Basal Left Ventricular Segments Research Articles

Reference Values for Inward Displacement in the Normal Left Ventricle: A Novel Method of Regional Left Ventricular Function Assessment.

Regional functional left ventricular (LV) assessment using current imaging techniques remains limited. Inward displacement (InD) has been developed as a novel technique to assess regional LV function via measurement of the regional displacement of the LV endocardial border across each of the 17 LV segments. Currently, normal ranges for InD are not available for clinical use. The aim of this study was to validate the normal reference limits of InD in healthy adults across all LV segments. InD was analyzed in 120 healthy subjects with a normal LV ejection fraction, using the three standard long-axis views obtained during cardiac MRI that quantified the degree of inward endocardial wall motion towards the true LV center of contraction. For all LV segments, InD was measured in mm and expressed as a percentage of the theoretical degree of maximal segment contraction towards the true LV centerline. The arithmetic average InD was obtained for each of the 17 segments. The LV was divided into three regions, obtaining average InD at the LV base (segments 1-6), mid-cavity (segments 7-12) and apex (segments 13-17). Average InD was 33.4 ± 4.3%. InD was higher in basal and mid-cavity LV segments (32.8 ± 4.1% and 38.1 ± 5.8%) compared to apical LV segments (28.6 ± 7.7%). Interobserver variability correlations for InD were strong (R = 0.80, p < 0.0001). We provide clinically meaningful reference ranges for InD in subjects with normal LV function, which will emerge as an important screening and assessment imaging tool for a range of HFrEF therapies.

Abstract 17765: Stress Myocardial Blood Flow is Abnormal During Acute Takotsubo Syndrome

Introduction: Coronary microvascular dysfunction (CMD) is a proposed mechanism for takotsubo syndrome (TS). Therefore, we performed cardiac magnetic resonance imaging (CMR) with quantitative stress/rest perfusion and T2 mapping during acute TS and at 6-month post recovery. AIM: Quantitate stress/rest myocardial blood flow (MBF) in acute/recovery TS and compare basal with apical MBF. Methods: TS diagnosed by internationally accepted criteria. Each patient underwent acute and 6-month recovery CMR with automated in-line quantification of global/regional MBF, cine imaging, T2-mapping, and late gadolinium enhancement (LGE) imaging. Normal rest and stress MBF are 0.8-1.0 and &gt; 2.0 ml/min/g, normal myocardial perfusion reserve (MPR) is &gt; 2.4. Results: Acute and recovery studies were performed on 7 patients, all women, average age 63 + 8.5 years. CMR was performed within 72 hours of TS diagnosis. Initial versus (vs) follow-up EF: 40.3% vs 67.1%, left ventricular (LV) mass: 108.7 grams vs 86.3 grams. Acute studies demonstrated hypokinesis in the mid-apical segments with corresponding myocardial edema, LGE was absent in all patients. Myocardial edema and wall motion abnormality normalized at recovery. During acute TS, rest and stress MBF were 1.14 and 2.58 ml/min/g (base) vs 0.96 and 1.73 ml/min/g (apex). While at recovery, rest-stress MBF were 1.14 and 3.12 ml/min/g at base versus 1.09 and 2.76 ml/min/g at apex (Figure). MPR improved from acute to recovery: 2.14 vs 2.74 (global), 2.25 vs 2.84 (base), and 1.85 vs 2.64 (apex); p = 0.126; 0.035; 0.012 respectively (Figure). Conclusion points: Resting MBF is normal during acute TS in both basal and apical LV segments despite typical apical ballooning consistent with stunned myocardium. MPR is more abnormal in apical than base segments during acute TS, returning to normal at recovery. Myocardial edema might contribute to apical CMD during acute TS.

Comparative analysis of left ventricular strain parameters in patients with heart failure of ischemic and non-ischemic genesis

Aim. To carry out a comparative analysis of left ventricular (LV) strain parameters, determined by the two-dimensional strain imaging in patients with heart failure (HF) with LV ejection fraction (EF) ≤35%, depending on the origin of HF.Material and methods. The study included 133 patients with NYHA class 3-4 HF with LVEF ≤35%, taking optimal therapy. Based on the HF origin, 2 following groups of patients were formed: ischemic cardiomyopathy (ICM) (n=70), nonischemic cardiomyopathy (NICM) (n=63). All patients underwent speckle-tracking echocardiography.Results. All patients included in the study showed significant alterations in longitudinal strain parameters in most myocardial segments, most pronounced in the basal and middle parts of the LV. Comparative analysis of the peak systolic longitudinal strain showed the worst characteristics in patients with ICM were found in the apical segments (p=0,008), and in patients with NICM, in the basal segments of the LV (p=0,046). The studied groups had comparable LV global longitudinal and circumferential strain (p=0,26; p=0,67; respectively).Conclusion. Groups of patients with HF of ischemic and non-ischemic origin, despite comparable LVEF values, differ in the distribution of the decrease in local longitudinal strain of LV segments. The worst strain characteristics in patients with ICM and NICM are detected in LV apical and basal segments, respectively.

Specific deformation pattern in hypertensive patients with septal bulge and preserved systolic function.

A wide range of subclinical changes in left ventricular (LV) geometry and function can be observed, even in the early course of arterial hypertension (HTN). Aim of the study was to investigate if the appearance of isolated basal septal hypertrophy (BSH, septal bulge) in asymptomatic young and middle-aged adults with HTN could be a marker of incipient LV systolic dysfunction when other measures of global LV function are still normal. A total of 138 patients with primary arterial hypertension, aged less than 65years, with no comorbidities and with preserved LV ejection fraction (EF) were included. Complete 2D transthoracic echocardiography study was preformed according to standardized protocol, as well as deformation study using speckle tracking echocardiography. Global and regional longitudinal strain was measured in apical 4-, 2- and 3-chamber views according to 18-segments model. Global and regional circumferential and radial strains were measured in short axis view. Average was taken from each of the six basal, middle and apical LV segments. Patients were divided into two groups according to BSH presence and values were compared. Basal septal hypertrophy was found in half of the patients (53.6%). The whole cohort had altogether normal LV global systolic function, as well as global indices of radial strain (GRS 43.86 ± 10.75%) and longitudinal strain (GLS - 19.73 ± 2.19%), while global circumferential strain (GCS) was mildly reduced (GCS - 19.5 ± 2.81%). BSH patients had more expressed LV geometry changes (LV mass: 89.19 ± 24.59g/m2 vs 109.15 ± 25.33g/m2, p < 0.001; relative wall thickness: 0.3 ± 0.08 vs 0.38 ± 0.11, p < 0.001) and also revealed a specific pattern of longitudinal deformation impairment in three LV segments (basal and mid interventricular septum, basal anteroseptum). "Strain gradient" from LV base to apex (basal < mid < apical) was observed in the whole population for longitudinal and circumferential strain, and it was more pronounced in the BSH group. This group had more impaired basal LS, while apical CS was improved. Subendocardial longitudinal strain was also more impaired in the BSH group. This study brings new meaning to basal septal hypertrophy (BSH) occurrence in hypertensive patients with discrete global concentric remodeling. Regional systolic dysfunction of the basal and mid LV segments is found, while apical segments increase in deformation. This specific "strain gradient" pattern was found to be more pronounced in patients with BSH. The recognition of BHS in apparently healthy hypertensive patients with no impairment in global systolic function may suggest latent target organ damage with regional impairment of systolic function and the need to imply more aggressive treatment approach.

Abnormal Longitudinal Strain Reduction of Basal Left Ventricular Segments in Patients Recovered of COVID-19.

Background:The Severe acute respiratory syndrome coronavirus 2, is the pathogen that causes COVID-19. Cardiovascular (CV) involvement during this infection, has been related to adverse outcomes. Interestingly, some patients may remain symptomatic beyond the first 14 days of disease diagnosis. Although a particular reduction on left ventricular (LV) global longitudinal strain (GLS) in basal segments has been recently described in patients hospitalized with diagnosis of COVID-19, the correlation of these findings with the persistence of symptoms has not been determined.Objectives:The objective of this study is to describe echocardiographic findings in patients recovered from COVID-19 and to determine its association with persistent dyspnea.Methods:Seventy-six patients were analyzed. Forty-six were asymptomatic (group N°1) and 30 referred persistent dyspnea at the time of examination (group N°2), and a cohort of 25 healthy individuals was included as a control group. Total LV GLS, average basal LV GLS, and average mid-apical LV GLS were assessed. Basal-mid-apical index (BMAI) was calculated. A difference in BMAI bigger than 15% between both groups was stablished as cutoff point.Results:Nonsignificative differences on standard echocardiographic measurements were found between the analyzed groups. When compared to the control group, there was nonsignificative reduction on basal LV GLS values in patients with persistent dyspnea. However, BMAI values were bigger than 15% in 70% of patients from group N°2 but in none of the patients from the control group ( = 0.0002).Conclusions:This new index allowed to identify an abnormal relation in LV GLS values between basal and medium-apical segments among patients recovered from COVID-19 and persistent dyspnea.

Poorer Exercise Accommodation of Regional Systolic Myocardial Motion after Spironolactone Treatment in Heart Failure Patients with Preserved Ejection Fraction and Ventricular Dyssynchrony.

Patients with heart failure and preserved ejection fraction (HFpEF) are known to have reduced systolic myocardial velocity (Sm) with impaired accommodation to exercise. We tested the impact of an aldosterone antagonist on Sm at rest and post-exercise. Forty-nine HFpEF patients (65 ± 11 years, 24 male) with HF signs/symptoms, mitral E/Ea (annular early diastolic velocity) > 8, and left ventricular (LV) EF > 50% were randomized to spironolactone (25 mg/day, 25 patients) or the Control. At baseline and 6 months, we analyzed Sm of basal LV segments at rest and after a 6 min treadmill exercise. At 6 months, post-exercise mean Sm in the spironolactone group became greater than that in the Control (9.2 ± 1.6 vs. 8.3 ± 1.0 cm/s, p = 0.021), mainly due to the increment of post-exercise % increase of lateral Sm (44 ± 30 vs. 30 ± 19% at baseline, p = 0.045). Further analyses showed the presence of systolic dyssynchrony (standard deviation of electromechanical delay of 6-basal LV segments > 35 ms) was independently associated with a poorer response to spironolactone, defined as a post-exercise % increase of lateral Sm < 50% (OR = 2.7, 95% CI = 1.8–4.2) and the increment of Ea < 1.5 cm/s (OR = 1.5, 95% CI = 1.1–2.3). Spironolactone could improve exercise accommodation of regional systolic myocardial velocity for HFpEF patients. However, its benefits could be decreased in those with ventricular dyssynchrony. This suggested possible therapeutic impacts from underlying heterogeneity within HFpEF patients.

Post-COVID-19 syndrome: morpho-functional abnormalities of the heart and arrhythmias

Aim. To study the myocardial morpho-functional abnormalities, the incidence and nature of cardiac arrhythmias in patients 3 months after the coronavirus disease 2019 (COVID-19).Material and methods. The study included 77 patients (mean age, 35,9 years) treated for coronavirus infection, which underwent echocardiography and 24-hour Holter monitoring 3 months after COVID-19. The patients were divided into 3 groups: group 1 — 31 patients with upper respiratory tract involvement; group 2 — 27 patients with bilateral pneumonia (CT grade 1, 2), 3 — 19 patients with severe pneumonia (CT grade 3, 4). Statistical processing was carried out using Statistica 10.0.Results. According to echocardiography, the peak tricuspid late diastolic velocity and isovolumetric contraction time in all groups increased (P&lt;0,001). The tricuspid and mitral Em/Am ratio decreased depending on the disease severity. In group 3, the right ventricular and atrial size increased (P&lt;0,001). The pulmonary artery systolic pressure, left atrial volume in patients of the 2nd and 3rd groups was higher than in the control one (P&lt;0,001). In group 1 and 2 patients, the regional strain in basal and basal/middle segments decreased, respectively, while, in group 3, not only regional but also global left ventricular (LV) strain decreased (P&lt;0,001). In all groups, cardiac arrhythmias and pericardial effusion were found. The relationship was established between coronavirus activity and the structural and functional myocardial parameters (P&lt;0,001).Conclusion. Cardiovascular injury 3 months after COVID-19 was found in 71%, 93%, and 95% of patients with mild, moderate and severe course. In mild course patients, a decrease in regional myocardial strain in LV basal segments, signs of past pericarditis, and various cardiac arrhythmias were noted. In patients of moderate severity, these changes were more pronounced and were accompanied by an additional decrease in regional strain in LV middle segments, impaired right ventricular diastole and increased pulmonary artery pressure. In severe patients, in addition to the above changes, dilatation of the right heart and inferior vena cava was recorded, as well as LV diastolic and global systolic function decreased.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

Evaluating Left Ventricular Systolic Synchronicity with Real-Time 3D Echocardiography in Newborns.

Knowing the normal values of left ventricular (LV) systolic synchronicity in the early neonatal period is very important for understanding myocardial function. This retrospective study analyzed data of 105 newborns who were examined using real-time 3-dimensional echocardiography (RT3DE). The time to the point of minimal regional systolic volume (Tmsv) was measured from volume-time curves in each segment. Standard deviation (SD) and maximal difference (Dif) of Tmsv were calculated from 16 (6 basal/6 mid/4 apical), 12 (6 basal/6 mid), and 6 (basal) LV segments with the corresponding parameters adjusted for the R-R interval. Influences of age, sex, gestational age, birth weight, and heart rate on parameters were explored. Data showed no significant difference among Tmsv-16-SD, Tmsv-12-SD, and Tmsv-6-SD. A strong correlation was found between Tmsv-6-SD and Tmsv-6-Dif (r = 0.83, P < 0.001), Tmsv-12-SD and Tmsv-6-SD (r = 0.77, P < 0.001), and Tmsv-12-Dif and Tmsv-6-Dif (r = 0.76, P < 0.001) and a moderate correlation was found between Tmsv-16-SD and Tmsv-16-Dif (r = 0.66, P < 0.001), Tmsv-6-SD and Tmsv-12-Dif (r = 0.62, P < 0.001), and Tmsv-12-SD and Tmsv-6-Dif (r = 0.61, P < 0.001). Heart rate correlated negatively with Tmsv (r = -0.03 to -0.11, P < 0.004-0.000), but had no effect on parameters adjusted for %R-R. Age, sex, gestational age, and birth weight did not affect any of these parameters. Tmsv-Dif and Tmsv-SD measured from 16 segments using RT3DE are useful as possible parameters for evaluating LV systolic synchronicity in normal newborns.

Analysis of left ventricular rotational deformation by 2D speckle tracking echocardiography: a feasibility study in athletes

2D speckle tracking echocardiography (2DSTE) is established to analyse left ventricular (LV) longitudinal function. The analysis of LV rotational deformation is challenging and requires standardization of image acquisition as well as postprocessing analysis. The aim of this study was to test the feasibility to analyse LV rotational deformation using 2DSTE by introducing a novel algorithm for the detection of artefacts. The study was performed in 20 healthy subjects serving as a control group and in 53 competitive sportsmen. Circumferential, radial strain (CS, RS) and LV rotation were analysed by 2DSTE in parasternal short axis views. The stepwise algorithm to exclude potential artefacts starts with the visual estimation of the image quality with respect to complete visualization of all myocardial segments during the entire cardiac cycle followed by the exclusion of data sets in participants with conduction abnormalities. The next step is the optimization of tracking areas and a cross-check of implausible strain waveforms in multiple acquired comparable cineloops. The last step is the exclusion of strain curves with persisting implausible waveforms if standardization failures and incorrect LV wall tracking are fixed. Plausible physiological strain curves were observed in 89% (n = 65/73) of all subjects. In controls all implausible waveforms could be verified as artefacts. The algorithm was applied in 53 professional athletes to test and confirm its feasibility. Abnormal CS waveforms were documented in 25 athletes, verified as artefacts due to tracking failures in 22 athletes and due to incorrect image acquisition in 3 athletes. CS artefacts were mostly located in the basal posterior and lateral LV segments. (endocardial: 6%, n = 4/70; p < 0.05) and basal posterior (endocardial: 8%, n = 5/70; p < 0.05) segments were highly susceptible to artefacts. 2DSTE of parasternal short axis views to analyse circumferential and radial deformation as well as LV rotation is feasible in athletes. The proposed algorithm helps to avoid artefacts and might contribute to standardization of this technique. 2DSTE might provide an interesting diagnostic tool for the detection of viral myocarditis, e.g. in athletes.

Clinical outcome of cardiac resynchronization therapy in patients randomized to an active fixation bipolar left ventricular lead versus a passive quadripolar lead

Objectives: To compare the clinical outcome of cardiac resynchronization therapy (CRT) in patients receiving a bipolar left ventricular (LV) lead with a side helix for active fixation to the outcome in patients receiving a quadripolar passive fixation LV lead. Design: Sixty-two patients (mean age 72 ± 11 years) were blindly and randomly assigned to the active fixation bipolar lead group (n = 31) or to the quadripolar lead group (n= 31). The LV leads were targeted to the basal LV segment in a vein concordant to the LV segment with the latest mechanical contraction chosen on the basis of preoperative radial strain (RS) echocardiography. Results: At the 6-month follow-up (FU), the reduction in LV end-systolic volume and LV reverse remodelling responder rate, defined as LV end-systolic volume reduction >15%, was 77% in the active fixation group and 83% in the quadripolar group, which was not significantly different. At the 12-month FU, the LV ejection fraction (LVEF) did not differ between the groups. There were no significant differences between the two groups in changes in New York Heart Association (NYHA) functional class or Minnesota Living with Heart Failure Questionnaire score. The occurrence of phrenic nerve stimulation (PNS) was 19% in the active fixation group versus 10% in the quadripolar group (p=.30), and all cases were resolved by reprogramming the device. All patients were alive at the 12-month FU. There was no device infection. Conclusions: There were no significant differences between the active fixation group of patients and the quadripolar group of patients concerning improvement in echocardiographic parameters or clinical symptoms. ClinicalTrials.gov number, NCT04632472

Myocardial rupture and systemic lupus erythematosus: a case report.

BackgroundSystemic erythematous lupus (SLE) is an autoimmune disease associated with significant cardiovascular morbidity and mortality, even in young patients.Case summaryA young female with recently diagnosed SLE under corticotherapy developed pulmonary oedema and respiratory failure. The diagnostic workup revealed mildly elevated cardiac troponin, significantly elevated NT-proB-type natriuretic peptide (NT-proBNP) and mild pericardial effusion without other echocardiographic abnormalities. Systemic erythematous lupus-associated myocarditis was presumed, and her clinical status improved after corticotherapy intensification. However, transthoracic echocardiogram repeated days later revealed a large pericardial effusion with findings suggestive of a contained myocardial rupture originating in the inferolateral basal left ventricular (LV) segment, which was confirmed by computed tomography scan. Cardiac catheterization exhibited normal coronary arteries. The patient was submitted to cardiac surgery and the LV pseudoaneurysm was successfully repaired.DiscussionMyocardial rupture with LV pseudoaneurysm formation usually occurs in the setting of acute myocardial infarction, but also in other rare contexts. Cardiac rupture is associated with an extremely high mortality unless early diagnosis and urgent surgical intervention are provided.

Nonselective versus selective His bundle pacing: An acute intrapatient speckle‐tracking strain echocardiographic study

We aimed to compare the acute differences in left ventricular (LV) function and mechanical synchrony during nonselective His bundle pacing (ns-HBP) versus selective His bundle pacing (s-HBP) using strain echocardiography. Consecutive patients with permanent His bundle pacing, in whom it was possible to obtain both s-HBP and ns-HBP, were studied in two centers. In each patient, echocardiography was performed sequentially during s-HBP and ns-HBP. Speckle-tracking echocardiography parameters were analyzed: Global longitudinal strain (GLS), the time delay between peak systolic strain in the basal septaland basal lateral segments (BS-BL delay), peak strain dispersion (PSD) and strain delay index. Right ventricle function was assessed using tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler velocity of the lateral tricuspid annulus (S'). A total of 69 patients (age: 75.6 ± 10.5 years; males: 75%) were enrolled. There were no differences in LV ejection fraction and GLS between s-HBP and ns-HBP modes: 59% versus 60%, and -15.6% versus -15.7%, respectively; as well as no difference in BS-BL delay and strain delay index. The PSD value was higher in the ns-HBP group than in the s-HBP group with the most pronounced difference in the basal LV segments. No differences in right ventricular function parameters (TAPSE and S') were found. The ns-HBP and s-HBP modes seem comparable regarding ventricular function. The dyssynchrony parameters were significantly higher during ns-HBP, however, the difference seems modest and clarification of its impact on LV function requires a larger long-term study.

The value of left ventricular longitudinal strain in the diagnosis and differential diagnosis of myocardial amyloidosis

Objective: To investigate the characteristics of left ventricular longitudinal strain (LS) in myocardial amyloidosis (CA), hypertrophic cardiomyopathy (HCM) and Fabry disease (FD), as well as the correlation between left ventricular LS and these diseases. Methods: A total of 14 CA patients, 28 HCM patients and 5 FD patients who visited the Department of Cardiology of the First Affiliated Hospital of Suzhou University from June 2017 to November 2019 were retrospectively included. EchoPAC software was used to analyze left ventricular LS, and univariate logistic regression analysis was used to analyze the correlation between echocardiographic LS indexes and various myocardial hypertrophy diseases. The receiver operating characteristic (ROC) curve was used to assess the sensitivity and specificity of echocardiograph LS indexes in the diagnosis of various myocardial hypertrophy diseases. Results: There were significant differences in LS of left ventricular basal segment, inferior wall, posterior wall, lateral wall and posterior septum among the three groups (P<0.05). The absolute value of LS in the left ventricular basal segment decreased in the CA group; the absolute value of LS in left ventricular posterior wall and lateral wall decreased significantly in the FD group (P<0.05); the absolute values of LS in left ventricular basal segment, inferior wall, posterior septum, lateral wall and posterior wall increased significantly in the HCM group (P<0.05). The absolute value of LS < 7.9% in the left ventricular basal segment, or > 13.2% in the inferior wall and > 9.2% in the basal segment, or < 8.3% in the lateral wall and < 7.9% in the posterior wall were the indicators of high sensitivity and specificity in the diagnosis of CA, HCM and FD, respectively. Conclusions: Left ventricular LS was an important index to differentiate myocardial hypertrophy. Combined with their respective clinical characteristics, it could provide certain reference value for clinical practice.

Prevalence and prognostic implications of increased apical basal strain ratio in aortic stenosis undergoing transcatheter aortic valve replacement

Abstract Background A substantial number of elderly patients with aortic stenosis (AS) have been reported to have coexisting transthyretin cardiac amyloidosis (ATTR). These patients are characterized by advanced heart failure symptoms and increased NTproBNP. Raising clinical suspicion of ATTR in AS patients seems difficult. Recent data has shown that an increased apical-basal strain ratio (ABr) derived by echocardiography predicts the diagnosis of cardiac amyloidosis (CA) in patients with left ventricular (LV) hypertrophy. However, the prevalence and prognostic value of ABr, a potential marker of ATTR, in patients with symptomatic AS undergoing transcatheter aortic valve replacement (TAVR) is unknown. The aim of this study was to investigate the preoperative prevalence, relation to symptoms and prognostic implications of elevated ABr in patients with symptomatic AS undergoing TAVR. Methods We obtained data including survival status from 499 consecutive AS patients who underwent TAVR in the period 2016–2018 at our institution. From 2D echocardiographic apical images ABr was calculated as mean longitudinal strain of the 5 LV apical segments divided by the mean of the 6 LV basal segments. Patients were stratified according to ABr; 0–1.9 was considered normal, 2–2.9 mildly increased, 3.0–3.9 moderately increased and ≥4 severely increased. Results Median follow-up time was 743 days. Mean age was 80±7 years. The prevalence of ABr ≥4 was 16% (n=78). These patients had higher preoperative NYHA class (77% were NYHA III or IV compared to 59% in ABr 0–1.9, p=0.003). Median preoperative NTproBNP levels for ABr ≥4 were 1781 pmol/l compared to 876 pmol/l in ABr 0–1.9 (p=0.003). NTproBNP levels decreased for all ABr subgroups at three months follow-up but remained considerably elevated in ABr ≥4 (median of ABr ≥4 was 1262 pmol/l compared to 645 pmol/l for ABr 0–1.9, p=0.001). LV ejection fraction (EF) in ABr 0–1.9 and ≥4 was 50% and 46%, p=0.014. The preoperative aortic valve stenosis severity derived by echo Doppler parameters were comparable across ABr subgroups. Overall, increased ABr ≥4 was associated with poor survival (fig. 1). In univariate analysis ABr ≥4 (HR 1.90, p=0.018), preoperative NTproBNP levels above the median of 1226 pmol/l (HR 3.14, p=0.003), increasing age (HR 1.05, p=0.018), TAPSE &amp;lt;19 mm (HR 1.91, p=0.011) and LV EF &amp;lt;50% (HR 1.60, p=0.045) were significant predictors of mortality. Preoperative NTproBNP &amp;gt;1226 pmol/l emerged as the only significant outcome predictor in a multivariate analysis (HR 2.67, p=0.029). Conclusion Increased ABr ≥4 occurs frequently and is associated with significantly higher pre- and postoperative NYHA class, NTproBNP levels and reduced survival in symptomatic AS patients undergoing TAVR. Some of these patients might have undiagnosed CA. The echocardiographic derived ABr could in future studies prove to be a useful tool in raising suspicion of ATTR leading to referral for diagnostic testing for CA. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Danish Independent Research Fund

Prominent involvement of basal left ventricular longitudinal strain in patients with monoclonal gammopathy of undetermined significance

Abstract Background In cardiac amyloidosis the application of Speckle Tracking Echocardiography allows to identify a specific left ventricular (LV) longitudinal strain (LS) pattern characterized by “apical sparing”, with a prominent involvement of basal and middle segments and normal LS of apical cap. The pattern of regional LS has been never investigated in monoclonal gammopathy of undetermined significance (MGUS), a condition which can predispose to cardiac amyloidosis. Purpose To compare LV regional LS patterns and LS base-to-apex behaviour of patients affected by MGUS in comparison with healthy subjects. Methods We enrolled 40 patients affected by MGUS (M/F=20/20; age 62.6±13.8 years), asymptomatic for cardiac symptoms, and a control group of 40 healthy subjects, matched for sex and age. Nineteen (47%) MGUS patients showed prevalent free K light chain and 21 (53%) had prevalent free λ light chain. Participants underwent standard echo-Doppler exam, including Speckle Tracking of the three apical views. Global longitudinal strain (GLS), the average LS of six basal (BLS), six middle (MLS), and six apical (ALS) segments (considered in absolute values) and relative regional strain ratio RRSR [=ALS/(BLS+MLS)] were computed. Exclusion criteria were overt heart failure, LV ejection fraction &amp;lt;53%, coronary artery and congenital heart disease, moderate to severe valvular disease, primary cardiomyopathies, atrial fibrillation and inadequate echo imaging. Results The two groups were comparable for body mass index, blood pressure and heart rate. LV mass index, relative wall thickness, left atrial volume index and Doppler-derived LV diastolic parameters did not differ significantly between the two groups. LV ejection fraction was also similar in MGUS and healthy controls. GLS resulted significantly lower in MGUS group than in controls (20.5±3.0 vs. 22.4±2.0%, p&amp;lt;0.02). BLS (17.1±3.7 vs. 19.2±2.2%, p=0.004), MLS (24.9±3.8 vs. 27.1±3.6%, p&amp;lt;0.01) and ALS (25.1±3.8 vs. 27.1±3.5%, p&amp;lt;0.01) were significantly lower in MGUS than in controls. The intergroup difference of RRSR (0.60±0.05 vs. 0.58±0.04) did not achieve the statistical significance (p=0.26) and none of the MGUS patients had RRSR&amp;gt;1. The figure depicts a LS bull'eye of a MGUS patient showing the prominent involvement of LV basal segments. Conclusions In presence of a normal LV ejection fraction, MGUS patients show a subclinical LV longitudinal systolic dysfunction. This is testified by a reduction of GLS and of regional LS which involves mainly LV basal segments, without substantial changes of relative regional strain ratio. LV regional longitudinal dysfunction could be useful to monitor LV myocardial mechanics during follow-up of MGUS patients. LS bull's eye in a MGUS patient Funding Acknowledgement Type of funding source: None

1033 Prominent longitudinal strain involvement of left ventricular basal segments in native hypertensive patients without clear-cut hypertrophy

Abstract Background Left ventricular (LV) global longitudinal strain (GLS) is able to detect an early subclinical dysfunction and it has been demonstrated to be a prognosticator in arterial hypertension. Information of regional longitudinal strain (LS) pattern has not been investigated in this clinical setting. Purpose We analyzed regional LV patterns of LS and base-to-apex behaviour of LS in newly diagnosed and never-treated hypertensive patients (HTN) without clear-cut LV hypertrophy (LVH). Methods 166 HTN (M/F = 107/59; age 43.9 ± 14.3 years, blood pressure [BP] = 146.5± 10.7/90.1 ± 7.5 mmHg) and a control group of 94 healthy subjects (M/F = 58/36; age 41.2 ± 15.0 years) underwent standard echo-Doppler exam, including speckle tracking quantification of regional LS and GLS (considered in absolute values). The average LS of six basal (BLS), six middle (MLS), and six apical (ALS) segments and relative regional strain ratio - RRSR = [ALS/(BLS + MLS)] - were also computed. Exclusion criteria were LVH (LV mass index ≥45 g/m^2.7 in females and ≥49 g/m^2.7 in males), diabetes mellitus, coronary artery disease, overt heart failure, hemodynamically significant valve heart disease, primary cardiomyopathies, atrial fibrillation and inadequate echo imaging. Results The two groups were comparable for sex, age, heart rate and LV ejection fraction (EF). Body mass index (BMI), systolic (SBP), diastolic (DBP) and mean BP (MBP) (all p &amp;lt; 0.0001), LV mass index (p = 0.03), relative wall thickness (RWT) (p &amp;lt; 0.02) and E/e’ ratio (p &amp;lt; 0.01) were higher, and GLS lower (21.6 ± 2.0 vs. 22.2 ± 2.1%, p &amp;lt; 0.02) in HTN. By analyzing regional LS, BLS (18.2 ± 2.1% vs. 19.2 ± 2.1%, p &amp;lt; 0.0001) and MLS (20.7 ± 2.0 vs. 21.4 ± 2.1%, p = 0.007) resulted significantly lower in HTN, without significant difference in ALS (26.0 ± 3.6 vs. 25.9 ± 3.8%, p = 0.98). Accordingly, RRSR was higher in HTN (0.67 ± 0.09 vs. 0.64 ± 0.09, p &amp;lt; 0.01). Even after excluding patients with LV concentric remodeling (RWT &amp;gt; 0.42) (n = 34), BLS (p &amp;lt; 0.0001) and MLS (p &amp;lt; 0.002) were again lower and RRSR (p &amp;lt; 0.01) higher in HTN than in controls. In the pooled population, BLS negatively correlated with SBP (r=-0.22), DBP (r=-0.25) and MBP (r=-0.26) (Figure) (all p &amp;lt; 0.0001). By a multiple linear regression analysis, after adjusting for age, sex, BMI and RWT, the association between BLS and MBP remained significant (β coefficient=-0.23, p &amp;lt; 0.0001), with an additional significant impact of male sex (β=-0.33, p &amp;lt; 0.0001) (cumulative R²=0.18, SEE = 1.9%, p &amp;lt; 0.0001). Conclusions Besides normal LV EF, GLS is lower in HTN. LS dysfunction involves basal and, with a lower extent, middle myocardial segments, with a compensation of apical segments. RRSR appears to be significantly higher in HTN. These results are even confirmed in hypertensive patients with normal LV geometry. The association of BLS and BP appears to be independent on several confounders. Regional LS pattern might be useful to detect very early LV systolic abnormalities in arterial hypertension. Abstract 1033 Figure. Relation between MBP and BLS

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Abstract Funding Acknowledgements Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP. A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement. This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP. Abstract 1642 Figure. CMR images of arrhythmogenic MAD

P5686Role of internal stretch fraction parameter in quantification of mechanical dyssynchrony and prediction of cardiac resynchronization therapy outcome

Abstract Background Dyssynchronous activation of the heart is a prerequisite for cardiac resynchronization (CRT) efficacy. Although the main goal of CRT is to resynchronize ventricular contraction, our abilities to quantify mechanical dyssynchrony are still limited. However, so called “internal stretch fraction” (ISF) might serve as a marker of global discoordination of ventricular contraction. Methods and aim of the study Thirty-six CRT candidates and 7 healthy controls underwent MRI scanning. Feature tracking data (in short axis) were analysed using Segment software and cicrumferential strain (S)/ strainrate (SR) was obtained for each of the 16 left-ventricular (LV) segments. ISF was calculated as an extent of stretch (product of number of stretched regions and their mean amount of stretch, integrated over given time period; ie. area under the positive part of the global SR curve) in relation to the extent of shortening (area under the negative part of the global SR curve) in 6 basal LV segments during the ejection time (ET). The onset and end of ejection for ISF calculation were set from the global S curve (obtained by the averaging of S curves in 6 basal LV segments). For flow-derived ISF (FISF) parameter, ET was defined from the MRI-flow through pulmonic and aortic valve (Fig-1). Higher ISF and FISF marks more ineffective ventricular contraction. Aim of our study was to assess the ability of ISF and FISF to distinguish healthy controls from CRT candidates and to predict CRT responders (↓LVESV&gt;15% after 6 months of CRT). Results ISF and FISF were significantly higher in CRT candidates than in healthy controls, greater difference between the two groups exhibited FISF (Fig-2). There were 37% of nonresponders among CRT recipients. Both parameters (ISF and FISF) were higher in future CRT responders. Cut-off value discriminating CRT responders from CRT nonresponders was &gt;0,045 for ISF and &gt;0,174 for FISF, however FISF had higher sensitivity than ISF (Fig-3; sensitivity 71% (ISF) versus 79% (FISF) and specificity 70% for both ISF and FISF). Conclusion Internal stretch fraction might be a useful parameter for selection of patients with discoordinated ventricular contraction who might profit from CRT. Higher sensitivity of FISF compared to ISF may be explained by the fact that ET derived from global S curve reflects only part of the ejection phase whereas FISF describes presence of ventricular discoordination in the entire ejection phase. Acknowledgement/Funding Supported by Ministry of Health of the Czech Republic, grant nr. 15-31398A. All rights reserved.

Echocardiographic reference ranges for myocardial work in healthy subjects: A preliminary study.

Myocardial work (MW) estimation by pressure-strain loops (PSL) allows the non-invasive assessment of myocardial performance. Aim of this study is to provide the reference values for global myocardial work index (WI), constructive work (CW), wasted work (WW), and work efficiency (WE) in a group of healthy volunteers accounting for age and gender. 2D standard and speckle-tracking echocardiography were performed in 115 healthy volunteers (median age 36.3 [18-69] years, males: 67%). PSLs were used to assess MW. Mean±standard deviation or median and inter-quartile range, 5° and 95° percentile values for global myocardial WI, CW, WW, and WE in the whole population were 1926±247mmHg, (1534-2356); 2224±229mmHg, (1894-2647); 90 (61-123) mmHg%, (38-195); and 96 (94-97)%, (91-98), respectively. Global WI (2031±247 vs 1874±232mmHg%, P=.001) and global CW (2289±261 vs 2194±207mmHg%, P=.04) were higher in women than in men. Age did not affect MW parameters. The segmental analysis showed that myocardial WI, CW, and WE were lower in the left ventricular basal segments than in the apex. The apex-to-base gradient was inverted for WW (all P<.0001). The assessment of MW is feasible in normal subjects. The presented referral ranges of global myocardial WI, CW, WW, and WE were not affected by age. An apex-to-base gradient was observed for all MW parameters. Nevertheless, the wide variability of MW parameters prevents for the moment the application of this technique in the routine clinical setting.