Improvement In Left Ventricular Systolic Function Research Articles

Effect of exercise based cardiac rehabilitation on LV systolic function & exercise stress parameters in patients with ischemic cardiomyopathy post anterior STEMI

Background: Cardiovascular diseases are a leading cause of death worldwide. Multiple meta-analysis have demonstrated the benefit of exercise based cardiac rehabilitation. However, the effect of exercise training on left ventricular (LV) systolic function in patients with ischemic cardiomyopathy has been controversial in the literature. Objective: To study the effect of exercise-based cardiac rehabilitation (EBCR) on left ventricular (LV) systolic function and exercise stress parameters (METs achieved, HR recovery and HR reserve) in post anterior STEMI patients with ischemic cardiomyopathy (EF≤45%). Patients and methods: The study included 50 patients with ischemic cardiomyopathy (Post anterior STEMI successfully treated by 1ry PCI) referred for cardiac rehabilitation unit at Ain Shams University Hospitals. The patients were subjected to 3 months of formal exercise based cardiac rehabilitation. Before the CR program, they were subjected to a symptom-limited exercise test (modified Bruce protocol) to exclude any remaining ischemia and calculate enrolment HR reserve, baseline heart rate recovery in 1st minute and 2nd minute (HRR1 and HRR2). Another symptom-limited exercise test was done post CR program to assess the forementioned exercise parameters after completion of the program. Echocardiography was done at baseline and after completion of the CR program for assessment of LV systolic function by ejection fraction (assessed by 2D Simpson’s method) and peak longitudinal strain of the left ventricle (measured using speckle tracking echocardiography). Results: Exercise-based cardiac rehabilitation was associated with significant improvement in LV systolic function as reflected by significant improvement in Global longitudinal strain (GLS) (P-value = 0.0001) in patients with ischemic heart failure. CR was also associated with improvement in the functional capacity as reflected by the improvement in METs as well as in the HRR and HR reserve (P-value = 0.0001). However, there was no significant change regarding EF before and after cardiac rehabilitation (P-value= 0.4582).

ASSESSMENT OF LEFT VENTRICULAR FUNCTION AFTER CORONARY ARTERY BYPASS GRAFTING

Coronary artery bypass grafting (CABG) is a commonly performed surgical intervention for coronary artery disease (CAD), aiming to restore blood flow to the myocardium and improve cardiac function. Left ventricular (LV) systolic function is a crucial determinant of postoperative outcomes in CABG patients, yet the predictors of adverse outcomes remain incompletely understood. Objective: This study aimed to evaluate left ventricular function outcomes following CABG and identify predictors of mortality among CABG patients. Methods: A prospective cohort study was conducted at, Ch. Pervaiz Elahi Institute Of Cardiology (CPEIC), Multan, Pakistan, from December 2022 to December 2023. The study included 96 patients undergoing CABG surgery. Preoperative data collection encompassed demographic information, medical history, and baseline clinical characteristics. Left ventricular function was assessed using echocardiography preoperatively and postoperatively. Statistical analysis involved descriptive statistics, univariate analysis, and univariate regression. Results: The study cohort comprised 96 participants, with a mean age of 56.1 years (±12.2) and a male predominance (67.7%). Prevalent comorbidities included diabetes mellitus (78.1%) and hypertension (79.2%). LV systolic dysfunction (30.2%) and old ischemic heart disease (72.9%) were common preexisting conditions. Intraoperative variables included perioperative inotropes (5.2%) and emergent surgeries (3.1%). Postoperative complications included reoperation for bleeding (5.2%) and deterioration of LV ejection fraction (34.4%). The mortality rate was 5.2%. Postoperatively, the mean LVEF increased significantly from 32.00% (±5.219) to 37.00% (±9.801) in isolated CABG patients. Conclusion: This study confirms the significant improvement in LV systolic function following CABG and underscores the high benefit of CABG in patients with reduced EF. However, diabetes mellitus, advanced diastolic dysfunction, and the insertion of IABP were identified as significant predictors of adverse outcomes. Identifying patients with these risk predictors could provide complementary prognostic information and help optimise care, monitoring, and follow-up to improve their expected poor outcomes.

Differences in left ventricular myocardial function and infarct size in female patients with ST elevation myocardial infarction and spontaneous coronary artery dissection.

Differences in pathophysiology, clinical presentation, and natural course of ST-elevation myocardial infarction in female patients due to either spontaneous dissection (SCAD-STEMI) or atherothrombotic occlusion (type 1 STEMI) have been discussed. Current knowledge on differences in left ventricular myocardial function and infarct size is limited. The aim of this study was to assess baseline clinical characteristics, imaging findings, and therapeutic approach and to compare differences in echocardiographic findings at baseline and 3-month follow-up in patients with SCAD-STEMI and type 1 STEMI. This was a prospective multicenter study of 32 female patients (18-55 years of age) presenting with either SCAD-STEMI due to left anterior descending coronary artery (LAD) dissection or type 1 STEMI due to atherothrombotic LAD occlusion. The two groups were similar in age, risk factors, comorbidities, and complications. SCAD-STEMI patients more often had Thrombolysis in Myocardial Infarction 3 flow, while type 1 STEMI patients were more often treated with percutaneous coronary intervention and dual antiplatelet therapy. Baseline mean left ventricular (LV) ejection fraction (LVEF) was similar in the two groups (48.0% vs. 48.6%, p = 0.881), but there was a significant difference at the 3-month follow-up, driven by an improvement in LVEF in SCAD-STEMI compared to type 1 STEMI patients (Δ LVEF 10.1 ± 5.3% vs. 1.8 ± 5.1%, p = 0.002). LV global longitudinal strain was slightly improved in both groups at follow-up; however, the improvement was not significantly different between groups (-4.6 ± 2.9% vs. -2.0 ± 2.8%, p = 0.055). The results suggest that female patients with SCAD-STEMI are more likely to experience improvement in LV systolic function than type 1 STEMI patients.

Cardiovascular involvement in later-onset malonyl-CoA decarboxylase deficiency: Case studies and literature review

BackgroundMalonyl-CoA decarboxylase deficiency (MLYCDD) is an ultra-rare inherited metabolic disorder, characterized by multi-organ involvement manifesting during the first few months of life. Our aim was to describe the clinical, biochemical, and genetic characteristics of patients with later-onset MLYCDD. MethodsClinical and biochemical characteristics of two patients aged 48 and 29 years with a confirmed molecular diagnosis of MLYCDD were examined. A systematic review of published studies describing the characteristics of cardiovascular involvement of patients with MLYCDD was performed. ResultsTwo patients diagnosed with MLYCDD during adulthood were identified. The first presented with hypertrophic cardiomyopathy and ventricular pre-excitation and the second with dilated cardiomyopathy (DCM) and mild-to-moderate left ventricular (LV) systolic dysfunction. No other clinical manifestation typical of MLYCDD was observed. Both patients showed slight increase in malonylcarnitine in their plasma acylcarnitine profile, and a reduction in malonyl-CoA decarboxylase activity. During follow-up, no deterioration of LV systolic function was observed.The systematic review identified 33 individuals with a genetic diagnosis of MLYCDD (median age 6 months [IQR 1–12], 22 males [67%]). Cardiovascular involvement was observed in 64% of cases, with DCM the most common phenotype. A modified diet combined with levocarnitine supplementation resulted in the improvement of LV systolic function in most cases. After a median follow-up of 8 months, 3 patients died (two heart failure-related and one arrhythmic death). ConclusionsFor the first time this study describes a later-onset phenotype of MLYCDD patients, characterized by single-organ involvement, mildly reduced enzyme activity, and a benign clinical course.

Abstract 17616: The Association Between Hypokinetic Left Ventricle And Pulmonary Embolism

Case Description: A 49-year-old male patient working as a public transport driver presented with syncope lasting a few minutes, followed by non-exertional substernal discomfort. He was hemodynamically stable with a normal physical examination. Laboratory tests revealed an elevated D-dimer of 1146 mg/L and troponin peaking at 1.38 ng/mL. CT Pulmonary angiography was performed, revealing a saddle embolus with signs of right heart strain (Figure 1). A transthoracic echocardiogram revealed a left ventricular (LV) ejection fraction (EF) of 31-35%, and moderately decreased left ventricular systolic function. A venous duplex and hypercoagulability workup yielded negative results. Left-heart catheterization showed normal coronary arteries. A repeat transthoracic echocardiogram three days later showed improvement in LV systolic function with an EF of 41-45% and normal LV function. He was discharged on apixaban with appropriate follow-up. Discussion: Saddle embolism is one of the rare but life-threatening forms of pulmonary embolism. It causes RV dilatation and flattening of the interventricular septum towards the left side, decreasing cardiac output via the “Reverse Bernheim Effect". Rarely, it affects LV contractility and LV ejection fraction. Together, this can lead to severe hemodynamic instability and increase the risk of complications like pulmonary infarction, cardiac arrhythmias, and cardiogenic shock. Therefore, clinicians must be aware of this possibility, as early detection and timely treatment improve patient outcomes.

The impact of age on ablation outcomes in AF-mediated cardiomyopathy.

The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population. To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF-mediated cardiomyopathy) following CA. Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance. The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF(34 ± 9 vs. 33 ± 8 ≥65 years, p = .686), atrial and ventricular dimensions (left atrial volume index:55 ± 21 vs. 56 ± 14 mL/m2 age ≥ 65, p = .834; indexed left ventricular end-diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m2 age ≥ 65, p = .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65, p = .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all p > .05) albeit a higher CHADS2 VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65, p < .001). Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38-1.48, LogRank p = .283) as was AF burden [0% (interquartile range, IQR: 0.0-2.1) vs. age ≥ 65: [0% (IQR 0.0-1.7), p = .516], irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65, p = .913), with LV recovery in the vast majority (73% vs. 69%, respectively, p = .759) at 13 (IQR: 12-16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class p = .851; 6-min walk distance 50 ± 61 vs. 93 ± 134 min age ≥ 65, p = .066), biomarkers (ΔN-terminal-pro brain natriuretic peptide -139 ± 246 vs. -168 ± 181 age ≥ 65,p = .629) and HF symptoms (Short Form-36 survey Δphysical component summary p = .483/Δmental component summary, p = .841). In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.

Echocardiographic evaluation of the effect of dapagliflozin on epicardial adipose tissue and left ventricular systolic function in type 2 diabetes mellitus

Background and aimsEpicardial adipose tissue (EAT) is associated with cardiovascular disease, and sodium-glucose cotransporter-2 inhibitors (SGLT-2I) have been reported to reduce the occurrence of cardiovascular events. This study was designed to investigate the effect of an SGLT-2 inhibitor (dapagliflozin) on EAT and left ventricular (LV) systolic function in type 2 diabetes mellitus (T2DM) patients during a 6-month follow-up. MethodsTwenty-seven T2DM patients who received dapagliflozin for the first time were enrolled in this study to measure EAT thickness and evaluate LV function before and after 6 months of SGLT-2 administration. The thickness of EAT was measured as the echo-free space between the free wall of the right ventricle and the visceral layer of the pericardium at end-systole by echocardiography. LV systolic function was evaluated by LV global longitudinal strain (LV GLS) obtained through two-dimensional speckle tracking echocardiography (2D-STE) technology. ResultsAfter a 6-month follow-up, twenty-five patients completed this study. The values of EAT thickness, HbA1c, body weight, body mass index (BMI), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were significantly reduced, while the LV GLS value was significantly increased. Moreover, the increase in LV GLS was independently associated with the reduction in EAT thickness, HbA1c, weight, and SBP (all p < 0.05). ConclusionsDapagliflozin can reduce EAT thickness and improve LV systolic function in T2DM patients. 2D-STE can be used for the early evaluation of the beneficial effect of dapagliflozin on LV systolic function. The improvement in LV systolic function is independently associated with a reduction in EAT thickness.

Changes in Computed-Tomography-Derived Segmental Left Ventricular Longitudinal Strain After Transcatheter Aortic Valve Implantation

Patients with severe aortic stenosis (AS) may show left ventricular (LV) apical longitudinal strain sparing. Transcatheter aortic valve implantation (TAVI) improves LV systolic function in patients with severe AS. However, the changes in regional longitudinal strain after TAVI have not been extensively evaluated. This study aimed to characterize the effect of the pressure overload relief after TAVI on LV apical longitudinal strain sparing. A total of 156 patients (mean age 80 ± 7years, 53% men) with severe AS who underwent computed tomography before and within 1year after TAVI (mean time to follow-up 50 ± 30days) were included. LV global and segmental longitudinal strain were assessed using feature tracking computed tomography. LV apical longitudinal strain sparing was evaluated as the ratio between the apical and midbasal longitudinal strain and was defined as an LV apical to midbasal longitudinal strain ratio >1. LV apical longitudinal strain remained stable after TAVI (from 19.5 ± 7.2% to 18.7 ± 7.7%, p=0.20), whereas LV midbasal longitudinal strain showed a significant increase (from 12.9 ± 4.2% to 14.2 ± 4.0%, p ≤0.001). Before TAVI, 88% of the patients presented with LV apical strain ratio >1% and 19% presented with an LV apical strain ratio >2. After TAVI, these percentages significantly decreased to 77% and 5% (p=0.009, p ≤0.001), respectively. In conclusion, LV apical sparing of strain is a relatively common finding in patients with severe AS who underwent TAVI and its prevalence decreases after the afterload relief after TAVI.

Left Ventricular Systolic Function After 3 Months of SGLT2 Inhibitor Therapy in Heart Failure Patients with Reduced Ejection Fraction.

Not much is known about the effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on echocardiographic parameters of left ventricular (LV) systolic function in patients with heart failure and reduced ejection fraction (HFrEF).We prospectively included 59 outpatients with HFrEF: 41 patients received SGLT2i with OMT (SGLT2i+ group), whereas eighteen patients received OMT without SGLT2i (SGLT2i- group). Myocardial work index (MWI), 3D ejection fraction (3D LVEF), and global longitudinal strain (GLS) were measured at baseline and after 3 months following treatment. At 3-month follow-up, the SGLT2i+ group showed significantly greater improvement in MWI than the SGLT2i- group. In both groups, there was a significant improvement in 3D LVEF and LV GLS, circulating NT-proBNP levels, and NYHA functional class, with significantly greater improvement in the SGLT2i+ group.In conclusion, the addition of SGLT2i to fully optimized background medical therapy resulted in a greater improvement of LV systolic function among outpatients with HFrEF.

Acute vasopressin neutralization improves cardiac function in rats with chronic heart failure

Vasopressin is one of the leading pathophysiological drivers of chronic heart failure (CHF) acting via V1a-, V1b- and V2 receptors. Selective V2 and dual V1a-V2 receptor antagonists increases plasma sodium levels, but failed to reduce mortality in clinical studies. Vasopressin neutralization is an original alternative to receptor blockers but its effect in CHF is unknown. For this purpose, we investigated the short-term cardiac and vascular effects of the vasopressin neutralizing aptamer NOX-F37. Left ventricular (LV) function (hemodynamic by LV catheterization) and LV tissue perfusion (MRI) as well as mesenteric artery endothelial function (flow-mediated dilation by arteriography) were determined 2 hours after NOX-F37 administration (80 nM/kg; IP) to rats with CHF induced by left coronary artery ligation. Two hours after administration, NOX-F37 improved LV systolic function, illustrated by the increase in LV end-systolic pressure volume relationship (CHF: 20.2 ± 0.0.7; CHF + NOX: 23.3 ± 1.0 mmHg/RVU; P < 0.05) and diastolic function, illustrated by the decrease in LV end-diastolic pressure volume relationship (CHF: 4.03 ± 0.48; CHF + NOX: 2.06 ± 0.21 mmHg/RVU; P < 0.01), together with an increase in LV tissue perfusion (CHF: 6.12 ± 0.24; CHF + NOX: 10.10 ± 0.26 ml/min/g LV tissue; P < 0.001). However, mesenteric artery flow-induced dilatation was not improved (% dilatation at 150 μL/min; CHF: 10 ± 7; CHF + NOX: 9 ± 8). These results illustrate the immediate beneficial effects of vasopressin neutralization on cardiac function in CHF, confirming the existence of a deleterious vasopressinergic tone in this pathophysiological context. Investigations still needed to evaluate the persistence of effects of vasopressin neutralization over time during chronic and could contribute to the resolution of acute heart failure.

Value of Speckle Tracking Echocardiography Combined with Stress Echocardiography in Predicting Surgical Outcome of Severe Aortic Regurgitation with Markedly Reduced Left Ventricular Function.

Predicting outcomes of surgical aortic valve replacement (AVR) in patients with chronic severe aortic regurgitation (AR) and markedly reduced left ventricular (LV) function remains a challenge. This study aimed to explore the preoperative echocardiographic index that could predict the recovery of LV systolic function after surgery in patients with chronic severe AR and reduced left ventricular ejection fraction (LVEF). The study group consisted of 50 patients diagnosed with chronic severe AR ( 6 months) and significantly reduced LVEF (18~35%, average 26.2 5.3%). Low-dose dobutamine stress echocardiography (DSE) was performed before surgery. Only patients with an absolute increase in LVEF 8% during DSE were referred for surgical AVR. During following up (over six months to one year after surgery), the patients were divided into two groups by postoperative LVEF ( or 40%). DSE- and speckle tracking echocardiography (STE)-derived LV functional parameters were compared between groups to identify predictors of post-operative improvement in LVEF. A total of 38 patients underwent AVR. One patient died before discharge. Post-surgical LV size and LVEF improved markedly after surgery in all patients (n = 37). Pre-surgical LV end-systolic diameter, baseline global longitudinal strain (GLS) and peak GLS were better in the group with LVEF 40% (n = 18; p 0.05, t test). Baseline GLS and peak GLS correlated moderately with post-surgery LVEF (R = -0.581, p 0.001; R = -0.596, p 0.001; respectively). Logistic regression analysis demonstrated baseline GLS and peak GLS were the independent predictors of post-surgery improvement of LVEF. Peak GLS had the highest prediction value (area under the curve = 0.895, sensitivity and specificity: 89.5% and 77.8%, respectively), with a cutoff value of -9.4%. This study shows that STE combined with DSE can provide sensitive quantitative indices for predicting improvement of LV systolic function after AVR in patients with chronic severe AR and significantly decreased LVEF.

Myocardial recovery after percutaneous coronary intervention in coronary artery disease patients with impaired systolic function- predictive utility of global longitudinal strain

ObjectiveCoronary revascularization is associated with better outcomes in coronary artery disease patients. We aim to investigate the prevalence, and factors associated with left ventricular (LV) improvement following successful percutaneous coronary intervention (PCI) of patients with impaired systolic function with specific reference to the value of baseline GLS. MethodsThis retrospective study reviewed the records of coronary artery disease patients with impaired systolic function who were admitted and treated with PCI. ResultOut of 420 consecutive acute coronary syndrome patients with an impaired systolic function who were admitted and treated with PCI during the period from January 2021 to December 2021, 147 patients (35%) showed no improvement in the Left ventricular ejection fraction (LVEF) post PCI and 273 patients (65%) showed improvement of the LVEF post PCI in their follow up echocardiogram. Larger myocardial injury dilated LV dimension at the acute phase showed a strong impact on further improving LV systolic function. Baseline GLS showed a higher statistical difference between the Non-improving LVEF and improving LVEF groups. Moreover, the early GLS and further LV systolic function improvement were strongly correlated (P < 0.001) with higher sensitivity and specificity. A receiver operating characteristic curve (ROC) analysis demonstrated that GLS values greater than 9% are a predictor of significant LVEF improvement in the follow-up stage. ConclusionSizable proportion of patients with impaired systolic function following successful PCI show further LV systolic recovery. We demonstrated that the baseline GLS values of more than 9% are an accurate predictor of significant LVEF improvement.

Cardiac resynchronization therapy optimization in nonresponders and incomplete responders using electrical dyssynchrony mapping

Nonresponse to cardiac resynchronization therapy (CRT) occurs in ∼30%-50% of patients. There are no well-accepted clinical approaches for optimizing CRT in nonresponders. The purpose of this study was to demonstrate the effect of CRT optimization using electrical dyssynchrony mapping on left ventricular (LV) function, size, and dyssynchrony in selected patients with nonresponse/incomplete response to CRT. We studied 39 patients with underlying left bundle branch block or interventricular conduction delay who had an LV ejection fraction of ≤40% after receiving CRT and had significant electrical dyssynchrony. Electrical dyssynchrony was measured at multiple atrioventricular delays and interventricular delays. The QRS area between combinations of 9 anterior and 9 posterior electrograms (QRS area under the curve) was calculated, and cardiac resynchronization index (CRI) was defined as the percent change in QRS area under the curve compared to native conduction. Electrical dyssynchrony maps depicted CRI over the wide range of settings tested. Patients were programmed to an optimal device setting, and echocardiograms were recorded 5.9 ± 3.7 months postoptimization. CRI increased from 49.4% ± 24.0% to 90.8% ± 10.5%. CRT optimization significantly improved LV ejection fraction from 31.8% ± 4.7% to 36.3% ± 5.9% (P < .001) and LV end-systolic volume from 108.5 ± 37.6 to 98.0 ± 37.5 mL (P = .009). Speckle-tracking measures of LV strain significantly improved by 2.4% ± 4.5% (transverse; P = .002) and 1.0% ± 2.6% (longitudinal; P = .017). Aortic to pulmonic valve opening time, a measure of interventricular dyssynchrony, significantly (P = .040) decreased by 14.9 ± 39.4 ms. CRT optimization of electrical dyssynchrony using a novel electrical dyssynchrony mapping technology significantly improves LV systolic function, LV end-systolic volume, and mechanical dyssynchrony. This methodology offers a noninvasive, practical clinical approach to treating nonresponders and incomplete responders to CRT.

Device treatment of heart failure

Background: The incidence of heart failure (HF) is rapidly increasing, introducing a significant burden and challenges in clinical practice. Non-pharmacological cardiac device therapy has been established as an essential component of optimal HF management, particularly for the prevention of sudden cardiac death and the improvement of HF symptoms, left ventricular (LV) systolic function, quality of life, and eventually survival.Current Concepts: Cardiac resynchronization therapy (CRT) can correct atrioventricular or inter/intraventricular dyssynchrony, thereby improving LV systolic function. Recently, the concept of CRT is being expanded, including His bundle (HB), HB-optimized LV, left bundle branch (LBB), and LBB optimized LV pacing CRTs. Newly introduced CRT approaches by stimulating the cardiac conduction system are expected to correct dyssynchrony better and consequently exhibit better CRT outcomes than the conventional biventricular pacing CRT. The current versions of implantable cardioverter-defibrillators (ICDs) or CRT devices can continuously monitor multiple biosignals. CRT/ICD can calculate a single index by combining these multiple bio-signal data for early detection of HF aggravation. Recently, subcutaneous and transvenous ICDs showed comparable safety and efficacy in HF patients. In drug-refractory HF patients without LV dyssynchrony, cardiac contractility modulation therapy provides some promising results.Discussion and Conclusion: Recent technological advancements have improved the efficacy and safety of cardiac device therapy. Therefore, cardiac device therapy should be used more actively to manage HF patients better.

NP202 treatment improves left ventricular systolic function and attenuates pathological remodelling following chronic myocardial infarction

AimsMyocardial injury is a major contributor to left ventricular (LV) remodelling activating neurohormonal and inflammatory processes that create an environment of enhanced oxidative stress. This results in geometric and structural alterations leading to reduced LV systolic function. In this study we evaluated the efficacy of NP202, a synthetic flavonol, on cardiac remodelling in a chronic model of myocardial infarction (MI). Main methodsA rat model of chronic MI was induced by permanent surgical ligation of the coronary artery. NP202 treatment was commenced 2 days post-MI for 6 weeks at different doses (1, 10 and 20 mg/kg/day) to determine efficacy. Cardiac function was assessed by echocardiography prior to treatment and at week 6, and pressure-volume measurements were performed prior to tissue collection. Tissues were analysed for changes in fibrotic and inflammatory markers using immunohistochemistry and gene expression analysis. Key findingsRats treated with NP202 demonstrated improved LV systolic function and LV geometry compared to vehicle treated animals. Furthermore, measures of hypertrophy and interstitial fibrosis were attenuated in the non-infarct region of the myocardium with NP202 at the higher dose of 20 mg/kg (P < 0.05). At the tissue level, NP202 reduced monocyte chemoattractant protein-1 expression (P < 0.05) and tended to attenuate active caspase-3 expression to similar levels observed in sham animals (P = 0.075). SignificanceImproved LV function and structural changes observed with NP202 may be mediated through inhibition of inflammatory and apoptotic processes in the MI setting. NP202 could therefore prove a useful addition to standard therapy in patients with post-MI LV dysfunction.

Glucocorticoids in myocarditis therapy after COVID-19

Abstract The aim of the study - to evaluate the efficacy of glucocorticoids (GC) in patients with acute myocarditis (AM) after COVID-19 infection. Material and methods We included 60 pts with severe AM and heart failure (HF) with reduced (&amp;lt;40%) left ventricular (LV) ejection fraction (EF) who had COVID-19 infection 1–2 months before the enrollment. According to the results of cardiac magnetic resonance (CMR) included pts had ≥2 Lake Louise criteria for myocarditis. All pts on the background of HF therapy (β-blockers, ACE-inhibitors, MRA antagonists, diuretics) were prescribed GC: 0.25 mg/kg per day methylprednisolone for 3 months, followed by a gradual dose reduction of 1–2 mg per week until complete discontinuation after 6 months. Evaluation before the start of GC therapy and after 6 months included CMR, 2D- and speckle-tracking echocardiography. Results After 6 months according to the results of CMR the number of LV segments with inflammatory lesions decreased to (3,58±0,42) from (6,32±0,77) segments in average (p=0,001). This was followed by improvement of LV systolic function: increase of LV EF in average to (43,5±2,6) from (32,2±2,4) % (p=0,003), longitudinal global systolic strain (LGSS) absolute value to (11,3±1,1) from (7,9±0,5) % (p=0,012) and circumferential global systolic strain (CGSS) to (12,1±1,0) from (8,9±0,6) % (p=0,023). Also we observed LV volume reduction: decrease of LV end-diastolic (from 118,9±8,6 to 95,3±7,2 ml/m2, p=0,033) and LV end-systolic (from 80,1±5,1 to 59,1±4,4 ml/m2, p=0,027) volume indexes. Wherein in 24 of 60 pts (41,6%) on the background of significant decrease in the number of LV segments with inflammatory lesions (to 1,34±0,21 from 6,12±0,73 segments, p=0,0001) after 6 months we observed the recovery of LV EF ≥50%, followed by an improvement of LGSS and CGSS on 42,1 and 39,4% respectively (p=0,001). According to multivariate regression analysis, predictors of LV EF recovery (≥50%) after 6 months of GC treatment were established: presence of inflammatory lesions in ≤5,0 LV segments, values of LGSS and CGSS ≥9.0% and ≥9.5% respectively before the start of GC. Conclusions The use of GC in pts with severe AM after COVID-19 was followed by the decrease of LV segments number affected by inflammation, improvement of LV systolic function and reduction of LV volume indexes. In 41,6% of pts GC therapy was associated with LV EF recovery after 6 months and predictors of its effectiveness were found: presence of inflammatory lesions in ≤5,0 LV segments, values of LGSS and CGSS ≥9.0% and ≥9.5% respectively before the start of GC. Funding Acknowledgement Type of funding sources: None.

Visualizing myocardial injury from elective cardioversion with CMR

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Association of Cardiothoracic Anaesthesiologists Research Grant Background Despite everyday use of electrical interventions in cardiovascular care, the extent and type of concomitant myocardial injury is not fully understood. Current literature disagrees about the question whether and how cardioversion or defibrillation damage the myocardium, especially when serologic markers are used. Such markers are not always cardiac-specific, nor diagnostic for type and region of myocardial injury. These limitations may be overcome by parametric T1 and T2 mapping. We aimed to investigate whether the acute and long-term impact of electrical cardioversion on myocardial structure and function is detectable using CMR imaging. Methods Patients scheduled for elective cardioversion were enrolled to undergo three CMR exams (3 Tesla): on the morning prior to cardioversion to assess pre-existing injury; two to five hours after cardioversion to assess the acute response; and six to ten weeks later to investigate chronic injury. The CMR exam studied left ventricular (LV) function, T2 mapping to measure edema, and extracellular volume (ECV) from T1 maps to measure diffuse fibrosis. Both the degree of injury and proportion (%) of myocardial area affected were analysed. Results Eight patients completed the study, requiring 1-2 shocks (totalling 120-300 J biphasic energy) to achieve sinus rhythm. LV ejection fraction increased after cardioversion from 47 ± 13% to 55 ± 15% (p = 0.020), and was 52 ± 16% at the third exam (p = 0.199). Even prior to intervention, some patients showed edema (baseline T2 &amp;gt; 40ms) afflicting 49 ± 23% of their LV myocardium. Area affected by edema expanded to 72 ± 18% after cardioversion (p = 0.002) and returned to 54 ± 24% by the third exam. T2 rose from baseline (40.4 ± 1.8ms) after cardioversion acutely to 44.1 ± 5.2ms (p = 0.028) and normalized until the late exam (40.8 ± 3.1ms). Myocardial area affected by diffuse fibrosis (ECV &amp;gt; 30%) was 28.3 ± 9.4% at baseline and 38.8 ± 18.9% late after cardioversion (p = 0.018). Pathologic T2 increases (indicative of edema) were not observed in all patients, but individuals with higher baseline ECV also experienced greater T2 increase after cardioversion (r = 0.840, p = 0.036). Conclusion Elective cardioversion improves LV systolic function, but also aggravates myocardial edema and possibly adds to diffuse fibrosis during several weeks thereafter. Such sequelae of cardioversion were observed mainly in patients with a greater burden of pre-existing myocardial injury. More data is needed to corroborate these preliminary findings and to study whether this type of myocardial injury predicts worse outcome. Moreover, changes in CMR markers caused by electrical interventions including defibrillation, may have the potential to confound diagnostic assessments of the underlying cardiac injury. Abstract Figure

Acute recoordination rather than functional hemodynamic improvement determines reverse remodelling by cardiac resynchronisation therapy

Purpose: Cardiac resynchronisation therapy (CRT) improves left ventricular (LV) function acutely, with further improvements and reverse remodelling during chronic CRT. The current study investigated the relation between acute improvement of LV systolic function, acute mechanical recoordination, and long-term reverse remodelling after CRT. Methods: In 35 patients, LV speckle tracking longitudinal strain, LV volumes & ejection fraction (LVEF) were assessed by echocardiography before, acutely within three days, and 6 months after CRT. A subgroup of 25 patients underwent invasive assessment of the maximal rate of LV pressure rise (dP/dtmax,) during CRT-implantation. The acute change in dP/dtmax, LVEF, systolic discoordination (internal stretch fraction [ISF] and LV systolic rebound stretch [SRSlv]) and systolic dyssynchrony (standard deviation of peak strain times [2DS-SD18]) was studied, and their association with long-term reverse remodelling were determined. Results: CRT induced acute and ongoing recoordination (ISF from 45 ± 18 to 27 ± 11 and 23 ± 12%, p < 0.001; SRS from 2.27 ± 1.33 to 0.74 ± 0.50 and 0.71 ± 0.43%, p < 0.001) and improved LV function (dP/dtmax 668 ± 185 vs. 817 ± 198 mmHg/s, p < 0.001; stroke volume 46 ± 15 vs. 54 ± 20 and 52 ± 16 ml; LVEF 19 ± 7 vs. 23 ± 8 and 27 ± 10%, p < 0.001). Acute recoordination related to reverse remodelling (r = 0.601 and r = 0.765 for ISF & SRSlv, respectively, p < 0.001). Acute functional improvements of LV systolic function however, neither related to reverse remodelling nor to the extent of acute recoordination. Conclusion: Long-term reverse remodelling after CRT is likely determined by (acute) recoordination rather than by acute hemodynamic improvements. Discoordination may therefore be a more important CRT-substrate that can be assessed and, acutely restored.

Two-year left ventricular systolic function of percutaneous coronary intervention vs optimal medical therapy for patients with single coronary chronic total occlusion.

In this study, two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (RT-3DE) were applied to compare the changes of left ventricular systolic function associated with percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with single chronic total occlusion (CTO). 63 single CTO patients (age 61.88±8.86years) were examined by echocardiography and were divided into the PCI group (n=27) and OMT group (n=36) according to the initial treatment strategy. Two-dimensional left ventricular ejection fraction (2D-LVEF), two-dimensional indexed left ventricular end-systolic volume (2D-LVESVI), and two-dimensional indexed left ventricular end-diastolic volume (2D-LVEDVI) were measured using two-dimensional echocardiography (2DE). Three-dimensional left ventricular ejection fraction (3D-LVEF), three-dimensional indexed left ventricular end-systolic volume (3D-LVESVI), and three-dimensional indexed left ventricular end-diastolic volume (3D-LVEDVI) were measured using RT-3DE. Global circumferential strain (GCS) and global longitudinal strain (GLS) were measured using 2D-STE. After 2years of follow-up, there were no significant differences in the 2D-LVEF, 2D-LVESVI, 3D-LVEF, 3D-LVESVI, 3D-LVEDVI, and GCS, except for GLS (P=.001) between the CTO-PCI and CTO-OMT groups. GLS decreased significantly in OMT group (P=.016) in contrast with PCI group in which GLS increased significantly (P=.007). Left ventricular systolic function assessment using 2D-STE showed a significant difference in GLS between CTO-PCI and CTO-OMT. And the patients who chose PCI revascularization at the 2-year follow-up had better left ventricular systolic function improvement than those who were conservatively treated with OMT.

Combination of chronic myocarditis and progressive coronary artery disease: differential diagnosis and stepwise treatment

Aim. To assess the differential diagnosis in a patient with a combination of coronary artery disease and myocarditis and the results of stepwise treatment (including immunosuppressive therapy (IST), and coronary stenting).Material and methods. A 56-year-old female patient with hypertension, obesity (body mass index, 31,6 kg/m2), diabetes and psoriasis developed shortness of breath after a respiratory viral infection. Primary echocardiography revealed left heart dilatation, ejection fraction (EF) of 21%. Coronary angiography revealed anterior descending artery stenosis of 75%, circumflex artery — 80%, right coronary artery (RCA) — 70%. RCA stenting was performed and cardiovascular and diuretic therapy was started. However, shortness of breath and low exercise tolerance persisted.Results. In the blood test, anti-endothelial cell antibodies were 1:320, anticardiomyocyte and anti-smooth muscle antibodies — 1:80, anti-cardiac conduction system fibers — 1:320 (N≤1:40). During myocardial perfusion scintigraphy with computed tomography, an uneven distribution of the indicator was noted. Signs of myocardial scarring and indications for further revascularization were not revealed. Cardiac magnetic resonance imaging confirmed a decrease in left ventricular (LV) contractility (LVEF 37%) and moderate dilatation. Biopsy was not performed due to dual antiplatelet therapy. The condition is regarded as infectious-immune myocarditis. IST was started with azathioprine 150 mg/day. We noted dyspnea relief and a stable increase in LVEF to 50-52%. The clinical course was complicated by sick sinus syndrome with pauses up to 6 seconds and presyncope; a pacemaker was implanted. After 5 years from the onset of IST, dyspnea episodes reappeared without exacerbation of myocarditis. As their cause, ischemia was diagnosed due to the progression of coronary atherosclerosis. Symptoms regressed after repeated coronary stenting.Conclusion. The presence of moderate coronary atherosclerosis without signs of ischemia and myocardial infarction should not be considered as the only cause of severe systolic myocardial dysfunction. Diagnosis and treatment of myocarditis in combination with coronary artery disease is carried out according to the standard principles and can improve LV systolic function and control the heart failure symptoms.