Left Ventricular Fractional Area Change Research Articles

Echocardiographic findings in non-hospitalised children and adolescents following acute COVID-19.

Although COVID-19 is known to have cardiac effects in children, seen primarily in severe disease, more information is needed about the cardiac effects following COVID-19 in non-hospitalised children and adolescents during recovery. This study aims to compare echocardiographic markers of cardiac size and function of children following acute COVID-19 with those of healthy controls. This single-centre retrospective case-control study compared 71 cases seen in cardiology clinic following acute COVID-19 with 33 healthy controls. Apical left ventricle, apical right ventricle, and parasternal short axis at the level of the papillary muscles were analysed to measure ventricular size and systolic function. Strain was analysed on vendor-independent software. Statistical analysis was performed using t-test, chi-square, Wilcoxon rank sum, and regression modelling as appropriate (p < 0.05 significant). Compared to controls, COVID-19 cases had slightly higher left ventricular volumes and lower left ventricular ejection fraction and right ventricular fractional area change that remained within normal range. There were no differences in right or left ventricular longitudinal strain between the two groups. Neither initial severity nor persistence of symptoms after diagnosis predicted these differences. Echocardiographic findings in children and adolescents 6 weeks to 3 months following acute COVID-19 not requiring hospitalisation were overall reassuring. Compared to healthy controls, the COVID-19 group demonstrated mildly larger left ventricular size and lower conventional measures of biventricular systolic function that remained within the normal range, with no differences in biventricular longitudinal strain. Future studies focusing on longitudinal echocardiographic assessment of patients following acute COVID-19 are needed to better understand these subtle differences in ventricular size and function.

Prognostic significance of subpulmonary left ventricular size and function in patients with a systemic right ventricle.

To assess the additional prognostic significance of echocardiographic parameters of subpulmonary left ventricular (LV) size and function in patients with a systemic right ventricle (SRV). All adults with an SRV who underwent transthoracic echocardiography in 2010-18 at a large tertiary centre were identified. Biventricular size and function were assessed at the most recent examination. The study endpoint was all-cause mortality or heart/heart-lung transplantation. We included 180 patients, with 100 (55.6%) males, with a mean age of 42.4 ± 12.3 years, of whom 103 (57.2%) had undergone Mustard/Senning operations and 77 (42.8%) had congenitally corrected transposition of great arteries. Over 4.9 (3.8-5.7) years, 28 (15.6%) patients died and 4 (2.2%) underwent heart or heart-lung transplantation. Univariable predictors of the study endpoint included age, New York Heart Association functional Class III or IV, history of atrial arrhythmias, presence of a pacemaker or cardioverter defibrillator, high B-type natriuretic peptide, and echocardiographic markers of SRV and subpulmonary LV size and function. On multivariable Cox analysis of echocardiographic variables, indexed LV end-systolic diameter [ESDi; hazard ratio (HR) 2.77 (95% confidence interval, CI) 1.35-5.68, P = 0.01], LV fractional area change [FAC; HR 0.7 (95% CI 0.57-0.85), P = 0.002), SRV basal diameter [HR 1.66 (95% CI 1.21-2.29), P = 0.005], and SRV FAC [HR 0.65 (95% CI 0.49-0.87), P = 0.008] remained predictive of mortality or transplantation. On receiver-operating characteristic analysis, subpulmonary LV parameters performed better than SRV markers in predicting adverse events. SRV basal diameter, SRV FAC, LV ESDi, and LV FAC are significantly and independently associated with mortality and transplantation in adults with an SRV. Accurate echocardiographic assessment of both SRV and subpulmonary LV is, therefore, essential to inform risk stratification and management.

Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism)

In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p=0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p=0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p=0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p=0.32).In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.

Impairment of Right Ventricular Function in Patients with Systemic Sclerosis and Interstitial Lung Disease: Tissue Doppler Evaluation

Introduction: Systemic sclerosis (SSc) is an autoimmune tissue connective disease that courses with fibrosis and microvascular dysfunction. Involvement of the visceral organs, including the lungs and heart, is the main cause of death among patients with SSc. In this context, here we analyzed the relationship between right ventricle (RV) parameters assessed by tissue Doppler echocardiography and lung involvement in patients with SSc. Methods: Patients fulfilling the 2013 SSc Classification Criteria underwent tissue Doppler echocardiography for the assessment of left ventricular (LV) systolic function (ejection fraction) and RV fractional area change (FAC), tissue Doppler s’ (systolic) velocity, myocardial performance index, and tricuspid annular plane systolic excursion for the assessment of RV systolic function. Pulmonary systolic pressure was estimated using tricuspid regurgitation. Chest high-resolution computed tomography was used to evaluate the presence of pulmonary fibrosis. The patients were divided into two subgroups accordingly: Group I, patients with pulmonary fibrosis (n=26); and Group II, those without fibrosis (n=17). Results: Among the 43 patients with SSc, most were female (86%), and the mean age was 51 ± 12 years. All patients had normal systolic ventricular function as evidenced by an LV ejection fraction &gt; 55% and an RV FAC &gt; 35%. No significant intergroup difference was noted in age or disease duration. Except for a decreased tissue Doppler s’ velocity in patients with lung fibrosis, all indexes of RV performance were similar. Conclusion: In patients with SSc and pulmonary fibrosis, tissue Doppler identified early RV longitudinal myocardial involvement despite preserved RV radial systolic performance.

Cardiac function unchanged following reanimation with normothermic regional perfusion in donation after circulatory death.

ObjectivesTo determine whether hearts reanimated with normothermic regional perfusion (NRP) have clinically detectable changes in function using echocardiography comparing the prearrest and post-NRP imaging. As heart transplantation from donation after circulatory death (DCD) continues to increase, preliminary results suggest outcomes comparable with donation after brain death. It is unknown whether the obligatory period of warm ischemia experienced during DCD withdrawal process causes immediate changes in cardiac allograft function following in situ reanimation.MethodsWe retrospectively reviewed and compared predonation with postreanimation echocardiographic findings in all DCD donors at our institution from January to October 2021. All DCD donor organs were reanimated with in situ thoracoabdominal NRP after circulatory death. Echocardiographic assessment included (1) 2-dimensional and speckle-tracking measures of chamber size and function; (2) ejection fraction; (3) fractional area change; and (4) global longitudinal strain.ResultsAltogether, 4 DCD heart donations were performed during the study period. Basic demographics and withdrawal ischemic time periods are reported. There were no changes in left ventricular ejection fraction and right ventricular fractional area change when comparing the predonation and the postreanimation echocardiogram. There was a minimal, nonstatistically significant decrease in left ventricular global longitudinal strain and right ventricular free-wall systolic strain in 3 of the 4 donors following reanimation.ConclusionsDCD cardiac allografts reanimated with NRP demonstrated no change in echocardiographic parameters used for a standard predonation donor heart evaluation. Findings suggest cardiac function of DCD allografts reanimated with thoracoabdominal NRP is not adversely impacted by limited period of warm ischemia following circulatory arrest.

Incremental Value of Myocardial Deformation in Predicting Postnatal Coarctation of the Aorta: Establishment of a Novel Diagnostic Model

Prenatal detection of coarctation of the aorta (CoA) still suffers from high false-positive and false-negative rates. The objective of this study was to develop a novel model to improve the diagnostic accuracy of fetal CoA. A retrospective study was conducted in 122 fetuses with suspected CoA who also had postnatal follow-up. Fetuses with confirmed diagnoses of CoA after birth were defined as the CoA group, and the non-CoA group comprised those with false positives. Conventional fetal echocardiographic measurements, including great arterial dimensions and flow characteristics, were obtained. Left ventricular (LV) functional parameters were determined using two-dimensional speckle-tracking echocardiography. A novel multiparametric diagnostic model, including gestational age at diagnosis, aortic isthmus (AOI) Z score, and LV longitudinal strain (LVLS), was developed in univariate and multivariate logistic regression analyses. The model was validated prospectively by a validation cohort of 48 fetuses. CoA was confirmed in 62 of 122 patients (50.8%) after birth. Fetuses with postnatal CoA were diagnosed significantly earlier than those with false-positives (median, 24.5weeks [interquartile range, 23.3-26.4weeks] vs 27.8weeks [interquartile range, 24.5-30.4weeks]; P<.001). The Z scores of aortic dimensions (aortic valve annulus, ascending aorta, transverse aortic arch, and AOI) were significantly smaller (P<.001 for all), whereas the Z scores of pulmonary dimensions (pulmonary valve annulus and main pulmonary artery) were significantly greater (P<.05 for all), in cases of confirmed CoA than false positives. Compared with the non-CoA group, the CoA group displayed lower LV ejection fraction (P=.005), LV fractional area change (P<.001), and LVLS (P<.001). A multivariate logistic regression model incorporating gestational age (odds ratio, 0.74; 95% CI, 0.60-0.88; P=.001), AOI Z score (odds ratio, 0.20; 95% CI, 0.08-0.41; P<.001), and LVLS (odds ratio, 1.79; 95% CI, 1.41-2.42; P<.001) was shown to diagnose CoA more accurately (Akaike information criterion=81.77, C statistic=0.945). The performance of this model was confirmed prospectively in the validation cohort. In fetuses with suspected CoA, speckle-tracking analysis of LVLS may have incremental value in predicting postnatal CoA. The diagnostic model presented here, including gestational age, AOI Z score and LVLS, may provide a good tool for stratification of risk in fetal CoA and contribute to patient-specific perinatal management.

Cardiac remodeling in patients with centrifugal left ventricular assist devices assessed by serial echocardiography.

The aim of the study was to characterize the remodeling process in a large cohort of patients supported with a centrifugal left ventricular assist device (cfLVAD) by standardized serial echocardiography. From 3/2018 all cfLVAD patients underwent transthoracic echocardiography at 6 and 12 months after implantation using a standardized protocol. A total of 512echocardiograms were reviewed (216preoperative, 156at 6 months, 140at 12 months). While on cfLVAD support, left ventricular (LV) diameter decreased (p<.001). LV ejection fraction (LVEF) and LV fractional area change improved (p<.001). Potential for cfLVAD explantation (as defined by an LVEF ≥45% and opening of the aortic valve [AV]) was seen in nine patients at 6 and 21patients at 12months. The tricuspid annular excursion decreased significantly, while the right ventricular fractional area change did not change. Tricuspid regurgitation (TR) and mitral regurgitation (MR) improved significantly during LVAD support. Opening of the AV was seen in >64% of the patients at 6 months and in 66% at 12 months. Moderate aortic regurgitation (AR) was rare with 3.8% at 6 months but increased with the duration of cfLVAD support (8.5% at 12 months). We found no significant difference in echocardiographic parameters between patients supported with a HeartWareHVAD™ or a HeartMate3™ device. LVAD therapy can lead to reverse LV remodeling and improvement of MR and TR. However, right ventricular function does not improve and prevalence of AR progressively increases during mechanical support.

The Association of Pulmonary Flow Characteristics With Cardiac Function in Tricuspid Valve Malformation Fetuses: Study With Two-Dimensional Speckle Tracking Echocardiography.

To explore the relationship between cardiac function and pulmonary flow characteristics in tricuspid valve malformation (TVM) fetuses by conventional and speckle tracking echocardiography. Eighty-eight TVM fetuses were retrospectively included and compared with 80 normal controls. TVM fetuses in each trimester were divided into two subgroups according to pulmonary flow characteristics: those with normal pulmonary flow (TVM-N) and those with reduced or absent pulmonary flow (TVM-R/A). Cardiac measurements, Celermajer index, and Simpson-Andrews-Sharland (SAS) score were obtained. Speckle tracking echocardiography was used to compute ventricular deformation parameters. TVM fetuses demonstrated significantly lower global longitudinal strain (GLS) and strain rate for both ventricles than controls (all P < .05). When compared with TVM-N, left ventricular (LV) ejection fraction, LV fractional area change, right ventricular (RV) fractional area change, LVGLS, and RVGLS were significantly reduced (all P < .05), while the RV diameter Z-score, RV/LV diameter, SAS score, and Celermajer index were obviously increased in TVM-R/A in both trimesters (all P < .05). Both LVGLS and RVGLS correlated with cardiothoracic circumference ratio, RV diameter Z-score, RV/LV diameter, Celermajer index, and SAS score (all P < .01). There was a slow decline for LVGLS and RVGLS in TVM-N fetuses throughout the gestation. Conversely, these two parameters worsened rapidly in TVM-R/A group. TVM fetuses present biventricular dysfunction by deformation analysis in the second and third trimester of pregnancy. TVM fetuses with reduced or absent pulmonary flow exhibit significantly greater impairment and more rapid deterioration of cardiac function, which may contribute to poor outcomes.

Right ventricular contractility affects the clinical efficacy of add-on tolvaptan following hospitalization for heart failure in patients with significant tricuspid regurgitation.

Tricuspid regurgitation (TR) is a common condition that is independently associated with high mortality rates in patients with heart failure (HF). Several studies have demonstrated the clinical efficacy of add-on tolvaptan in patients hospitalized for HF. However, the effects of add-on tolvaptan in patients with significant TR are less well understood. Among the patients with moderate-to-severe TR assessed by transthoracic echocardiography during hospitalization for congestive HF, 39 patients who could complete the clinical course after starting add-on tolvaptan were included in the study. Rehospitalization due to HF and cardiac death were defined as adverse cardiac events in this study. We investigated the presence or absence of cardiac events within 2years following the introduction of tolvaptan and evaluated echocardiographic functional parameters associated with cardiac events. The average patient age was 75 ± 14years, and 23 patients (59%) experienced adverse cardiac events within 2years after add-on tolvaptan administration. Serum creatinine (mg/dL) and brain natriuretic peptide (pg/mL) concentrations at discharge were significantly higher in patients with cardiac events than in those without cardiac events {1.48 [1.02-1.58] vs. 1.07 [0.79-1.41], p = 0.03; 526 [414-1044] vs. 185 [104-476], p = 0.01, respectively}. The presence or absence of past hospitalization for HF was also significantly higher in the event-positive group compared to event-free group (78 vs. 44%, p = 0.04). Comparison of echocardiographic parameters revealed that patients with cardiac events had a significantly lower left ventricular ejection fraction (40 ± 16 vs. 49 ± 15%, p = 0.049) and lower right ventricular fractional area change (RVFAC) (35 ± 12 vs. 45 ± 10%, p = 0.008) than those without cardiac events. Multiple logistic regression analysis revealed that RVFAC and past hospitalization for HF were independently associated with cardiac events following the introduction of tolvaptan (odds ratio, 0.934 and 4.992; p = 0.048 and 0.04, respectively). Right ventricular contractility as well as past history of admission for HF, left ventricular ejection fraction, renal function, and brain natriuretic peptide level at discharge may reflect the clinical outcomes after HF hospitalization in patients with significant TR who were treated with tolvaptan.

An innovative ovine model of severe cardiopulmonary failure supported by veno-arterial extracorporeal membrane oxygenation

Refractory cardiogenic shock (CS) often requires veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to sustain end-organ perfusion. Current animal models result in heterogenous cardiac injury and frequent episodes of refractory ventricular fibrillation. Thus, we aimed to develop an innovative, clinically relevant, and titratable model of severe cardiopulmonary failure. Six sheep (60 ± 6 kg) were anaesthetized and mechanically ventilated. VA-ECMO was commenced and CS was induced through intramyocardial injections of ethanol. Then, hypoxemic/hypercapnic pulmonary failure was achieved, through substantial decrease in ventilatory support. Echocardiography was used to compute left ventricular fractional area change (LVFAC) and cardiac Troponin I (cTnI) was quantified. After 5 h, the animals were euthanised and the heart was retrieved for histological evaluations. Ethanol (58 ± 23 mL) successfully induced CS in all animals. cTnI levels increased near 5000-fold. CS was confirmed by a drop in systolic blood pressure to 67 ± 14 mmHg, while lactate increased to 4.7 ± 0.9 mmol/L and LVFAC decreased to 16 ± 7%. Myocardial samples corroborated extensive cellular necrosis and inflammatory infiltrates. In conclusion, we present an innovative ovine model of severe cardiopulmonary failure in animals on VA-ECMO. This model could be essential to further characterize CS and develop future treatments.

On the way to routine cardiac MRI at 7 Tesla - a pilot study on consecutive 84 examinations

IntroductionCardiac magnetic resonance (CMR) at ultrahigh field (UHF) offers the potential of high resolution and fast image acquisition. Both technical and physiological challenges associated with CMR at 7T require specific hardware and pulse sequences. This study aimed to assess the current status and existing, publicly available technology regarding the potential of a clinical application of 7T CMR.MethodsUsing a 7T MRI scanner and a commercially available radiofrequency coil, a total of 84 CMR examinations on 72 healthy volunteers (32 males, age 19–70 years, weight 50–103 kg) were obtained. Both electrocardiographic and acoustic triggering were employed. The data were analyzed regarding the diagnostic image quality and the influence of patient and hardware dependent factors. 50 complete short axis stacks and 35 four chamber CINE views were used for left ventricular (LV) and right ventricular (RV), mono-planar LV function, and RV fractional area change (FAC). Twenty-seven data sets included aortic flow measurements that were used to calculate stroke volumes. Subjective acceptance was obtained from all volunteers with a standardized questionnaire.ResultsFunctional analysis showed good functions of LV (mean EF 56%), RV (mean EF 59%) and RV FAC (mean FAC 52%). Flow measurements showed congruent results with both ECG and ACT triggering. No significant influence of experimental parameters on the image quality of the LV was detected. Small fractions of 5.4% of LV and 2.5% of RV segments showed a non-diagnostic image quality. The nominal flip angle significantly influenced the RV image quality.ConclusionThe results demonstrate that already now a commercially available 7T MRI system, without major methods developments, allows for a solid morphological and functional analysis similar to the clinically established CMR routine approach. This opens the door towards combing routine CMR in patients with development of advanced 7T technology.

Abstract 14102: Prognostic Impact of Peak Systolic Pulmonary Arterial Pressure in Nonagenarians: An Echocardiographic Study

Introduction: Recently, a low threshold of estimated peak systolic pulmonary arterial pressure (eSPAP) of 30 mm Hg was reported to be associated with mortality in the general population. However, less is known about the prognostic impact of eSPAP in nonagenarians. Methods: We retrospectively reviewed 596 patients ≥90 years of age referred for echocardiography with a recorded eSPAP and left ventricular ejection fraction ≥50%. eSPAPs were characterized according to their quartile distribution: first quartile (reference group) (&lt;30 mm Hg), second quartile (30-38 mm Hg), third quartile (39-48 mm Hg), fourth quartile (&gt;49 mm Hg). The associations between quartiles of eSPAP and all-cause mortality were tested in Cox models (adjusting for age, sex, body mass index, hypertension, coronary arterial disease, atrial fibrillation, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, left-sided valve disease, left atrial area, NYHA class ≥II, left ventricular mass and right ventricular fractional area change). Results: Of the 596 patients, 61% were female, and the median age was 92 years (IQR 91-95). The median eSPAP was 39.0 mm Hg (IQR 30.3-49.0) (Figure). During the median follow-up of 522 days (IQR 59-1337), a total of 268 deaths (45%) occurred. The adjusted risk of mortality in eSPAP 39-48 mm Hg and eSPAP &gt;49 mm Hg were 1.6 and 1.7 times higher than in eSPAP &lt;30 mm Hg, respectively (Table). Conclusions: In conclusion, eSPAP ≥39 mm Hg was independently associated with mortality in nonagenarians. Estimated peak systolic pulmonary arterial pressure could help in prognostic stratification even in oldest-old patients.

Systolic dysfunction of the subpulmonary left ventricle is associated with the severity of heart failure in patients with a systemic right ventricle

BackgroundThe study aimed to assess the relation between echocardiographic parameters of subpulmonary left ventricular (LV) size and function, and the severity of heart failure in patients with a systemic right ventricle (SRV). Methods and resultsA total of 157 patients (89 post Mustard/Senning operations, 68 with congenitally corrected transposition of great arteries [ccTGA]) were included. The size and function of the SRV and subpulmonary LV were assessed on the most recent echocardiographic exam. Clinical data were collected from the electronic records.The majority (133, 84.7%) were in NYHA functional class 1–2. Median BNP concentration was 79.5[38.3–173.3] ng/l, and 100 (63.7%) patients were receiving heart failure therapy. Both LV and SRV fractional area change (FAC) differed significantly between patients with NYHA class 1–2 vs 3–4 (48[41.5–52.8]% vs 34[28.6–38.6]%, p < 0.0001 and 29.5[23–35]% vs 22[20–27]%, p < 0.0001, respectively), but LV FAC had a higher discriminative power for functional class >2 than SRV FAC (AUC 0.90, p < 0.0001 vs 0.79; p < 0.0001, respectively). A LV FAC cut-off value <39.2% had the highest accuracy in identifying patients with NYHA class 3–4 (sensitivity 83% and specificity 88%). In multivariable logistic regression analysis, LV FAC and SRV FAC independently associated to NYHA class 3–4 (OR 0.80 [95%CI 0.72–0.88], p < 0.0001 and OR 0.85 [95%CI 0.76–0.96], p = 0.007, respectively). ConclusionsSubpulmonary LV systolic dysfunction is associated with NYHA functional class 3–4 in patients with ccTGA or after Mustard or Senning operation. Careful evaluation of the subpulmonary LV should be a part of the routine assessment of patients with a SRV.

Tricuspid Valve Anterior Leaflet Strains in Ovine Functional Tricuspid Regurgitation

Functional tricuspid regurgitation (FTR) is thought to arise due to annular dilation and alteration of right ventricular (RV) geometry in the presence of normal leaflets, yet mitral leaflets have been shown to remodel significantly in functional mitral regurgitation. We set out to evaluate tricuspid valve anterior leaflet deformations in ovine FTR. Eleven animals (FTR group) underwent implantation of a pacemaker with high rate pacing to induce biventricular dysfunction and at least moderate TR. Subsequently, both FTR (n = 11) and Control (n = 12) animals underwent implantation of 6 sonomicrometry crystals around the tricuspid annulus, 4 on the anterior leaflet, and 14 on RV epicardium. Tricuspid valve geometry and anterior leaflet strains were calculated from crystal coordinates. Left ventricular ejection fraction and RV fractional area change were significantly lower in FTR animals versus Control. Tricuspid annular area, septo-lateral diameter, RV pressures were all significantly greater in the FTR group. Mean TR grade (+0-3) was 0.7 ± 0.5 in Control and 2.4 ± 0.5 in FTR (P = < 0.001). The anterior leaflet area and length increased significantly. Global radial leaflet strain was significantly lower in FTR mostly driven by decreased free edge leaflet strain. Global circumferential anterior leaflet strain was also significantly lower in FTR with more remarkable reduction in the belly region. Rapid ventricular pacing in sheep resulted in a clinically pertinent model of RV and annular dilation with FTR and leaflet enlargement. Both circumferential and radial anterior leaflet strains were significantly reduced with FTR. Functional TR may be associated with alteration of leaflet mechanical properties.

Is There Any Role of Gene Expression Profiling Test in Asymptomatic Pediatric Heart Transplant Recipients?

Our objective was to correlate AlloMap score with acute cellular rejection (ACR) by endomyocardial biopsy (EMB), donor specific antibody (DSA), cardiac hemodynamic data, cardiac allograft vasculopathy (CAV), and allograft function by echocardiography in pediatric heart transplant (HT) recipients. Retrospective data were collected on all consecutive pediatric HT patients, who had AlloMap tests, cardiac catheterization, EMB, left ventricular shortening fraction (LV SF), ejection fraction (LV EF), and fractional area change in right ventricle (RV FAC) by echocardiography that were obtained concomitantly on same day for routine surveillance for cardiac rejections in asymptomatic patients. Fifty five patients included in the study. Median age at HT was 5.1 years (range, 0.9 -14.1). Median number of RHC was 4 and both RHC and LHC was 2 per patient. The median AlloMap score for entire cohort was 32 (range, 18-37), in both grade 0R (n=67) and grade 1R (n=140) were 32 (range, 29-35), whereas in grade 2R (n=3) score was 35 (range, 33-37). There was no significant difference in AlloMap scores between ACR grades (Fig A), DSA (Fig B), or CAV status (Fig C). There was modest correlation between AlloMap scores and mean RAP (R2 = 0.05, p = 0.002), and PCWP (R2 = 0.03, p = 0.02). Patients on Tacrolimus only had higher scores (Fig D). No correlation between AlloMap score was found with LV SF (p=0.3), LV EF (p=0.5), or RV FAC (p=0.8). AlloMap scores were higher in <2 versus ≥2 years of age at HT (Fig E), and scores were trending higher with time after HT (Fig F). AlloMap scores are not predictive of ACR in asymptomatic pediatric HT recipients. Moreover, AlloMap scores are higher in children <2 years of age at the time of HT. Monitoring of serial AlloMap scores could potentially reflect changes in allograft performance which could help determine indications for EMB. Patients have predictably higher AlloMap scores with time after HT due to changes in hemodynamics associated with cardiac remodeling.

ABNORMAL GLOBAL LONGITUDINAL STRAIN PERSISTS AFTER RECOVERY OF PERIPARTUM CARDIOMYOPATHY

Peripartum cardiomyopathy (PPCM) is a rare pregnancy associated heart failure resulting in substantial morbidity and mortality. Assessment of global left ventricular strain and right ventricular fractional area change at presentation have been shown to be prognostic of recovery. While the majority

P679 Subpulmonary left ventricular dysfunction is associated with severity of heart failure in patients with systemic right ventricle

Abstract Background Dysfunction of systemic right ventricle (SRV) in patients with congenitally corrected transposition of great arteries (ccTGA) or simple transposition (TGA) is commonly associated with exercise intolerance, heart failure and death. However, the relevance of subpulmonary left ventricular (LV) function in these settings is unknown. Purpose To examine the relation between severity of heart failure and echocardiographic parameters of subpulmonary LV size and function in patients with SRV. Methods We identified all patients with SRV from our digital echocardiographic database between 2014 and 2018. The size and function of SRV and subpulmonary LV were assessed in the most recent examination. Clinical data were collected from electronic patient records. Results We included 157 patients with SRV, median age 40.6 [33.1; 46.8] years, 57% male. 133 (85%) patients had NYHA functional class 1-2 and 24 (15%) NYHA class 3-4. Patients with NYHA class 3-4 were older, had larger SRV and subpulmonary LV with poorer function and higher BNP level (Table, Figure A). LV fractional area change (FAC) had higher sensitivity and specificity in differentiation of patients with severe heart failure than SRV FAC (Figurel B) with LV FAC cut-off value &amp;lt;39.2% showing the highest accuracy in prediction of NYHA class 3-4 (Se 83% and Sp 88%) and 86% Sp in predicting BNP &amp;gt; 100 ng/l. LV end-diastolic diameter and area, MAPSE and FAC significantly correlated with BNP level (p &amp;lt; 0.0001; p = 0.001; p = 0.007; and p = 0.0002, respectively). In Multivariate Cox regression analysis LV FAC and RV FAC were the only independent associates of NYHA class 3-4 (HR 0.69 [95%CI 0.55-0.86], p = 0.001 and HR 0.71 [95%CI 0.55-0.93], p = 0.012, respectively), while age, degree of tricuspid regurgitation and BNP were not. Conclusions Subpulmonary LV dysfunction is strongly associated with NYHA class 3-4 heart failure in patients with SRV. LV FAC is more accurate than SRV FAC in predicting heart failure symptoms. Subpulmonary LV should be accurately assessed in all SRV patients and be taken into account in clinical decision making and timing for interventions. Characteristics of 157 patients with SRV Parameter NYHA Class 1-2 (N = 133) NYHA Class 3-4 (N = 24) P value Age, years 39.1 (31.9; 45.7) 46.5 (43.9; 58.1) &amp;lt;0.0001 RV EDAi, cm2/m2 17.4 (15.2; 20.1) 21.8 (17.5; 25.6) 0.0002 RV FAC, % 29.5 (23; 35) 22 (20; 27) &amp;lt;0.0001 LV EDAi, cm2/m2 12.0 (10.1; 14.1) 16.4 (11.6; 19.1) 0.0008 Reduced LV function by eyeballing 3 (2%) 18 (75%) &amp;lt;0.0001 BNP, ng/l 66 (35; 109) 356 (196; 512) &amp;lt;0.0001 Data presented as median (25th; 75th percentiles) Abstract P679 Figure.

AIUM Practice Parameter for the Performance of Fetal Echocardiography.

AIUM Practice Parameter for the Performance of Fetal Echocardiography.

FUNCTIONAL ASSESSMENT OF DCD HEARTS FOLLOWING NORMOTHERMIC REGIONAL PERFUSION CAN PREDICT POST-TRANSPLANTATION CONTRACTILITY

Procurement of DCD hearts using normothermic regional perfusion (NRP) leads to rapid organ reperfusion and allows for a complete cardiac assessment in situ, ensuring only suitable hearts are procured. We aimed to identify which parameters measured following NRP could predict myocardial performance post-transplantation. Donor pigs underwent hypoxic circulatory arrest followed by 15min of warm ischemia and resuscitation with NRP. They underwent 3h of cold ischemia, transplantation, and reperfusion for 3h. We assessed cardiac function using left ventricular (LV) pressure-volume loops, right ventricular (RV) catheterization, and echocardiography following NRP and at 3h of reperfusion. Lactate levels at the time of arrest and time from withdrawal of care to arrest were measured. We performed linear regressions to identify correlations post-transplant cardiac performance. Predictors and outcomes were analyzed as absolute and relative (% from baseline) values. Relative LV fractional area change was the best predictor of relative preload recruitable stroke work (R2=0.754; p=0.002). Lactate concentration immediately before NRP also was a good predictor of relative stroke work (R2=0.788; p < 0.001). Relative and absolute RV stroke work index (SWI) and RV S’, and time to arrest were predictors of recovery in RV function. Only RV functional parameters were capable of predicting global myocardial performance following transplantation. RV S’ showed the strongest correlation with absolute (R2=0.540; p=0.01) and relative (R2=0.500; p=0.022) cardiac index (Table 1). Contractility and biochemical markers measured before heart procurement seemed to predict myocardial performance accurately. Functional parameters demonstrated a more significant number of correlations and provided a better evaluation following NRP. It is of critical importance to also assess DCD heart function to determine organ suitability before transplantation.

Effects of Positive End-Expiratory Pressure on Pulmonary Oxygenation and Biventricular Function during One-Lung Ventilation: A Randomized Crossover Study.

Although the application of positive end-expiratory pressure (PEEP) can alter cardiopulmonary physiology during one-lung ventilation (OLV), these changes have not been clearly elucidated. This study assessed the effects of different levels of PEEP on biventricular function, as well as pulmonary oxygenation during OLV. Thirty-six lung cancer patients received one PEEP combination of six sequences, consisting of 0 (PEEP_0), 5 (PEEP_5), and 10 cmH2O (PEEP_10), using a crossover design during OLV. The ratio of arterial oxygen partial pressure to inspired oxygen fraction (P/F ratio), systolic and diastolic echocardiographic parameters were measured at 20 min after the first, second, and third PEEP. P/F ratio at PEEP_5 was significantly higher compared to PEEP_0 (p = 0.014), whereas the P/F ratio at PEEP_10 did not show significant differences compared to PEEP_0 or PEEP_5. Left ventricular ejection fraction (LV EF) and right ventricular fractional area change (RV FAC) at PEEP_10 (EF, p < 0.001; FAC, p = 0.001) were significantly lower compared to PEEP_0 or PEEP_5. RV E/E’ (p = 0.048) and RV myocardial performance index (p < 0.001) at PEEP_10 were significantly higher than those at PEEP_0 or PEEP_5. In conclusion, increasing PEEP to 10 cmH2O decreased biventricular function, especially on RV function, with no further improvement on oxygenation compared to PEEP 5 cmH2O during OLV.