroidectomy.

Strain echocardiography is a highly sensitive modality for detecting myocardial disease at an early stage. Therefore, we aim to evaluate subclinical left ventricular dysfunction in primary hyperparathyroidism (PHPT) patients with myocardial strain imaging in addition to conventional echocardiography and to look for its reversal after parathyroidectomy (PTx). Thirty patients who underwent curative parathyroidectomy for PHPT were included. All patients were evaluated with M mode echo, 2D echo and strain imaging before and 6months after PTx. Left ventricular ejection fraction, left ventricular diastolic dysfunction, left ventricular hypertrophy (LVH), Global Longitudinal Strain (GLS) and global circumferential strain (GCS) were recorded. On M mode echo, LVH was present in 15 patients and 8 of them improved completely after PTx (p<0.038). Incidence of systolic and diastolic dysfunction on 2D echo was 10% and 13.3% respectively; while myocardial strain imaging showed impaired systolic function in 46.7% patients. Hence, compared to conventional 2D echo, strain imaging showed 36.7% high detection rate of subnormal cardiac function. There was improvement in left ventricle dysfunction (p = 0.083), GLS and GCS (p = 0.034) after PTx. Serum parathormone demonstrated a strong positive correlation with change in GLS and GCS (p = 0.013, p = 0.126) while serum calcium showed a weak correlation with change in GLS and GCS following surgery. Myocardial strain imaging should be considered for all PHPT patients as early identification of subclinical ventricle dysfunction provides an opportunity for an early intervention and thereby preventing development of irreversible LV dysfunction.

Tafamidis improves myocardial longitudinal strain in A97S transthyretin cardiac amyloidosis.

Transthyretin cardiomyopathy (ATTR-CM) is a debilitating disease that has received much attention since the emergence of novel treatments. The Transthyretin Cardiomyopathy Clinical Trial showed that tafamidis, a transthyretin tetramer stabilizer, effectively reduced the declines in functional capacity and quality of life. However, Ala97Ser (A97S) hereditary ATTR-CM is underrepresented in major ATTR-CM tafamidis trials. We aim to investigate the change in global longitudinal strain (GLS) of A97S ATTR-CM patients after 12 months of tafamidis treatment. We retrospectively analysed a prospective cohort of patients with A97S ATTR-CM who received tafamidis meglumine (61 mg/day) at the National Taiwan University Hospital. Echocardiography with speckle tracking strain analysis was performed at baseline and 12 months after treatment. In all, 20 patients were included in the cohort. The baseline left ventricular ejection fraction (LVEF) and interventricular septum (IVS) thickness were 59.20 ± 13.23% and 15.10 ± 3.43 mm, respectively. After 12 months of tafamidis treatment, the LVEF and IVS were 61.83 ± 15.60% (p = 0.244) and 14.59 ± 3.03 mm (p = 0.623), respectively. GLS significantly improved from -12.70 ± 3.31% to -13.72 ± 3.17% (p = 0.048), and longitudinal strain (LS) in apical and middle segments significantly improved from -16.05 ± 4.82% to -17.95 ± 3.48% (p = 0.039) and -11.89 ± 4.38% to -13.58 ± 3.12% (p = 0.039), respectively. Subgroup analysis showed that patients with LVEF < 50% had a better treatment response and improvement in GLS. The patients with an IVS ⩾ 13 mm had an improvement in two-chamber LS from -10.92 ± 4.25% to -13.15 ± 3.87% (p = 0.042) and an improvement in apical left ventricular LS from -15.30 ± 5.35% to -17.82 ± 3.99% (p = 0.031). Tafamidis significantly improved GLS, and particularly apical and middle LS in A97S ATTR-CM patients.

Early improvement of global longitudinal strain after iron deficiency correction in heart failure with reduced ejection fraction.

Iron deficiency correction with ferric carboxymaltose improves symptoms and reduces rehospitalization in patients with reduced left ventricular ejection fraction. The mechanisms underlying these improvements are poorly understood. This study aimed to determine changes in left ventricular contractility after iron treatment as reflected in global longitudinal strain. Prospective single-center study including 43 adults with reduced ejection fraction, non-anemic iron deficiency, and functional class II-III heart failure despite optimal medical treatment. Global longitudinal strain through speckle-tracking echocardiography was measured at baseline and 4weeks after ferric carboxymaltose. A significant improvement in global longitudinal strain was detected (from -12.3%±4.0% at baseline to -15.6%±4.1%, p<.001); ferritin and transferrin saturation index had increased, but ejection fraction presented no significant changes (baseline 35.7%±4.6%, follow-up 37.2%±6.6%, p=.073). In patients with heart failure and reduced ejection fraction, the correction of iron deficiency with ferric carboxymaltose is associated with an early improvement in global longitudinal strain, possibly suggesting a direct effect of iron correction on myocardial contractility.

Imaging of Myocardial αvβ3 Integrin Expression for Evaluation of Myocardial Injury After Acute Myocardial Infarction.

[68Ga]Ga-NODAGA-Arg-Gly-Asp (RGD) is a PET tracer targeting αvβ3 integrin, which is upregulated during angiogenesis soon after acute myocardial infarction (AMI). We prospectively evaluated determinants of myocardial uptake of [68Ga]Ga-NODAGA-RGD and its associations with left ventricular (LV) function in patients after AMI. Methods: Myocardial blood flow and [68Ga]Ga-NODAGA-RGD uptake (60 min after injection) were evaluated by PET in 31 patients 7.7 ± 3.8 d after primary percutaneous coronary intervention for ST-elevation AMI. Transthoracic echocardiography of LV function was performed on the day of PET and at the 6-mo follow-up. Results: PET images showed increased uptake of [68Ga]Ga-NODAGA-RGD in the ischemic area at risk (AAR), predominantly in injured myocardial segments. The SUV in the segment with the highest uptake (SUVmax) in the ischemic AAR was higher than the SUVmean of the remote myocardium (0.73 ± 0.16 vs. 0.51 ± 0.11, P < 0.001). Multivariable predictors of [68Ga]Ga-NODAGA-RGD uptake in the AAR included high peak N-terminal pro-B-type natriuretic peptide (P < 0.001), low LV ejection fraction, low global longitudinal strain (P = 0.01), and low longitudinal strain in the AAR (P = 0.01). [68Ga]Ga-NODAGA-RGD uptake corrected for myocardial blood flow and perfusable tissue fraction in the AAR predicted improvement in global longitudinal strain at follow-up (P = 0.002), independent of peak troponin, N-terminal pro-B-type natriuretic peptide, and LV ejection fraction. Conclusion: [68Ga]Ga-NODAGA-RGD uptake shows increased αvβ3 integrin expression in the ischemic AAR early after AMI that is associated with regional and global systolic dysfunction, as well as increased LV filling pressure. Increased [68Ga]Ga-NODAGA-RGD uptake predicts improvement of global LV function 6 mo after AMI.

Cardiac damage extent in patient with isolated severe aortic stenosis referred to surgical aortic valve replacement: is it reversible after surgery?

Abstract Background Aortic stenosis (AS) may lead to progressive and adverse cardiac remodeling. A recently-proposed staging classification regarding extravalvular cardiac damage in AS patients undergoing aortic valve intervention was shown to have significant prognosis implications. However, cardiac damage evolution and reversibility after intervention remain unknown. Aims to assess extravalvular cardiac damage evolution after surgical aortic valve replacement (SAVR) in patients with isolated severe AS. Methodology we performed a single-center, prospective cohort study enrolling consecutive patients with severe aortic stenosis undergoing SAVR. Those with previous cardiomyopathy or concomitant severe valve dysfunction beyond AS were excluded. All patients performed transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) within 3 months before SAVR as well as at the 3rd to 6th post-operative month. Patients were classified according to the extent of cardiac damage into 4 groups: stage 0: no damage; stage 1: left ventricle (LV) hypertrophy (indexed LV mass &amp;gt;95 g/m2 [women] or &amp;gt;115 g/m2 [men]), LV diastolic (E/e′ &amp;gt; 14) or systolic (ejection fraction &amp;lt;50%) dysfunction; stage 2: dilated left atrium (&amp;gt;34mL/m2) or atrial fibrillation; stage 3: pulmonary hypertension (systolic pulmonary artery pressure ≥60mmHg); stage 4: significant right ventricle (RV) dysfunction. Global longitudinal strain (GLS) was also assessed to further characterize the extent of LV damage – a GLS &amp;gt; -14.7% was considered abnormal. Due to the impact of on-pump cardiac surgery on RV systolic longitudinal function, RV ejection fraction assessed by CMR (&amp;lt;45%) was used to define significant post-operative RV dysfunction. Results A total of 67 patients were included (mean age 71 ± 8 years; 50% male; mean valvular transaortic gradient 60 ± 19 mmHg; mean indexed aortic valve area 0.4 ± 0.01 cm2/m2; mean LV ejection fraction by TTE 58 ± 9%). Overall, a significant number of patients still showed sign of structural cardiac damage after surgery – 14 vs. 10 on stage 1, 44 vs. 39 on stage 2, 1 vs. 1 on stage 3 and 4 vs. 4 on stage 4 after AVR- figure 1. However, a statistically significant improvement in the number of patients at stage 0 after surgery (4 vs. 11, paired McNemar test p=0.016) was observed, as well as a significant improvement in GLS (mean GLS pre and post AVR -14.8 ± 3.6% vs. -16.6 ± 3.3%, respectively; 45 vs. 21% patients with abnormal GLS before and after AVR, p=0.001). Conclusion Extravalvular cardiac damage is common in a selected cohort of severe AS and potentially reversible after SAVR. A significant improvement in GLS, although not a part of the previously established staging system, was observed after AVR. Whether or not these findings may correlate with long-term patient prognosis or if additional favorable cardiac remodeling is seen on a longer-term follow-up remains to be determined.

Left ventricular twist in patients with severe aortic stenosis: meaning and evolution after surgery

Abstract Background Structural and functional left ventricular (LV) remodeling is the result of myocardial adaptation to chronic pressure overload in patients with severe aortic stenosis (AS). Changes in LV rotational dynamics are supposed to occur due to increased afterload in order to maintain LV ejection fraction (EF) in this setting. However, data regarding rotational dynamics with AS severity and their evolution after aortic valve replacement (AVR) are scarce. Goal To describe LV twist in patients with severe AS according to LV remodeling and assess its evolution after surgical AVR. Methodology Single center prospective cohort study of patients with classical isolated severe AS referred to surgical AVR. Complete transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were performed before surgery for both valvular and LV remodeling assessment. TTE was performed at the 3rd to 6th post-operative month. LV twist was defined as the peak difference in systolic rotations of LV apex and base as viewed from the apex and calculated at bidimensional strain in short axis views. LV remodeling was categorized by CMR according to Figure 1. Correlation analysis was performed for indexes of AS severity and LV function. Results A total of 80 patients with classical high flow, high gradient, preserved LV EF (46% male; mean age 71 ± 8 years old; mean aortic valve [AV] gradient 61±17.6mmHg, mean AV area 0.73±0.18cm2 , mean LVEF: 58 ± 9%) were included. LV twist before surgery was 24.5 +/- 9.7% and this was modestly correlated with both LV flow (r = 0.315, p= 0.001) and AV gradients (r = 0.315, p = 0.013). Rotational indexes were no different across distinct types of LV remodeling. After AVR there was a significant decrease in LV twist (24.5 +/- 9.7% vs. 16.5 +/- 8.3%, p&amp;lt;0.001), despite significant improvement in global longitudinal strain (-14.7 ± 3.9% vs -16.1 ± 3.1%, p &amp;lt; 0.001) and maintenance of preserved LVEF (58 ± 9% vs 60 +/- 8%, p = 0.07). Conclusion As LV twist has an inverse relation to GLS after AVR, this may represent a compensatory mechanism for LVEF preservation in patients with severe AS. Rotational mechanics seems to be independent from structural LV remodeling in this setting.

Multi-dimensional evaluation in patients with aortic stenosis who are candidates for cardiac surgery

Abstract Introduction In patients with severe aortic stenosis (AS), the presence of left ventricular systolic dysfunction is one of the main predictors of adverse events after valve replacement surgery (SAVR). However, more and more patients are being referred for surgery early on and have preserved systolic function at the time of surgery. Within this category, global longitudinal strain (GLS) has been proposed as a marker of ventricular remodeling after cardiac surgery. Objectives Our study aims to identify the variation of GLS in patients undergoing SAVR and any differences compared to classes of diastolic dysfunction. Materials and methods From June 2020 to October 2022, we analyzed 100 patients with AS with an indication for cardiac surgery treatment admitted to the cardiac surgery department of our AOU. All patients underwent an echocardiogram immediately before surgery and in the early postoperative period (mean 7 days); 52 of them were enrolled for follow-up and repeated an echocardiogram at least 3 months after surgery. In all cases, the GLS of the left ventricle was calculated and patients were divided into four classes by the degree of diastolic dysfunction (0-III) according to the most recent international guidelines; moreover, patients were divided into 2 groups: group A for grades 0-1 of diastolic dysfunction and Group B for grades 2-3. The data were analyzed with SPSS 28 software. Analysis of variance was performed with a t-test and ANOVA test. Results In the final analysis, 100 patients with AS were included, with a mean age of 70.8±8.27, of whom 43 were women (43%) and 57 were men (57%). In 20 patients (20%) ischaemic heart disease with an indication for coronary revascularization was also present. The mean preoperative ejection fraction was 58.98±9.5%. The mean GLS values before surgery were 15.13±4.56% with a reduction immediately post-cardiac surgery of 12.26±3.67%, p&amp;lt;0.0001. GLS values were comparable within the various classes of diastolic dysfunction at preoperative examination (p=0.579) and immediately postoperative (p=0.286). At follow-up, analysis was repeated for 52 patients: an improvement in mean GLS was found: 16.09±3.64%, p&amp;lt;0.0001. The mean GLS in the two groups at follow-up was statistically different: 17.38±3.35% in group A vs 13.44±3.63% in group B, p&amp;lt;0.0001. Conclusions In our case series, patients with severe aortic stenosis undergoing SAVR show a significant early reduction in GLS regardless of the degree of diastolic dysfunction, while after at least 3 months of follow-up, they show a great recovery, significantly better in patients with Grades 0 or 1 diastolic dysfunction.GLS at the 3 times

Association of GDF15, NTpoBNP and PLGF with subclinical cardiac dysfunction in type 2 diabetes: effects of novel antidiabetic treatment

Abstract Background In type 2 diabetics, we investigated the effects of insulin, GLP-1Ra, SGLT-2i and their combination on blood biomarkers of cardiac function and their association with left ventricular and atrial function. Patients and methods A total of 200 diabetics (60.3±10.3-year-old) treated with metformin were randomized to insulin (n= 50), liraglutide (n=50), empagliflozin (n=50) or their combination (GLP-1RA+SGLT-2i) (n= 50) . We measured at baseline and 6 months post-treatment: (a) perfused boundary region of the sublingual arterial microvessels (marker of endothelial glycocalyx thickness), (b) pulse wave velocity (PWV), (c) Left Ventricular (LV) Global Longitudinal Strain (GLS) and Torsion, (d) LV Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), Global Work Efficiency (GWE), (e) Left atrial reservoir strain (LASr) and (f) Growth/Differentiation Factor-15 (GDF-15), NTproBNP, Placental Growth Factor (PLGF) as markers of cardiac dysfunction. Results Increasing GGDF-15 levels at baseline were related with increasing PWV (r=0.357, p&amp;lt;0.001). Moreover, increasing GDF-15 was related with reduced absolute GLS values (r=-0.425, p=0.005), increased LV Torsion (r=0.309, p=0.035), Twisting Velocity (r=0.345, p=0.018) and E/E’ (r=0.307, p=0.041) as well as reduced Untwisting velocity (r=-0.383, p=0.008) and LASr (r=-0,388, p=0.005). Increasing NTproBNP concentration at baseline was related with increasing PWV (r=0.445, p=0.001 and PBR5-25 (r=0.222, p=0.04) . Also, increasing NTroBNP was related with reduced absolute GLS (r=-0.454, p=0.002), LV GL strain rate (r=-0.360, p=0.008) , increased LV Torsion (r=0.329, p=0.029) and E/E’ (r=0.365, p=0.021). Increasing NTproBNP was also related with decreasing GWI (r=-0.471, p&amp;lt;0.001), GWE (r=-0.555, p&amp;lt;0.001), Untwisting velocity (r=-0.383, p=0.008) and LASr (r=-0,424, p=0.002). PLGF concentration at baseline was related with reduced absolute GLS (r=-0.341, p=0.012), LV GL strain rate (r=-0.302, p=0.008) and LASr (r=-0.321, p=0.036). At 6 months, the reduction of GDF-15 and NTproBNP levels was related with the respective reduction of PWV (p=0.022 and p=0.34) Furthermore, the reduction of NTproBNP at 6 months was related with an increase of GWI and GWE (r=0.455, p=0.006/ r=0.631, p=0.001,respectively). In patients treated with GLP-1RA, SGLT-2i and their combination, there was greater improvement of GLS, Torsion, Myocardial Work, LASr, NTproBNP, GDF-15 PLGF compared to patients treated with insulin (p&amp;lt;0.05) post-treatment. In patients treated with insulin, NTproBNP, GDF-15 and PLGF changes post-treatment were not related with the respective changes of the examined cardiac and vascular markers. Conclusion Elevated levels of GDF15, PLGF and NTproBNP are associated with cardiac and vascular dysfunction in patients with type 2 diabetics and their improvement after 6 months of treatment with GLP-1RA and /or SGLT2i is associated with improved cardiovascular function.

Changes in Left Ventricular Global Longitudinal Strain in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial.

Background Left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information over LV ejection fraction in patients with heart failure (HF) and secondary mitral regurgitation. We examined the prognostic impact of LV GLS improvement in this population. Methods and Results The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial randomized symptomatic patients with HF with severe (3+/4+) mitral regurgitation to transcatheter edge-to-edge repair with the MitraClip device plus maximally tolerated guideline-directed medical therapy (GDMT) versus GDMT alone. LV GLS was measured at baseline and 6-month follow-up. The relationship between the improvement in LV GLS from baseline to 6 months and the composite of all-cause death or HF hospitalization between 6- and 24-month follow-up were assessed. Among 383 patients, 174 (45.4%) had improved LV GLS at 6-month follow-up (83/195 [42.6%] with transcatheter edge-to-edge repair+GDMT and 91/188 [48.4%] with GDMT alone; P=0.25). Improvement in LV GLS was strongly associated with reduced death or HF hospitalization between 6 and 24 months (P<0.009), with similar risk reduction in both treatment arms (Pinteraction=0.40). By multivariable analysis, LV GLS improvement at 6 months was independently associated with a lower risk of death or HF hospitalization (hazard ratio [HR], 0.55 [95% CI, 0.36-0.83]; P=0.009), death (HR, 0.48 [95% CI, 0.29-0.81]; P=0.006), and HF hospitalization (HR, 0.50 [95% CI, 0.31-0.81]; P=0.005) between 6 and 24 months. Conclusions Among patients with HF and severe mitral regurgitation in the COAPT trial, improvement in LV GLS at 6-month follow-up was associated with improved outcomes after both transcatheter edge-to-edge repair and GDMT alone between 6 and 24 months. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Improvement of Global Longitudinal Strain and Myocardial Work in Type 2 Diabetes Patients on Sodium-Glucose Cotransporter 2 Inhibitors Therapy.

Sodium-glucose cotransporter 2 inhibitors (SGLT2-i) are a novel class of oral hypoglycemic agents currently used among patients with type 2 diabetes mellitus (T2DM). The effects of SGLT2-i inhibitors on cardiac structure and function are not fully understood. The aim of this study is to evaluate the echocardiographic changing among patients with well-controlled T2DM treated with SGLT2-i in real-world setting. Thirty-five well-controlled T2DM patients (65 ± 9 years, 43.7% male) with preserved left ventricular ejection fraction (LVEF) and 35 age and sex-matched controls were included. T2DM patients underwent clinical and laboratory evaluation; 12-lead surface electrocardiogram; 2-dimensional color Doppler echocardiography at enrolment, before SGLT2-i administration, and at 6 months follow-up after an uninterrupted 10 mg once daily of empagliflozin (n: 21) or dapagliflozin (n: 14). Standard echocardiographic measurements, LV global longitudinal strain (LV-GLS), global wasted work, and global work efficiency were calculated. T2DM patients showed higher E\E' ratio (8.3 ± 2.5 vs. 6.3 ± 0.9; P < 0.0001 ) and lower LV-GLS (15.8 ± 8.1 vs. 22.1 ± 1.4%; P < 0.0001 ) and global myocardial work efficiency (91 ± 4 vs. 94 ± 3%; P: 0.0007 ) compared with age and sex-matched controls. At 6-month follow-up, T2DM patients showed a significant increase in LVEF (58.9 ± 3.2 vs. 62 ± 3.2; P < 0.0001 ), LV-GLS (16.2 ± 2.8 vs. 18.7 ± 2.4%; P = 0.003 ), and global work efficiency (90.3 ± 3.5 vs. 93.3 ± 3.2%; P = 0.0004 ) values; conversely, global wasted work values (161.2 ± 33.6 vs. 112.72 ± 37.3 mm Hg%; P < 0.0001 ) significantly decreased. Well-controlled T2DM patients with preserved LVEF who are treated with a SGLT2-i on top of the guidelines direct medical therapy showed a favorable cardiac remodeling, characterized by the improvement of LV-GLS and myocardial work efficiency.

Effect of patisiran on myocardial deformation parameters in patients with hereditary transthyretin amyloidosis

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Hereditary transthyretin amyloidosis (ATTRh) is a rare autosomal dominant disease caused by transthyretin (TTR) gene mutations. It can involve several systems on the basis of ATTR gene variant, age, duration of symptoms before diagnosis. Some TTR gene variants have a predominant cardiological or neurologic or mixed phenotype, therefore patients can have only cardiac amyloidosis or only polyneuropathy or both. Recently several advances have been performed in the diagnosis and treatment of cardiac amyloidosis, especially ATTRh amyloidosis using RNA-targeting and gene editing therapies. Particularly, patisiran is a small interfering RNAs that can be used only in patients with ATTRh polyneuropathy with or without concomitant cardiac amyloidosis (stage 1 or 2). Apollo A trial sub analysis demonstrated protective effects of patisiran on the heart. Purpose To assess the effects of patisiran on cardiac function in patients with ATTRh amyloidosis treated with patisiran. Methods a prospective study was carried out enrolling 31 subjects with ATTRh (20 men, 11 women, median age 61,7 ± 10,45 years old). 7 patients (22,6%) had cardiac amyloidosis plus polyneuropathy; 13 patients (41,9%) had only polyneuropathy without cardiac involvement; 11 patients were carriers without clinical manifestations. All patients except carriers were treated with patisiran. Cardiological evaluation including electrocardiogram and echocardiogram was performed in all patients at the time of enrollment and after an average period of 20 months of patisiran therapy. Comprehensive echocardiographic evaluation included the measurement of left ventricular global longitudinal strain (GLS), relative apical sparing, apical/basal strain ratio, myocardial work index expressed as global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE), left atrial reservoir strain (PALS) and atrial stiffness (LASi). Results the group of patients with only polyneuropathy remained clinically stable over time and all echocardiographic parameters didn’t change significantly. In patients with cardiac amyloidosis, we found a significant improvement in GLS (−12,39±3,31% at baseline vs − 16,32 ± 2,84%, p value 0,03) and in LASI (1,6±0,30 vs 1±0,5, p value 0,01). GWI, GWE and GCW increased during follow-up, GWW reduced but not significantly. Also a reduction in the relative apical sparing (1,08±0,36 vs 1,05±0,25, p value 0,85) and in apical/basal strain ratio (2,5±1,4 vs 2,37±1,59, p value 0,87) was observed. No other significant changes in echocardiographic parameters were found. Conclusion Patisiran seems to be effective in stabilizing cardiac disease in ATTRh, significantly improving GLS and LASI. These new echocardiographic parameters should be used to monitor response to therapy in cardiac amyloidosis. The main limitation of our study is represented by the small sample size and to confirm our results wider studies are awaited.

Regional impairment of left ventricular longitudinal strain in aortic regurgitation: have we found the missing piece?

Abstract Funding Acknowledgements Type of funding sources: None. Background Aortic regurgitation (AR) has been shown to have an impact on myocardial mechanics and recent studies have proved the value of global longitudinal strain (GLS) as an additional parameter in the assessment of disease severity and prognosis. However, a direct and localized influence of the regurgitant jet (RJ) on regional deformation has not yet been demonstrated. Purpose To assess if there is a regional pattern of longitudinal strain (LS) impairment in AR connected to the direction of the RJ, as well as its potential reversibility and prognostic impact. Methods We studied patients (pts) with chronic moderate and severe isolated AR referred for echocardiographic evaluation. For each patient, we established the direction of the RJ according to the myocardial segments impacted by its turbulent portion. Pts were considered to have a jet-related LS reduction (JRSR) when the wall segments impacted by the jet had a relative reduction in LS of at least 30% compared to non-affected segments. Parameters of AR severity and left ventricular size and function were assessed. For those who underwent surgical correction of AR, the postop TTE was also compared with the preop. Results Of the 203 AR pts screened, 80 met inclusion criteria (median age 57 years, 83% male). Mean GLS and ejection fraction (EF) were -16% and 54%, respectively. In 34 of the 80 pts, there was a regional reduction of 10 percentage points in the absolute value of LS in the segments impacted by the jet, compared to non-affected segments (median −8% vs −18%, p&amp;lt;0.001), corresponding to a 56% relative decrease. The predominant jet directions were towards the basal septum (44%), mid posterior/mid lateral segments (24%), and basal inferior segment (12%). Demographics, severity of AR and parameters of systolic and diastolic function did not significantly differ between those who had JRSR or not. Of the 34 pts with JRSR, 20 underwent corrective surgery. In an early postop TTE, the difference in LS between the segments impacted by the jet and the non-affected segments attenuated (4.7% absolute difference vs 10% in the preop TTE, p = 0.001). Pts with JRSR in the preop echo had lower rates of improvement of GLS (11 vs 46% of pts improved at least 2.5%, p = 0.043) and a tendency towards lower rates of recovery of EF after surgery (17% vs 46% recovered at least 5% in EF, p = 0.07). Conclusion This study identifies an association between the parietal impact of the RJ in AR and regional LS impairment. It suggests that external factors such as blood flow dynamics affect myocardial deformation. Additionally, the longstanding impact of the jet might damage the myocardium to the point of limiting recovery of systolic function after corrective surgery. This is, to our knowledge, the first reported case series showing the negative effect of the jet’s impact on LV longitudinal function and, most importantly, on postop outcomes. Longer follow-up is needed to confirm its prognostic role.

P69 SHORT–TERM EFFECT OF DAPAGLIFLOZIN ON LEFT VENTRICULAR LONGITUDINAL FUNCTION IN PATIENTS WITH HEART FAILURE WITH REDUCED LEFT VENTRICULAR EJECTION FRACTION

Abstract Background It is known that sodium–glucose cotransporter 2 (SGLT2) inhibitors have been shown to confer important clinical benefits in patients with congestive heart failure (HF). Several evidences show SGLT2 influence the longitudinal systolic function of the left ventricle after medium and long term follow–up (FUP) in patients with HF. The aim of this study is to demonstrate how dapagliflozin can modify the global longitudinal strain (GLS) in a population of patients with systolic congestive heart failure (HFrEF) evaluating possible correlations with the basal functional capacity. Methods Clinical and echocardiographic data were retrospectively analyzed in 60 HFrEF patients treated with dapagliflozin, within a dedicated outpatient HF clinic. Pre–treatment data were correlated with to clinical and instrumental FUP date that was generally performed after two months of treatment. The clinical and instrumental data consisted of the NYHA functional class, the left ventricular ejection fraction (LVEF) and the GLS. Results There was no significant change between baseline and FUP date on LVEF (25.2 ± 9.9% vs 25.6 ± 9.6% p.s.), while GLS showed significant improvement (13.1 ± 3.7% vs 14.3 ± 3.1% p &amp;lt; 0.03). GLS improvement in HFrEF patients with more impaired functional class (NYHA III/IV) was more significant from 10.9 ± 3.4% to 13.1 ± 2.2% (p &amp;lt; 0.01), compared to that in HFeEF patients with less compromised functional class (NYHA I–II) from 13.6 ± 2.4% to 14.1 ± 2.1% (p 0.07). Conclusions Dapagliflozin was associated with short term improvement in longitudinal left ventricular myocardial function in patients with chronic congestive systolic heart failure. This improvement is more evident in patients who start from a more impaired functional capacity than in clinically more stable patients.

P176 GLOBAL LONGITUDINAL STRAIN AS A PREDICTOR OF RESPONSE TO CARDIAC CONTRACTILITY MODULATION IN PATIENTS WITH HEART FAILURE: A CASE SERIES

Abstract Background Cardiac contractility modulation (CCM) in heart failure (HF) patients with reduced ejection fraction (HFrEF) is an innovative therapy which may contribute to increased exercise capacity and quality of life and reduced hospitalizations. With speckle–tracking echocardiography and global longitudinal strain (GLS), changes in myocardial function can be detected with greater sensitivity than conventional approaches for measuring diastolic and systolic function, including left ventricular ejection fraction. We aim to analyze the usefulness of GLS in detecting improvement in systolic function and response to CCM treatment. Methods We studied 5 patients with CCM referred to our outpatient cardiology clinic. All patients underwent complete echocardiography with evaluation of GLS and ejection fraction. Follow–ups were performed at 1, 3, and 6 months. Results All patients were men (mean age 65.3±15.7 yrs). Mean baseline ejection fraction was 37.1±9.3%, mean GLS was 7.7±3.1%, and patients had mild–to–moderate left ventricular enlargement (mean indexed telediastolic volumes 101.4±8.7 ml/m2). Follow–up performed at the first month showed values similar to baseline values. Between the third and sixth months, a non–significant improvement in ejection fraction and GLS was recorded (EF 40.75±9.6% p=0.51; GLS 8.9±4.2 p=0.62). Indexed telediastolic volumes were reduced (101.4±9.3 ml/m2 vs 89.5±7.4 ml/m2 p=0.05). Conclusions CCM therapy seems to be useful in achieving volumetric remodeling in patients with HFrEF. GLS assessment may be useful in detecting improvement in systolic function. Further studies with larger samples and longer follow–up are needed to confirm these results.

Right Ventricular Strain in Patients With Ductal-Dependent Tetralogy of Fallot

Right ventricular (RV) dysfunction is an independent predictor of poor outcomes in patients with tetralogy of Fallot (TOF), and global longitudinal strain (GLS) is a well-validated echocardiographic technique to measure RV function. Although trends in RV GLS have been examined in patients with TOF, they have not been studied specifically in those with ductal-dependent TOF, a group in which there is not a clear consensus on the best surgical strategy. The aim of this study was to assess the midterm trajectory of RV GLS in patients with ductal-dependent TOF, drivers of this trajectory, and differences in RV GLS between repair strategies. This was a retrospective two-center cohort study of patients with ductal-dependent TOF who underwent repair. Ductal dependence was defined as being initiated on prostaglandin therapy and/or undergoing surgical intervention on or before 30days of life. RV GLS was measured on echocardiography preoperatively, early after complete repair, and at 1 and 2years of age. RV GLS was trended over time and compared between surgical strategies and with control subjects. Mixed-effects linear regression models were used to evaluate the factors associated with changes in RV GLS over time. Forty-four patients with ductal-dependent TOF were included in the study, of whom 33 (75%) underwent primary complete repair and 11 (25%) underwent staged repair. Complete TOF repair was performed at a median of 7days in the primary-repair group and 178days in the staged-repair group. RV GLS improved over time from post-complete repair echocardiography through 2years of age (-17.4% [interquartile range, -15.5% to -18.9%] vs -21.5% [interquartile range, -18.0% to -23.3%], P<.001). However, compared with age-matched control subjects, patients had worse RV GLS at all time points. There was no difference in RV GLS between the staged and primary complete repair groups at 2-year follow-up. Shorter intensive care unit length of stay after complete repair was independently associated with improvement in RV GLS over time. Strain improved by 0.07% (95% CI, 0.01 to 0.12) for each fewer day in the intensive care unit (P=.03). RV GLS improves over time among patients with ductal-dependent TOF, though it is consistently reduced compared with control subjects, suggesting an altered deformation pattern in patients with ductal-dependent TOF. There was no difference in RV GLS between the primary- and staged-repair groups at midterm follow-up, suggesting that repair strategy is not a risk factor for worse RV strain in the mid postoperative period. A shorter complete-repair intensive care unit length of stay is associated with an improved trajectory of RV GLS.

The use of deformation imaging in the assessment of patients pre and post transcatheter aortic valve implantation

BackgroundDeformation imaging represents a method of measuring myocardial function, including global longitudinal strain (GLS), peak atrial longitudinal strain (PALS) and radial strain. This study aimed to assess subclinical improvements in left ventricular function in patients undergoing transcatheter aortic valve implantation (TAVI) by comparing GLS, PALS and radial strain pre and post procedure.MethodsWe conducted a single site prospective observational study of 25 patients undergoing TAVI, comparing baseline and post-TAVI echocardiograms. Individual participants were assessed for differences in GLS, PALS and radial strain in addition to changes in left ventricular ejection fraction (LVEF) (%).ResultsOur results revealed a significant improvement in GLS (mean change pre-post of 2.14% [95% CI 1.08, 3.20] p = 0.0003) with no significant change in LVEF (0.96% [95% CI − 2.30, 4.22], p = 0.55). There was a statistically significant improvement in radial strain pre and post TAVI (mean 9.68% [95% CI 3.10, 16.25] p = 0.0058). There was positive trend towards improvements in PALS pre and post TAVI (mean change of 2.30% [95% CI − 0.19, 4.80] p = 0.068).ConclusionIn patients undergoing TAVI, measuring GLS and radial strain provided statistically significant information regarding subclinical improvements in LV function, which may have prognostic implications. The incorporation of deformation imaging in addition to standard echocardiographic measurements may have an important role in guiding future management in patients undergoing TAVI and assessing response.

Subclinical and latent cardiac dysfunction in obstructive sleep apnea and effectiveness of continuous positive airway pressure

PurposeObstructive sleep apnea (OSA) is associated with various cardiovascular disorders. This study aimed to investigate the effects of OSA on left ventricular (LV) function in patients with OSA who were at risk for heart failure but who had not yet developed structural heart changes. The study also sought to determine the effects of continuous positive airway pressure (CPAP) in these patients.MethodsIn a retrospective study, consecutive patients with polysomnographic OSA (apnea-hypopnea index [AHI] >5) were categorized into mild (AHI < 15), moderate (15 ≤ AHI < 30), and severe OSA (AHI ≥ 30) groups. The subjects were patients with OSA and at risk for heart failure who had not yet developed structural heart changes. All study participants underwent echocardiography and two-dimensional speckle tracking analysis, and their global longitudinal strain (GLS) was calculated. ResultsOf 275 patients, there were 31 with mild, 92 with moderate, and 152 with severe OSA. Of patients with moderate to severe OSA (AHI ≥ 20), 206 started CPAP and 92 patients underwent follow-up echocardiogram and speckle tracking echo analysis (median period of CPAP use: 283 days [258 to 391]). GLS was significantly reduced in patients with moderate and severe OSA compared with mild OSA (−17.8±3.1 vs. −18.0±2.6 vs. −19.3±2.8%, p=0.038). The proportion of patients with GLS ≥ −18% was significantly higher among the patients with moderate to severe OSA than among those with mild OSA. GLS improved after CPAP therapy in patients with moderate to severe OSA (GLS: −18.1±2.7% to −19.0±2.8%, p=0.004). Significant improvement in GLS was confirmed, particularly among patients with good CPAP adherence.ConclusionModerate to severe OSA is associated with LV dysfunction and can be significantly improved by CPAP therapy.

Left ventricular function by strain in uncomplicated malaria: a prospective study from the Brazilian Amazon.

We hypothesized that adults with uncomplicated malaria have lower left ventricular contractile function compared to the general population and that this improves after antimalarial treatment. We examined uncomplicated malaria and the general population from the Western part of the Brazilian Amazon Basin. All persons underwent an echocardiographic examination and peripheral blood smears. Left ventricular function was assessed by speckle tracking analysis of global longitudinal strain (GLS). Logistic regression models were used to assess the association between malaria status (yes/no) and GLS and improvement in GLS by follow-upwas assessed using a paired T-test. We enrolled 99 adults with uncomplicated malaria (mean age 40 years, 46% female) of whom 75 had Plasmodium vivax, 22 Plasmodium falciparum and two had both species [median 1595 (528 to 6585) parasites/mm3]. Seventy adults completed a follow-up examination after standard malaria treatment (median 31 days). We examined 486 from the general population (mean age 41 years, 63% female). In persons with malaria at baseline, GLS was lower compared to the general population (18.7% vs. 19.4%, P = 0.002) and GLS improved at follow-up (19.2%, P = 0.032). In multivariable models adjusted for clinical, socioeconomic and echocardiographic confounders, baseline GLS remained significantly associated with malaria status [odds ratio 2.45 (95%CI 1.00 to 7.25), P = 0.023 per 1% increase]. Parasite density was associated with worsening in GLS [+ 16% (+ 0% to + 34%), P = 0.047 per 1 unit increase in GLS]. Adults with uncomplicated malaria had lower GLS compared to the general population and this improved after completed antimalarial treatment. Our results suggest that malaria infection may affect left ventricular contractile function, however, further studies are needed to fully elucidate such a relationship.

Effects of radiofrequency catheter ablation for premature ventricular complexes originating from the right ventricular outflow tract on right ventricular function.

This study aimed to elucidate the relationship between premature ventricular complexes (PVCs) and right ventricular (RV) dysfunction, and the effects of radiofrequency catheter ablation (RFCA) on RV function. A total of 110 patients (age, 50.8 ± 14.4 years; 30 men) without structural heart disease who had undergone RFCA for RV outflow tract (RVOT) PVCs were retrospectively included. RV function was assessed using fractional area change (FAC) and global longitudinal strain (GLS) before and after RFCA. Clinical data were compared between the RV dysfunction (n = 63) and preserved RV function (n = 47) groups. The relationship between PVC burden and RV function was analyzed. Change in RV function before and after RFCA was compared between patients with successful and failed RFCA. PVC burden was significantly higher in the RV dysfunction group than in the preserved RV function group (p < .001). FAC and GLS were significantly worse in proportion to PVC burden (p < .001 and p < .001, respectively). The risk factor associated with RV dysfunction was PVC burden [odds ratio (95% confidence interval), 1.092 (1.052-1.134); p < .001]. Improvement in FAC (13.0 ± 8.7% and -2.5 ± 5.6%, respectively; p < .001) and GLS (-6.8 ± 5.7% and 2.1 ± 4.2%, respectively; p < .001) was significant in the patients with successful RFCA, compared to the patients in whom RFCA failed. Frequent RVOT PVCs are associated with RV dysfunction. RV dysfunction is reversible by successful RFCA.