Left Ventricular End-diastolic Volume Research Articles

Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials

BackgroundRoutine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI). MethodsPubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA. ResultsA total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to −0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to −3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = −2.13, p = 0.03; z = −3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04). ConclusionTA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.

Effect of papillary muscle and trabeculae on left ventricular function analysis via computed tomography: A cross-sectional study.

Deciding whether to include or exclude the papillary muscles and trabeculae to blood pool is essential, because quantifications of left ventricular (LV) functional parameters and myocardial mass are significantly affected. As a result, such inclusion or exclusion might produce different indices for diagnosis and therapy. Using cardiac computed tomography (CT), we obtained standard values of the portion of papillary muscle and trabeculae in normal adults, and to find out how the inclusion or exclusion of papillary muscle and trabeculae affect LV functional parameters depending on the patient group. Excluding the papillary muscles from the LV mass results in easier automated contour detection using CT. The percentage portions of papillary muscle and trabeculae to LV end-diastolic volume (EDV) and LV mass (LVM) were 11.9 ± 5.6% and 20.2 ± 4.3%, respectively, significantly affecting disease diagnosis. Imaging should be consistent at follow-up and include or exclude the papillary muscles and trabeculae to avoid introducing significant differences between measurements.

Improving cardiac function of angiotensin receptor/neprilysin inhibitor in patients with acute myocardial infarction: a systematic review and meta-analysis.

As the impact of angiotensin receptor/neprilysin inhibitor (ARNI) on cardiac function in acute myocardial infarction (AMI) patients is unclear in clinical therapy, we conducted this research to investigate the actual effects of improving cardiac function with ARNI in AMI patients. Publications were checked up to June 2022. Standardised mean differences (SMD) and 95% confidence intervals (CI) were utilised for assessing the size of the effect of continuous variables. To assess the magnitude of the effect of dichotomous variables, a relative risk (RR) with 95% CI was used. ARNI could improve left ventricular ejection fraction (SMD = 0.40; 95% CI: 0.23 - 0.58), while lowering left ventricular end-diastolic volume (SMD = -0.43, 95% CI: -0.78 to -0.08), left ventricular end-systolic volume (SMD = -0.39, 95% CI: -0.66 to -0.11) and left ventricular enddiastolic diameter (SMD = -0.49; 95% CI: -0.65 to -0.33). Besides, it could decrease the rates of major adverse cardiac events (RR = 0.55; 95% CI: 0.43 - 0.69) and heart failure (RR = 0.42; 95% CI: 0.31 - 0.58). ARNI could greatly improve cardiac function in AMI patients.

Short-term study of atrial shunt and improvement of functional mitral regurgitation

BackgroundThis study used an atrial septal shunt to compare the treatment progress and prognosis for patients with heart failure (HF) who have different ejection fractions.MethodsTwenty HF patients with pulmonary hypertension, who required atrial septal shunt therapy, were included in this study. The patients underwent surgery between December 2012 and December 2020. They were divided into two groups based on their ejection fraction: a group with reduced ejection fraction (HFrEF) and a group with preserved ejection fraction(HFpEF) + mid-range ejection fraction (HfmrEF). Echocardiography was utilized to evaluate parameters such as left ventricular dimension (LVD), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic volume (LVEDV). Hemodynamic parameters were measured using cardiac catheterization. The patient's cardiac function was assessed using the six-minute walking test (6MWT), KCCQ score, NYHA classification, and the degree of functional mitral regurgitation (FMR). Followed-up visits were conducted at 1, 3, and 6 months, and any adverse effects were recorded.ResultsThe LVEF values were consistently higher in the HFpEF+HFmrEF group than HFrEF group at all periods (P < 0.05). Differences in LVD were observed between the two groups before the surgery. Statistically, significant differences were found at the preoperative stage, 1 month, and 3 months (P < 0.05, respectively). However, the LVEDV showed a significant difference between the two groups only at 3 months (P = 0.049). Notably, there were notable variations in LAPm, LAPs, and the pressure gradient between the LA-RA gradient at baeline, after implantation, and during the 6 months follow-up (all P < 0.05).ConclusionFollowing treatment, the HFpEF+HFmrEF group exhibited more significant improvements in echocardiographic and cardiac catheterization indices than the HFrEF group. However, there was no statistically significant difference between the two groups regarding the 6MWT and KCCQ scores. It is important to note that the findings of this study still require further investigation in a large sample size of patients.

Highlights of right ventricular characteristics of left ventricular noncompaction using 3D echocardiography

Highlights of right ventricular characteristics of left ventricular noncompaction using 3D echocardiography.The aspects of right ventricular volumes and function investigated with 3D echocardiography in a large cohort of left ventricular noncompaction morphology (LVNC) population remains unclear.The objective of our research was to study the left (LV) and right (RV) ventricular parameters using 3D echocardiography and analyze the clinical features of a LVNC population with preserved LV ejection fraction (EF > 50 %) in comparison with healthy controls (HC).We selected 41 LVNC subjects with preserved LV function (EF: 52.91 ± 3 %, male n = 26) and without any comorbidities and compared them with an age and sex-matched HC. Three dimensional endocardial contours were evaluated to determine the following LV and RV parameters: end-diastolic (EDV) and end-systolic (ESV) volumes, stroke volume, EF, LV global longitudinal and circumferential strain and RV septal and free wall longitudinal strain.Regarding the clinical characteristics, the family involvement had a notable proportion, accounting for 51%. The EF and strain values of the LVNC population were significantly decreased in both RV and LV compared to HC. Although the LV volumes of the LVNC group were significantly elevated, the RV volumetric parameters did not differ significantly compared to controls. We found significant correlations between LV and RV volumetric and functional parameters and linear regression models showed that LV EDV and LV ESV determined the RV volumetric values.While the alteration and relationship of the RV parameters may represent the potential of biventricular involvement, clinical characteristics of the LVNC group underlines the necessity of monitoring this population, even with preserved EF.

Dysautonomia, but Not Cardiac Dysfunction, Is Common in a Cohort of Individuals with Long COVID.

Despite the prevalence of dysautonomia in people with Long COVID, it is currently unknown whether Long COVID dysautonomia is routinely accompanied by structural or functional cardiac alterations. In this retrospective observational study, the presence of echocardiographic abnormalities was assessed. Left ventricular (LV) chamber sizes were correlated to diagnostic categories and symptoms via standardized patient-reported outcome (PRO) questionnaires. A total of 203 individuals with Long COVID without pre-existing cardiac disease and with available echocardiograms were included (mean age, 45 years; 67% female). Overall, symptoms and PRO scores for fatigue, breathlessness, quality of life, disability, anxiety and depression were not different between those classified with post-COVID dysautonomia (PCD, 22%) and those unclassified (78%). An LV internal diameter at an end-diastole z score < -2 was observed in 33 (16.5%) individuals, and stroke volume (SV) was lower in the PCD vs. unclassified subgroup (51.6 vs. 59.2 mL, 95% C.I. 47.1-56.1 vs. 56.2-62.3). LV end-diastolic volume (mean diff. (95% CI) -13 [-1--26] mL, p = 0.04) and SV (-10 [-1--20] mL, p = 0.03) were smaller in those individuals reporting a reduction in physical activity post-COVID-19 infection, and smaller LVMI was weakly correlated with worse fatigue (r = 0.23, p = 0.02). The majority of individuals with Long COVID report shared symptoms and did not demonstrate cardiac dysfunction on echocardiography.

Increased Left Ventricular End-Diastolic Volume Index Is Associated With Increased Adverse Events After MitraClip Implantation

This study investigated the association between the left ventricular end-diastolic volume index (LVEDVI) and the incidence of adverse clinical events in patients after MitraClip implantation. In this retrospective, observational study, 123 patients who underwent the MitraClip procedure were enrolled. Participants were divided into 2 groups according to the LVEDVI cut-off level, calculated using receiver operating characteristic curve analysis, to predict the primary end point and the occurrence of cardiovascular events was compared between the groups. The primary end point was all-cause mortality and hospitalization because of heart failure. The receiver operating characteristic curve analysis for the composite primary end point revealed an LVEDVI cut-off point of 118ml/m2. Based on this threshold, 61 patients (49.6%) were categorized into the LVEDVI <118 ml/m2 group, whereas 62 (50.4%) fell into the LVEDVI ≥118 ml/m2 group. Over a median follow-up period of 336days (interquartile range 80 to 667), the primary end points occurred in 15 and 26 patients in the LVEDVI <118 and LVEDVI ≥118 ml/m2 groups, corresponding to incidence rates of 24.6% and 41.9%, respectively. Patients in the LVEDVI ≥118ml/m2 group demonstrated a significantly higher risk of adverse clinical events than those in the LVEDVI <118ml/m2 group (hazard ratio 2.24, 95% confidence interval 1.17 to 4.28, p=0.01). This trend persisted even after adjusting for several confounders (p=0.02). In conclusion, increased LVEDVI values were associated with increased adverse clinical events after MitraClip implantation in patients with severe mitral valve regurgitation.

Mitral leaflet retraction and left ventricular reverse remodeling in patients with treated dilated cardiomyopathy

Abstract Background Enlargement of the mitral leaflets (MLs) adaptive to mechanical stress caused by dilated left ventricle (LV) was recognized, but their changes after the stimuli withdrawn remained unexplored. Aims To observe morphological changes in the MLs along with LV reverse remodeling (LVRR) occurred after standard care. Methods Patients with recent-onset dilated cardiomyopathy (RODCM) were prospectively enrolled (n=82), as well as a group of age, sex and body surface area matched normal controls (NC) (n=50). Two-dimensional transthoracic echocardiography was performed at baseline and 6-month follow-up with special interests in the length of anterior and posterior mitral leaflet (AML and PML), mitral annular dimension (MAD) and tenting height (TH). LVRR was measured as a reduction in the LV end-diastolic volume (LVEDV) of ≥15%. Results At the 6-month follow-up, LVRR was achieved in 69.5% patients and there were 26.9% patients who reported ≥1 grade reduction in secondary mitral regurgitation that related to LVRR. The AML (28±3 vs. 26±3mm, p=0.004) and PML (19±4 vs. 17±3mm, p&amp;lt;0.001) were decreased, as well as the MAD (31±5 vs. 28±5mm, p=0.001) and TH (10±3 vs. 8±2mm, p&amp;lt;0.001), but all remained larger than that of the NC group (all p&amp;lt;0.05). When compared with the control group, the AML and PML of the RODCM group was 16.7% and 35.7% longer at baseline, which remained 8.3% and 21.2% longer at the follow-up, respectively. The change in the AML (△AML) or PML (△PML) correlated moderately to the change in the LVEDV (△LVEDV) (r=0.487, p&amp;lt;0.001; r=0.516, p &amp;lt;0.001, respectively) (Figure 1). When compared between the subgroups stratified by LVRR, both the AML and PML decreased in the patients who had LVRR (+) (AML, 28±3 vs. 26±3, p=0.001; PML, 20±4 vs. 16±3, p&amp;lt;0.001), but remained the same length in those with LVRR (-) (AML, 27±4 vs. 28±4, p=0.318; PML, 17±3 vs. 17±3, p=0.790). The comparison in the △AML and △PML between the two subgroups is shown in Figure 2. Conclusion The enlarged MLs could retract with different behavior in the AML and PML, accompanied by LV reverse remodeling. This study conducted in patients with RODCM who received standard therapy provided the other facet of mitral leaflet plasticity adaptive to mechanical stretch.correlation between △MLs and △LVEDVCompare △MLs between LVRR subgroups

Hemodynamic implications of transcatheter tricuspid valve repair in HFpEF Patients - HERACLES-HFpEF

Abstract Background Patients with severe tricuspid regurgitation (TR) and heart failure with preserved ejection fraction (HFpEF) have been suggested to respond favourably to transcatheter edge-to-edge tricuspid valve repair (TEER), but the mechanisms remain poorly understood. Purpose The aim of this study was to investigate the pathophysiological implications of TV-TEER in patient with HFpEF and severe TR. Methods This was a prospective interventional single arm trial that included 20 HFpEF patients with invasive evidence of increased filling pressures (i.e. left-ventricular enddiastolic pressure [LVEDP] &amp;gt;15 mmHg and preserved ejection fraction i.e. LVEF ≥50%) at a single centre. All patients received transthoracic echocardiography and cardiac magnetic resonance imaging (MRI) immediately before and 1-month after TV-TEER. During the TV-TEER procedure LV pressure-volume loops were recorded by using a conductance catheter (Figure 1A). The primary outcome was the periprocedural change in the ratio of LVEDP to left-ventricular end-diastolic volume (LVEDV) as surrogate for preload independent diastolic function. The secondary outcomes included single-beat estimated end-diastolic pressure volume-relationships (EDPVRs), and LV distending pressure (calculated as LVEDP-mean right atrial pressure) as well as changes at 1-month in LVEDV and right ventricular EDV (RVEDV) as surrogates for ventricular interdependence. Results Between 02/2021 to 12/2022 20 patients (median age 78, IQR 72 to 83 years, 65% ♀) were included in the prospective HERACLES-HFpEF trial. All patients successfully underwent TV-TEER with a median TR grade reduction of 2 (IQR 2 to 1) on a five-grade scaling. Despite a periprocedural increase in LVEDV (p&amp;lt;0.001), LVEDP remained stable after successful TV-TEER (p=0.12). This led to a significant reduction of the primary endpoint LVEDP/LVEDV (p=0.001, Figure 1B). Load independent diastolic function improved with a rightward shift of the EDPVR (Figure 1C). LV distending pressure increased implying stronger LV distension in the restricted pericardial space. At one-month follow-up MRI (available for 17 patients) LVEDV increased (∆ median +5 ml, p=0.017), while RVEDV decreased (∆ median -17 ml, p=0.031). Interestingly, there was a significant inverse correlation between the change of LVEDV and RVEDV, again implying more favourable LV to RV interaction (Figure 1C). Conclusion TV-TEER in HFpEF patients leads to an immediate periprocedural increase in LV volume at maintained filling pressures. The improved diastolic function is possibly attributable to a more favourable LV to RV interaction where RV volumes are reduced to allow for the LV to better distend in the limited pericardial space. TV-TEER might pose a potential therapy for a subgroup of HFpEF patients with severe TR, meriting validation in prospective endpoint driven clinical trials.Figure 1

Left atrioventricular coupling index as a prognostic marker of cardiovascular events in heart failure with preserved ejection fraction

Abstract Background Left atrial (LA) structural remodeling is common and considered a marker of increased mortality in patients with heart failure with preserved ejection fraction (HFpEF). However, the left atrium is directly connected to the left ventricle during diastole and their functions are tightly coupled. A single left atrioventricular coupling index (LACI), defined by the ratio between the LA end-diastolic volume (LAV) and the LV end-diastolic volume (LVEDV) assessed by echocardiography, could be useful in the clinical routine to improve the risk stratification of HFpEF. Methods An analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 1231 patients hospitalized for acute heart failure (diagnosed by using the Framingham criteria) met the inclusion criteria: left ventricular ejection fraction (LVEF) ≥50% and brain natriuretic peptide ≥100 pg/ml. After excluding patients without persistent atrial fibrillation, we enrolled 863 patients (age, 81 ± 9 years; females, 56.1%; atrial fibrillation, 37.2%) whose LAV and LVEDV using the Simpson’s method were available at discharge. Heart failure hospitalizations and cardiovascular deaths were the primary endpoint. Results There was little correlation between the LAVI (median 50.2, interquartile range [IQR] 37.1–65.4 ml) and LVEDV (median 80.0, IQR 58.3–102.8 ml) (r = 0.16, p &amp;lt;0.001). As a result, the overall LACI was 0.94 (IQR 0.65–1.34). During a median follow-up of 729 (IQR 407–1180) days after discharge, 304 patients experienced the primary endpoint. The incidence incrementally increased with the LACI quartile groups (Q1: 26.9%, Q2: 37.5%, Q3: 34.0%, Q4: 42.6%, log-rank p = 0.005). After adjusting for age, gender, body mass index, left ventricular filling pressure, and serum brain natriuretic peptide levels, the LACI (hazard ratio, 1.19 per quartile increase; 95% confidence interval, 1.03-1.38; p = 0.021) was a significant predictor of the primary endpoint. Conclusions In the PURSUIT-HFpEF Registry, the degree of LA and LV structural remodeling differed between individuals. The LACI was a novel index for predicting cardiovascular outcomes in patients with HFpEF.

Exercise-induced cardiac remodelling in elite athletes is characterized by a stronger ventricular mass-volume association in females as compared with males: MRI results from the ELITE cohort

Abstract Background Differentiation between exercise-induced cardiac remodelling (EICR) and cardiac pathology constitutes a central challenge in sports cardiology. To assist clinicians, theoretical frameworks have been developed: i.e. dynamic sports are associated with ventricular dilatation, static sports with hypertrophy, and sports containing both components with both dilatation and hypertrophy. However, EICR frameworks have been almost exclusively based on findings in male athletes, and whether these associations are found in female athletes is to date unclear. Purpose We aimed to investigate intersex differences in left ventricular (LV) remodelling in the extreme phenotypes of elite athletes. Methods We included 227 healthy, elite athletes from the ELITE cohort who underwent cardiac magnetic resonance imaging (CMR). Our outcomes of interest were absolute and body surface area (BSA) indexed LV end-diastolic volume, LV end-diastolic wall mass, LV end-diastolic mass-volume ratio to express cardiac remodelling (LV end-diastolic wall mass / LV end-diastolic volume) and correlations of BSA-indexed LV mass with LV end-diastolic volume to compare LV remodelling between sexes. Results A total of 122 male and 105 female elite athletes (age 26±6 years) were included. The age and division in sports categories according to the ESC classification were similar between the sexes. Male athletes showed larger indexed LV end-diastolic volumes (127±19 versus 108±14 ml, p &amp;lt;0.001) and indexed LV wall mass (66±12 versus 50±11 grams, p &amp;lt;0.001) compared to female athletes. Male athletes had a proportionally larger LV mass-volume ratio than women (0.53±0.12 versus 0.46±0.09 g/ml, p &amp;lt;0.001). Female elite athletes showed a moderate association between indexed LV mass increase with indexed LV end-diastolic volume increase (Spearman’s rho 0.45, p &amp;lt;0.001), whereas male athletes showed a weak association (Spearman’s rho 0.25, p =0.006). Conclusions Elite male athletes have larger left ventricular volumes and wall mass, with a greater mass-volume ratio, than their female counterparts. However, female athletes demonstrate a stronger mass-volume association than males. Our findings suggest the presence of distinct sex-dependent features of EICR.

The effect of bariatric surgery type on cardiac reverse remodelling

Abstract Introduction Bariatric surgery has been shown to improve adverse cardiac remodelling associated with obesity. Three operations are commonly performed: Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Adjustable Gastric Band (LAGB). Whilst all three of these procedures result in weight loss, it is currently unclear as to which procedure is most effective at reversing cardiac remodelling. Purpose We assessed differences in cardiac remodelling following each type of surgery using cardiac magnetic resonance (CMR) imaging. Methods 58 patients underwent bariatric surgery (26 RYGB, 22 LSG and 10 LAGB) with CMR before and after surgery, including 46 with short-term (median 251, 219 and 273 days) and 43 with long-term (median 1026, 983 and 1027 days) follow-up. CMR was used to assess cardiac volumes, LV mass (LVM) and LV mass:volume ratio (LVMVR – a marker of concentric remodelling). Adipose tissue depots were also assessed during the scan, including visceral adipose tissue (VAT) at L5 level and epicardial adipose tissue (EAT) (manual contouring in end-ventricular systole on short axis slices from the mitral valve to the apex). Results Changes in percentage body weight were similar between surgery groups in the short term, but appeared to diverge in the longer term (LSG vs LAGB, p=0.039; RYGB vs LAGB, p=0.341) (Figure 1A). Percentage change in VAT and EAT however where significantly greater following RYGB and LSG compared to LAGB at both short- and long-term time points (Figure 1B). Changes in left ventricular end diastolic volume (LVEDV) were similar between groups in both the short term and long term (Figure 2A). We observed a significant difference in LVM change following RYGB or LSG versus LAGB (Figure 2B). This change in LVM at the long-term time point correlated with change in VAT normalised to body weight (r=0.3399, p=0.0368, Figure 2C). Finally, there was a significant decrease in LVMVR at the long-term time point following both RYGB (p=0.006) and LSG (p=0.021), whereas no such change was observed following LAGB (p=0.912). Conclusions Our results suggest that RYGB and LSG are significantly better at decreasing body adipose depots than LAGB. This greater reduction in visceral adipose tissue may account for the greater cardiac reverse remodelling seen with RYGB and LSG compared to LAGB.Figure 1Figure 2

Myocardial T1 dispersion in fabry disease: comprehensive evaluation of a novel measurement of cardiovascular disease severity

Abstract Background The cardiovascular manifestations of Fabry disease are common and represent the leading cause of death. Myocardial T1 dispersion has recently emerged as a robust predictor of adverse cardiac outcome in Fabry disease but the relationship between T1 dispersion and other cardiovascular manifestations has not been studied. Objective To evaluate the relationship between myocardial T1 dispersion and other cardiovascular manifestations of Fabry disease, and identify its determinants. Methods Prospective longitudinal cohort study including 181 participants with Fabry disease and 30 controls undergoing clinical cardiovascular magnetic resonance. T1 dispersion was assessed in relation to other structural and functional cardiovascular biomarkers and examined in Pre-hypertrophic, Hypertrophic and Fibrotic phenotypic sub-groups. Determinates of T1 dispersion were investigated using multivariable linear regression. Results T1 dispersion was similar in the Control, Pre-hypertrophic and Hypertrophic sub-groups, but was significantly elevated in the Fibrotic sub-group. Independent determinates of T1 dispersion were age, body surface area-indexed left ventricular mass, indexed left ventricular end diastolic volume, global longitudinal strain, native myocardial T1, non-ischaemic late gadolinium enhancement, and extracellular volume fraction (R2 0.414). T1 dispersion was consistently higher in females than males. Conclusions Myocardial T1 dispersion appears sensitive to both the T1 shortening effect of globotriaosylceramide accumulation and T1 lengthening effect of fibrosis, and accordingly increases as Fabry disease progresses. In conjunction with recent data showing it to be a robust predictor of adverse cardiac outcome, myocardial T1 dispersion is advocated as a key cardiovascular biomarker in Fabry disease.Figure 1Figure 2

Association of ventricular-arterial interaction with left ventricular remodelling after acute myocardial infarction: a 2-year follow-up study

Abstract Background/Introduction Adverse left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) is associated with heart failure. Purpose We aimed to investigated the association of ventricular-arterial interaction with LV remodelling in patients with STEMI. Methods In 109 patients within 48 hours of myocardial infarction post-primary percutaneous coronary intervention and after 2 years, we measured: (1) pulse wave velocity (PWV-Complior), (2) LV global longitudinal strain (GLS) and left atrial strain, (3) PWV/GLS ratio as a marker of ventricular-arterial interaction, and (4) LV end-diastolic and end-systolic volumes. A &amp;gt;15% decrease in LV end-systolic volume at 2-years follow-up was considered as a criterion of reverse LV remodelling. Results Compared with baseline, all patients had reduced PWV, PWV/GLS, LV end-diastolic and end-systolic volumes, while GLS and reservoir left atrial strain were increased (p&amp;lt;0.05) after 2 years. Both baseline and percentage change of PWV/GLS ratio were associated with LV end-systolic volume percentage change at 2 years (r=0.43, p=0.012 and r=0.35, p=0.038, respectively). Patients with LV end-systolic volume reduction &amp;gt;15% had lower baseline PWV and PWV/GLS and higher GLS and left atrial strain than patients with LV end-systolic volume reduction &amp;lt;15% (p&amp;lt;0.05). Multivariable analysis revealed that PWV and PWV/GLS were independently associated with LV remodelling. A baseline value of PWV of 8.1m/s and PWV/GLS of -0.52m/s% had a sensitivity of 84% and 82% and a specificity of 80% and 77% respectively for prediction of LV remodelling (area under the curve: 0.751, p=0.001 and 0.779, p&amp;lt;0.001). Conclusion Ventricular-arterial interaction is an independent predictor of LV remodelling after 2 years of the ischemic event.

Impact of early stages of CKD with and without proteinuria on cardiac remodelling in UK Biobank cohort

Abstract Background Chronic kidney disease (CKD) is an established predictor of left atrial (LA) and left ventricular (LV) morphological and functional changes, which translate into excessive cardiovascular morbidity and mortality. However, a focussed study exploring the impact of early stages of CKD defined as stage 1 (eGFR &amp;gt; 90 mL/min per 1.73 m2 + albuminuria) and stage 2 (eGFR 60–89 mL/min per 1.73 m2) with and without proteinuria on cardiac magnetic resonance (CMR) parameters is lacking. Purpose In this study, we analysed CMR structural and functional changes in participants with early stages of CKD in the UK Biobank population. Methods 41,095 participants from the UK Biobank imaging study were categorised into CKD stages. We calculated eGFR using the CKD-EPI 2021 equation and proteinuria was ascertained by the urinary protein creatinine ratio (defined as &amp;gt;30mg/mmol). We sought associations between CKD stages (exposure) and CMR parameters: LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV stroke volume (LVSV), LV ejection fraction (LVEF), LV global functional index (LVGFI), LV myocardial contractile function (LVMCF), LV mass (LVM), LV mass-to-volume ratio (LVMVR), LV global longitudinal strain (GLS), LV global radial strain (GRS), LV global circumferential strain (GCS), LA maximum volume and left atrial emptying fraction. In the multivariable regression model, we adjusted for covariates including age, sex, ethnicity, height, body mass index, hypertension, diabetes, smoking status, and hyperlipidaemia Results Among the participants, 26,779 (65.1%) had normal kidney function, 2,787 (6.8%) stage 1 CKD, 10,534 (25.6%) stage 2 CKD without proteinuria, 689 (1.7%) stage 2 CKD with proteinuria, 241 (0.6%) CKD stage 3A (eGFR 59-45mL/min per 1.73 m2) without proteinuria, 28 (0.1%) stage 3A with proteinuria and 37 (0.1%) with more advanced CKD defined as stages 3B and above. Approximately 8 years after characterisation of CKD stages these participants underwent CMR. Using adjusted multivariable regression models setting normal kidney function as the reference group, the presence of proteinuria in stage 3 CKD was associated with smaller LV volume, lower LVM and more impaired LV function (LVSV beta=-11ml, 95% confidence interval (CI): -5 to -16ml and GLS beta=0.9%, 95% CI: 0.2 to 1.7%). Conclusions This study highlights the relationship between proteinuria in the early stages of CKD and cardiac remodelling patterns using CMR. CKD sub-characterisation with presence or absence of proteinuria should be considered for risk stratification.Figure 1

Prognostic implications of right ventricular systolic and diastolic strain in heart failure

Abstract Background 2D- speckle-tracking echocardiography (2D-STE) has recently be used to assess subclinical myocardial dysfunction, however its utility in heart failure with reduced ejection fraction (HFrEF) has been specifically focusing on the longitudinal systolic function of the left ventricle (LV). Aim To assess the prognostic relation between right ventricular (RV) systolic and diastolic strain parameters with clinical outcome in patients with advanced heart failure (HFrEF). Methods and results Of the initial 2217 HFrEF patients screened for this study only 562 consecutive patients with HFrEF were eligible and retrospectively enrolled, and 2D-STE strain parameters assessed on the 2D-TTE images. All patients were prospectively followed for development of new outcome/cardiac events which included hospitalization for acute HF, CVS-related death, heart transplantation, or need for ventricular assist device implantation. Conventional TTE was performed in all subjects and reviewed. RV longitudinal strain parameters (RVLS, RVLD) by 2D-STE were assessed and averaged in all segments (apical 4CV, global RVLS and RVLD) and also averaged free-wall. Of the 562 patients at baseline, 263 had 117 new events during a mean follow-up of 1.4 ± 0.7 years. RV free wall and global RV systolic and diastolic strain parameters, elevated NT Pro-BNP, RV fractional area change, low TAPSE, LV end-diastolic volume and the presence of at least moderate TR, and PASP &amp;gt; 40mmHg were independently predictive of combined outcomes ( p &amp;lt;.001). Overall, the best performance parameters predictive of cardiovascular events were for RV Free Wall systolic and diastolic strain (AUC: 0.84 and 74), global RV systolic and diastolic strain (AUC: 0.77 and 70) and RV fractional area change (AUC: 0.67). The strongest association between the degree of RV dysfunction and the risk of cardiovascular events was only evident for RV strain (free wall &amp;gt; global strain). Conclusion Patients with HFrEF, RV strain parameters are stronger predictors of outcome than other conventional parameters and should be included for regular clinical screening as these parameters provide a stronger prognostic stratification.

Maternal myocardial recovery twelve months post-partum in women with pregnancies complicated by gestational diabetes or preeclampsia - single center, longitudinal cohort study

Abstract Background Gestational diabetes mellitus (GDM) and preeclampsia (PE) are the leading obstetric complications of pregnancy. Both are associated with a substantial increase in the risk of long-term cardiovascular disease. However, pregnant women are underrepresented in clinical research and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Objectives This longitudinal cohort study was designed to assess maternal cardiac alterations during the third trimester of pregnancy and their recovery twelve-months post-partum in women with GDM (n=30) or preeclampsia (n=24) compared to women with healthy pregnancies (HP)(n=38). Methods 31P-MRS and CMR were used to define PCr/ATP, tissue characteristics, left ventricular (LV) volumes, mass, EF, global longitudinal shortening (GLS), and mitral in-flow E/A ratio. Investigations were repeated 12-months postpartum. With obesity as a common risk factor for both GDM and PE, 10 overweight and 10 normal-weight nulliparous women served as non-pregnant controls. Results Participants were matched for age and ethnicity(Table-1). Both the GDM and PE groups had higher BMI compared to the HP. Compared to the HP group, women with GDM had higher LV mass (90[85,94] vs 103[96,112]g; p=0.001) and lower myocardial PCr/ATP (2.2[2.1,2.4] vs 1.9[1.7,2]; p&amp;lt;0.0001), LV end-diastolic volumes (EDV)(76[72,80] vs 67[63,71]ml, p=0.03) and GLS (20[18,21] vs 18[17,19]%; p=0.008). Compared to the HP group, at similar magnitudes to women with GDM, the women with PE exhibited higher LV mass (90[85,94] vs 118[111,125]g; p&amp;lt;0.0001) and lower myocardial PCr/ATP (2.2[2.1,2.4] vs 1.9[1.8,2.1]; p=0.0004) and GLS (20[18,21] vs 16[14,17]%; p=0.01). There were no significant differences in PCr/ATP, LV EDV, mass or GLS between the GDM and PE groups. Twelve-months postpartum there were no significant changes in any of the cardiac assessments in women in the HP, GDM or PE groups compared to their respective third-trimester pregnancy assessments (Figure-1). Compared to nulliparous normal-weight controls, HP was associated with no significant differences in myocardial PCR/ATP, LV volumes, mass, EF or GLS. The overweight nulliparous controls showed significantly higher LV mass and lower myocardial PCr/ATP and GLS than normal-weight controls. There were no significant differences in LV mass, PCr/ATP or GLS between the overweight nulliparous controls and GDM or PE groups during or after pregnancy. Conclusions Despite distinct aetiologies women with GDM and PE exhibit a similar myocardial phenotype during and after pregnancy with persistent subtle abnormalities in myocardial PCr/ATP ratio, LV mass and GLS compared to women with HP during pregnancy and twelve months’ postpartum assessments. Women with GDM and PE show similar myocardial alterations to nulliparous women with obesity, suggesting that the myocardial changes are predominantly driven by obesity-associated metabolic dysfunction.

Aortic diastolic flow displacement from phase-contrast CMR is associated with exercise capacity in healthy adults

Abstract Background Blood flow eccentricity, as determined by phase contrast (PC) CMR-assessed peak systolic flow displacement, has been linked to future aortic enlargement in patients with bicuspid aortic valve and thoracic aortic aneurysm. Its presence, extent and functional consequence in healthy adults are unknown. Purpose We quantified aortic flow eccentricity and studied its association with exercise capacity in a cohort of healthy Asian subjects using 2-dimensional (2D) PC-CMR and cardiopulmonary exercise testing (CPET), respectively. Method 169 community healthy volunteers (age 44±13 years, M:F 96:73) without cardiovascular diseases (the control group in a prospective observational study NCT03217240) underwent CMR, including 2D PC at an orthogonal plane just above the sinotubular junction, and CPET within one week. From 2D PC-CMR, we obtained the average flow displacements (FD) during systole (avFDSys), late systole (avFDLateSys) and diastole (avFDDias), as well as flow reversal ratios (FRR) during systole (FRRSys) and the whole cardiac cycle (FFRRR) (see Figure). Exercise capacity was determined by peak VO2 (PVO2) from CPET. Univariate analysis and multivariable regression using a model that included FD and FRR parameters as well as standard cine CMR-assessed left ventricular (LV) volumes and ejection fraction were performed to investigate the determinants of PVO2. Results Mean values of average flow displacements (avFDSys, avFDLateSys, avFDDias), and flow reverse ratios (FRRSys and FRRRR) were 17±6%, 19±8%, 29±7%, 5.9±5.1%, and 13.7±8.0%, respectively, which were positively correlated with age (R values of 0.623, 0.628, 0.353, 0.649, 0.708, respectively; all P &amp;lt;0.0001) and negatively correlated with PVO2 (R values of -0.302, -0.270, -0.253, -0.219, -0.205, respectively, all P &amp;lt;0.01). Women had higher avFDSys (18±7 vs. 15±6%, P=0.003) and avFDLateSys (21±9 vs. 18±8%, P=0.007), and lower PVO2 (median 21 vs. 26ml/kg/min, P &amp;lt;0.001) compared with men. On multivariable analysis, avFDDias (=-0.234, P=0.002) and LV end-diastolic volume (=0.116, P &amp;lt;0.001) were significantly associated with PVO2 after adjustment for age. For every 10-year increase in age, avFDDias increased by 1.4% in men and 2.6% in women; and for every 1% increase in avFDDias, PVO2 decreased by 0.2 ml/kg/min in men and 0.3 ml/kg/min in women. Conclusion Compared with men, women had more eccentric and less efficient aortic flow, and exhibited a higher ageing-related increase in avFDDias. The latter was independently associated with reduced PVO2, which lends support to its functional significance and potential application as a marker of cardiovascular health.Figure 1

Effect of empagliflozin on CMR-estimated pulmonary capillary wedge pressure in patients with type 2 diabetes, or prediabetes, and heart failure with reduced ejection fraction (SUGAR-DM-HF)

Abstract Background/Introduction Pulmonary capillary wedge pressure (PCWP) is a measure of left ventricular (LV) filling pressure usually invasively assessed during right heart catheterisation. A cardiac magnetic resonance (CMR) imaging-based model to non-invasively estimate PCWP was recently developed. Purpose In this exploratory analysis of the SUGAR-DM-HF trial (NCT03485092) we assessed the association of CMR-estimated PCWP (CMR-PCWP) with other imaging and circulating biomarker measures of congestion in patients with heart failure and reduced ejection fraction (HFrEF) and type 2 diabetes or prediabetes. We also investigated the effect of empagliflozin on CMR-PCWP and the relationship between CMR-PWCP and the remodelling effect of empagliflozin. Methods A total of 105 patients with HFrEF were randomly assigned 1:1 to empagliflozin 10 mg once daily or placebo. CMR-PCWP and other ultrasound and circulating biomarker measures of congestion were estimated at baseline and 36 weeks. CMR-PCWP (mmHg) was calculated using the formula: 6.1352 + (0.07204*left atrial volume) + (0.02256*LV mass). Results 105 patients with HFrEF, mean age 69 years, 73% males, mean left ventricular ejection (LVEF) 33% were randomised. Mean baseline CMR-PCWP was 15.0 mmHg. CMR-PCWP was ≥15 mmHg in 52 (50% patients) at baseline. At baseline, patients with higher PCWP (≥15 mmHg) were more frequently male, had higher body mass index, higher N-terminal pro-B-type natriuretic peptide (NT-proBNP), and a greater number of B-lines on lung ultrasound (LUS). Peripheral oedema was present in 69% and 57% of patients with higher PCWP and lower PCWP, respectively (p = 0.18). Pulmonary crepitations were present in 13% and 11% of patients with higher and lower PCWP, respectively (p = 0.74). At baseline, CMR-derived PCWP correlated with log-NT-proBNP (r = 0.31, p&amp;lt;0.001), left atrial (LA) volume (r = 0.94, p&amp;lt;0.001), E/e’ (r = 0.36, p = 0.02), MRI-derived LV volumes (LV end-systolic volume: r = 0.56 p&amp;lt;0.001; LV end-diastolic volume: r = 0.62 p&amp;lt;0.001), LVEF (r=-0.26 p = 0.01), and right ventricular (RV) volumes (RV end-systolic volume: r = 0.56 p&amp;lt;0.001; RV end-diastolic volume: r = 0.61 p&amp;lt;0.001). Mean CMR-PCWP decreased from baseline to 36 weeks by -0.37 (95% CI -0.78 to 0.05) mmHg and -0.17 (95% CI -0.69 to 0.36) mmHg in the empagliflozin and placebo groups, respectively; placebo-corrected difference -0.43 mmHg (95% CI -1.09 to 0.23), p = 0.20 (Figure 1). The beneficial effect of empagliflozin on reducing LV end-systolic volume index was not modified by baseline CMR-PCWP (p interaction = 0.98). Conclusions In patients with HFrEF, higher non-invasively measured CMR-derived PCWP was associated with NT-proBNP, MRI-derived LV and RV volumes and LUS markers of congestion. There were no between group difference in CMR-derived PCWP, although this study was not powered for this outcome.Figure 1

Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease

Abstract Background Chronic kidney disease (CKD) is associated with a higher incidence of cardiovascular death, particularly as the disease progresses and patients are on long term dialysis treatment. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging and controversial. Objective The aim of this study was to investigate the incremental value of resting deformation analysis with speckle tracking echocardiography in predicting positive results on stress transthoracic echocardiography in patients with end-stage renal disease on dialysis (stage 5 CKD). Methods Our cohort consisted of 61 consecutive patients (mean age 62.3±11.8, 65.7% men) with stage 5 CKD. Patients with a confirmed diagnosis of pre-existing cardiac diseases, such as obstructive coronary artery disease, heart failure, severe arrhythmias or severe valvular disease were excluded. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSCE) protocol. Positive results of DSCE were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities). Results The study cohort had normal or mildly impaired systolic function with mean LV ejection fraction (EF) of 49.17% (±10.41) and a mean LV GLS of 14.35% (±4.49) (Figure 1). In addition, half of our population had impaired LA strain: mean LA reservoir, LA conduit, and LA contractile reserve were 24.11% (±12.61), 10.56% (±5.88), and 13.60% (±9.15), respectively. DSCE was positive for ischemia in 55.7%. Age, gender, and history of diabetes were significantly correlated with positive result in DSCE (p=0.027, p=0.022 and p=0.039, respectively). Additionally, a significant negative association with DSCE results was found for the echocardiographic parameters LV EF, LV GLS, the conduit phase of LA strain, LV end diastolic volume as well as LA dimensions (p=0.002, p=0.002, p=0.004, p= 0.002 and p=0.048, respectively). Logistic regression analysis showed that LV global longitudinal strain was independently associated with DSCE outcome (p=0.007), after controlling for covariates. The area under the curve (AUC) to predict positive results for LV GLS was 0.92 with with a sensitivity of 96%, a specificity of 56% and an overall diagnostic accuracy of 84% (Fig 2). Conclusion The present findings demonstrate that resting LV deformation is associated with the presence of coronary ischemia and may be useful to better identify patients with advanced CKD who might benefit from coronary artery screening.LV GLSAUC