Left Ventricular Myocardial Contractility Research Articles

Real-time three-dimensional transthoracic echocardiography in quantification of left ventricular dyssynchrony

Aim. To compare endocardial and epicardial left ventricular (LV) pacing using real-time electrocardiography (ECG)-synchronized three-dimensional echocardiography (3DE).Methods. Experimental intraoperative study included 88 points obtained from 12 patients with compensated heart failure of II-IV functional class NYHA (LV ejection fraction < 35%) and cardiac resynchronization therapy indications - ECG pattern of complete left bundle branch block (LBBB) and QRS complex duration > 150 ms. During isolated LV pacing as part of cardiac resynchronization therapy implantation procedure endocardial and epicardial stimulation points matched under fluoroscopic control using quadripolar coronary sinus leads and endocardial electrodes for temporary pacing were obtained. The overall number of corresponding pacing sites included 44 endocardial and 44 epicardial stimulation positions. The mean age of patients was 68.5 [63; 73.5] years, 83% males (n=10). Before study enrollment, 12-channel ECG, echocardiography, and a six-minute walk test were performed for all participants along with cardiac magnetic resonance imaging and control coronary angiography if indicated. The prevalence of coronary heart disease was 50% (n=6) while dilated cardiomyopathy was the most common etiology of chronic heart failure in other cases. Intraoperative ECG with estimation of paced QRS complex morphology at each point was registered via LabSystem Pro Electrophysiological Recording System (Bard Electrophysiology, USA). 3DE was performed using TomTec and Philips Qlab 3DQ Advanced software (Philips Medical Systems, USA).Results. Three-dimensional parametric imaging of LV regional segmental excursion and myocardial contractility using 3DE revealed statistically significant difference in semi-quantative parameters such as ExcAvg (p<0.001), ExcMax (p=0.001), ExcMin (p<0.001) and LV ejection fraction based on 3D modelling (p=0.003) while endocardial pacing was more beneficial. During the course of endocardial stimulation, the 3DE dyssynchrony index estimated at the 2nd stimulation site was also significantly lower (p=0.03). Identical dyssynchrony parameters valid for the 16 and 12-segment 3D models (SDI-16, Tmsv-12SD) (at p=0.06) demonstrated only a tendency for significant difference. The duration of QRS complex at the time of endocardial pacing was significantly shorter (<190 [179;215] ms) (p=0.0008). Semi-quantitative and quantitative 3DE parameters showed the benefit of endocardial pacing resulting in cardiac contractility improvement with less dyssynchrony and LV volume reducing during intraoperative period.Conclusion. Endocardial pacing has potential benefit over the epicardial pacing represented by intraoperative dynamics of LV global and local contractility, intraventricular dyssynchrony estimated by 3DE and also ECG criteria. 3DE is helpful in more precise and reproducibile determing of late activation zone for target LV lead placement that is more manoeuvrable in case of endocardial stimulation.

Underprescribing of cardioprotective novel antidiabetic drugs in marginalized patients with type II diabetes mellitus

Abstract Background Cardiovascular disease is the most common cause of increased mortality in patients with type 2 diabetes mellitus (T2DM). Novel antidiabetic agents such as sodium-glucose co-transporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists were shown to reduce this risk. SGLT-2 inhibitors are considered a secondary treatment option in patients with heart failure with reduced ejection fraction (HFrEF) in patients with or without T2DM. In patients with T2DM, these medications not only reduce hyperglycemia but also reduce the progression of chronic kidney disease (CKD). GLP-1 agonists are indicated for treatment of not only T2DM, but also obesity, and were shown to improve left ventricular ejection fraction, myocardial contractility, and endothelial function. The literature suggests that there may be disparities in prescribing patterns in marginalized populations. Objective The purpose of this study was to conduct a retrospective chart review to assess the adherence to the new guidelines regarding the use of SGLT2 inhibitors and GLP-1 agonists in marginalized patients with T2DM. Methods The study was conducted at a resident-run clinic that serves a large number of under-resourced individuals. Inclusion criteria included patients between the ages of 18 and 75 with T2DM seen in the clinic within 18 months prior to the start of the study with an A1c greater than 9.0. Exclusion criteria included patients with type 1 diabetes mellitus and patients with T2DM under care of endocrinology. We performed retrospective chart review to determine providers’ prescription practices. We created electronic patient database for this study. Results The data showed that 26.87% (n= 381) of the clinic’s population had an A1c greater than 9.0, of those 343 patients met the inclusion criteria. About 7.87% (27/343) of patients were identified with HFrEF. Of those, only 40.74% (11/27) were found to be on an SGLT2 inhibitor. Patients with CKD constituted 17.49% (60/343) of patients, and only 16.67% (10/60) of those were on an SGLT2 inhibitor. We identified 27.70% (95/343) of patients with a BMI between 30-35, and 30.32% (104/343) with a BMI greater than 35, but only 56.84% and 64.42% of those, respectively, were on a GLP-1 agonist. The patients that were not on the cardioprotective agents were 50.19% (135/269), 11.15% (9/269), and 12.64% (34/269) African American, Hispanic, and Asian American, respectively. Conclusions This study demonstrates that SGLT2 inhibitors and GLP-1 agonists are underprescribed in marginalized patients diagnosed with T2DM, even in those with the additional indication of heart failure and CKD. Most of those patients are of racial minorities. There are a number of barriers that could be contributing to the poor adherence to the guidelines in this population. Our next step is to analyze those barriers and develop a quality improvement project that would improve guideline-directed therapy for this under-resourced population.

Glucocorticoids ameliorate cardiorenal syndrome through the NPR1/SGK1 pathway in natriuretic peptide receptor A‑heterozygous mice.

Natriuretic peptides, which are produced by the heart, bind to natriuretic peptide receptor A (NPR1 encoded by natriuretic peptide receptor 1 gene) and cause vasodilation and natriuresis. Thus, they serve an important role in regulating blood pressure. In the present study, microinjection of CRISPR associated protein 9/single guide RNA into fertilized C57BL/6N mouse eggs was performed to generate filial generation zero (F0) Npr1 knockout homozygous mice (Npr1-/-). F0 mice mated with wild-type (WT) mice to obtain F1 Npr1 knockout heterozygous mice with stable heredity (Npr1+/-). F1 self-hybridization was used to expand the population of heterozygous mice (Npr1+/-). The present study performed echocardiography to investigate the impact of NPR1 gene knockdown on cardiac function. Compared with those in the WT group (C57BL/6N male mice), the left ventricular ejection fraction, myocardial contractility and renal sodium and potassium excretion and creatinine-clearance rates were decreased, indicating that Npr1 knockdown induced cardiac and renal dysfunction. In addition, expression of serum glucocorticoid-regulated kinase 1 (SGK1) increased significantly compared with that in WT mice. However, glucocorticoids (dexamethasone) upregulated NPR1 and inhibited SGK1 and alleviated cardiac and renal dysfunction caused by Npr1 gene heterozygosity. SGK1 inhibitor GSK650394 ameliorate cardiorenal syndrome by suppressing SGK1. Briefly, glucocorticoids inhibited SGK1 by upregulating NPR1, thereby ameliorating cardiorenal impairment caused by Npr1 gene heterozygosity. The present findings provided novel insight into the understanding of cardiorenal syndrome and suggested that glucocorticoids targeting the NPR1/SGK1 pathway may be a potential therapeutic target to treat cardiorenal syndrome.

Characteristics of patients with chronic heart failure in different age groups

There are indications that the severity of clinical manifestations of chronic heart failure (CHF) is related to the age of patients, with older age groups characterized by a more severe course of CHF and more significant pathological changes in instrumental and laboratory parameters. In view of the above, the aim of the present study was to compare NT-proBNP level, other basic parameters of left ventricular myocardial contractility and the results of 6-min walk test, in CHF patients of different age. We investigated these parameters by dividing the total number of subjects into subgroups of young (18-44 years), middle-aged (45-59 years) and elderly (60-74 years) age according to WHO guidelines. There were 111 patients with CHF (82 men and 29 women) aged 20 to 74 years (mean age 60.4±1.25 years). The patients were divided into three subgroups: 1st - young age (21 patients), 2nd - middle age (37 patients) and 3rd - old age (53 patients). Echocardiographic examination, 6-minute walking test, determination of NT-proBNP level in blood plasma were used during the examination. The number of patients with decreased EF (<35%) was significantly lower among young patients, while those with preserved EF was significantly higher among elderly patients. There were more patients with signs of pulmonary hypertension (high systolic pulmonary artery pressure (SPAP)) among elderly patients. The average distance walked during a 6-minute walk was relatively shorter in elderly patients, as well as a greater number of patients with higher (III-IV functional classes (FC)). The number of patients with elevated blood NT-proBNP levels as well as mean NT-proBNP levels were also relatively higher in the older age groups. Thus, the clinical course of CHF is characterized by a more severe course in elderly patients, despite the prevalence of patients with preserved EF, which is confirmed by more frequent occurrence of FC III-IV, clinical-instrumental and laboratory parameters, and is associated, at least partly, with more frequent occurrence of comorbid pathology.

Peculiarities of the structural and functional state of the heart in patients with arrhythmias depending on the severity of cognitive disorders

Background. The purpose of our work was to find out the dependence of changes in the cognitive sphere on the features of the structural and functional state of the heart and central hemodynamics in patients with arrhythmias. Material and methods. We have examined 139 patients with different clinical forms of arrhythmias. All of them underwent extended neuropsychological testing and central hemodynamic studies. The state of central hemodynamics was assessed by an ultrasound examination of the heart. The state of intracardiac hemodynamics, structural changes in various parts of the heart were evaluated; based on this, the type of heart remodeling was determined. Correlations of hemodynamic indicators with the results of neuropsychological testing were evaluated. Results. In patients with mild cognitive disorders (CD), the left ventricular myocardial contractility index did not differ significantly from that in patients without CD, but in people with moderate CD it was 9.6 % lower (p = 0.044). With moderate CD, the dilatation of the left parts of the heart increased (end-diastolic volume — by 16.5%, p =0.049; left atrium — by 9.9 %, p = 0.049), which, along with increased hypertrophy of the interventricular septum by 12.8 % (p = 0.048) and of the left ventricular posterior wall by 12.9 % (p = 0.048), led to an increase in the pulmonary artery pressure by 24.8 % (p = 0.015). Among patients with CD, concentric (42.2 %) and eccentric (22.6 %) left ventricular hypertrophy was more often detected (p = 0.048 and p = 0.027); in those without CD, concentric remodeling of the left ventricle prevailed (p = 0.037). In patients with mild CD, higher stroke volume was recorded — by 8.3 % (p = 0.049) compared to those without CD. However, according to indicators of cardiac output, cardiac index and total peripheral vascular resistance, differences were unreliable (p > 0.05). Patients with moderate CD reported an increase in stroke volume and cardiac output by 7.6 (p = 0.043) and 14.9 % (p = 0.014), respectively, compared to those without CD. Indicators of central hemodynamics had the greatest impact on the sphere of attention, regulatory functions, visual-spatial and mnestic deficits. The highest odds ratio for the development of CD were found for left ventricular ejection fraction (2.52, 95% confidence interval: 1.82–3.29, p < 0.001). Conclusions. The identified associations of cognitive dysfunction, central hemodynamics and heart remodeling are important for optimizing an individualized approach to patient management and predicting the development of CD.

Complications and Mortality after CABG Surgery in Patients with Reduced Ejection Fraction

Coronary artery bypass grafting (CABG) is a complex, high-tech surgical intervention. Its success depends not only on the skill and experience of the surgeon but equally on the coherence of work and professionalism of all services involved in the operation. Severe left ventricular (LV) dysfunction after heart surgery is one of the main causes of cardiogenic shock, which is characterized by a local transient reduction of myocardial contractility (“stunned” myocardium) and/or significant cell damage caused by ischemia. In this state, systemic metabolic disorders often occur: increased concentration of free fatty acids, lactic acidosis, hypoxemia, and increased catecholamine content. General approaches to determining the risk of CABG surgery have not been definitively established. In addition, the data concerning the choice of optimal tactics in patients with a reduced ejection fraction (EF) are still limited. Relatively high early operative mortality in patients with reduced left ventricular EF requires further serious study.
 The aim. To determine the dominant complications and causes of fatal cases in patients with reduced LV contractility after CABG surgery.
 Materials and methods. The study included 210 patients with EF of 35% or less, who underwent CABG at the National Amosov Institute of Cardiovascular Surgery in the period from 01/01/2015 to 12/31/2021. Among them were 190 men (90.5%) and 20 women (9.5%). The age of the patients ranged from 29 to 83 years (61.1±8.9). Most patients underwent revascularization of three or more arteries.
 Results and discussion. In the group of patients with EF 35-30% in the postoperative period, acute heart failure (HF) occurred in 5 (3.8%) cases, respiratory failure (RF) was observed in 3 (2.3%) cases, renal failure in 3 (2.3%) cases, central nervous system (CNS) complications in 5 (3.8%). At the same time, along with the decrease in EF, the frequency of postoperative complications increased. In patients with EF below 24%, the frequency of postoperative complications increased significantly: acute HF was noted in 3 (15%) cases, RF in 5 (25%) cases, renal failure in 2 (10%) cases, CNS complications were noted in 0 (0%) cases. The duration of artificial lung ventilation increased significantly to 24.9±27.7 hours, the length of stay in the intensive care unit increased to 12.8±8 days, and the total length of stay of the patient in the hospital to 20.2±11.7 days.
 Conclusion. Based on the data we received, we concluded that: in patients with reduced LV myocardial contractility, such complications as HF, RF and renal failure, CNS complications most often occur; in addition, their frequency is higher than that in patients with preserved EF and increases with its decrease; one of the most frequent and life-threatening complications in this group of patients was acute HF; the use of intra-aortic balloon pump allows to avoid or improve treatment of HF and, at the same time, to increase survival in patients with reduced LV contractility.

Assessment of subclinical left ventricular systolic dysfunction and structural changes in patients with chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease (COPD) can develop left ventricular (LV) systolic dysfunction and geometric changes due to several reasons. To investigate subclinical LV systolic dysfunction and structural features in patients with COPD, and its correlation with the severity of airway obstruction, identified by GOLD classification. We studied 52 patients with COPD and 29 age and sex-matched controls, without any cardiac disease. In addition to conventional echocardiographic evaluation speckle tracking echocardiography (STE)-based strain imaging were performed to analyse sub-clinical LV systolic dysfunction. Also LV volumes were measured by using three-dimensional real time echocardiography (3DRTE). All patients underwent spirometry. Conventional echocardiographic parameters (LV wall thickness and diameters, LV EF) and LV volume measurements were similar between the groups. LV global longitudinal peak systolic strain (-14.76 ± 2.69% to -20.27 ± 1.41%, P < 0.001) and strain rate (0.75 ± 0.25 1/s to 1.31 ± 0.41 1/s, P < 0.001) were significantly impaired in patients, compared to controls demonstrating sub-clinical ventricular systolic dysfunction. Significant positive correlation was obtained between LV strain/strain rate and spirometry parameters (FEV1, FEV%, FEV1/FVC, PEF%) (r = 0.78/0.68, P < 0.001; r = 0.83/0.70, P < 0.001); r = 0.74/0.55, P < 0.001; r = 0.72/0.65, P < 0.001 respectively). In addition, there was significant negative correlation between LV strain/strain rate and GOLD classification (r = -0.80/ -0.69, P < 0.001 respectively). Subclinical LV systolic dysfunction can occur in COPD patients despite normal EF. STE is a technique that provides additional information for detailed evaluation of subtle changes in LV myocardial contractility, significantly associated with the severity of the disease in COPD patients.

Change of Left Ventricular Myocardial Contractility in Speckle Tracking Echocardiography After Transjugular Intrahepatic Portosystemic Shunt Predicts Survival

BackgroundLeft ventricular global longitudinal strain (LV-GLS) has been shown to better reflect the left cardiac contractility in cirrhosis than other investigations and might bear prognostic value. The aim of this study was to investigate the evolution of myocardial contractility assessed by speckle tracking echocardiography (STE) after transjugular intrahepatic portosystemic shunt (TIPS) placement and its prognostic value in outcome.MethodsIn this study, 206 (126 males) patients with liver cirrhosis receiving TIPS were included. In all study patients, conventional transthoracic echocardiography (TTE) was performed before and in the first weeks after TIPS placement to assess left and right ventricular volume, planar and functional parameters. Also, LV-GLS was measured by STE to assess left ventricular contractility as surrogate for myocardial dysfunction. Hemodynamic and clinical parameters were assessed before TIPS and during follow-up.ResultsAs expected, most conventional parameters of TTE showed a significant change after TIPS placement. However, neither the absolute values, nor the changes of conventional cardiac parameters of TTE before and after TIPS insertion were associated with survival. By contrast, an increase in contractility of more than 20% using STE after TIPS was an independent predictor of mortality.ConclusionThese results demonstrate that an increase of left ventricular contractility of more than 20% after TIPS insertion is an independent predictor of survival and this may identify patients at risk and in need of closer follow-up care.

Sympathetic Reinnervation After Heart Transplantation Assessed by Iodine-123 Metaiodobenzylguanidine (123I-MIBG) Imaging and Heart Rate Response to Exercise

<h3>Purpose</h3> The extent of sympathetic reinnervation of transplanted hearts varies among recipients. The purpose of this study is to investigate the relation between the functional response of the left ventricular (LV) myocardium to adrenergic stimulation and the findings of [¹²³I]metaiodobenzylguanidine (MIBG) scintigraphy in cardiac transplant recipients. <h3>Methods</h3> MIBG scintigraphy was performed in 20 heart transplant recipients (mean of 7.6 years after transplantation) and in 20 age-matched individuals with hemodynamically stable (NYHA functional class I) dilated cardiomyopathy (DCM). Heart rate and blood pressure as well as the ECG during exercise- or dobutamine-induced stress tests were measured in all patients. All patients also underwent endomyocardial biopsy, and some of the biopsy specimens were subjected to mRNA analysis. LV isovolumic contraction (<i>dP/dt</i>_max) and relaxation (tau) were measured simultaneously during stress tests in six transplant recipients and five patients with DCM. <h3>Results</h3> MIBG uptake was virtually undetectable in transplant recipients, with the exception of one individual who showed evidence of reinnervation in the anteroseptal region. The heart-to-mediastinum ratio was significantly smaller in transplant recipients than in patients with DCM (1.32 ± 0.6. vs. 2.22 ± 0.3, <i>p</i> < 0.0001). The change in <i>dP/dt</i>_max at peak heart rate during stress tests did not differ significantly between the two groups (83 ± 26 vs. 93 ± 20%, <i>p</i> = 0.335), whereas that in tau was smaller in transplant recipients than in DCM patients (31 ± 8 vs. 42 ± 9%, <i>p</i> < 0.05). RT-PCR analysis revealed that the amount of β-adrenergic receptor kinase-1 mRNA in the ventricular myocardium tended to be smaller in recipients who showed an attenuated response in stress tests than in those with a good response <h3>Conclusion</h3> LV contractility during adrenergic stimulation by dobutamine or exercise was preserved, whereas LV relaxation was attenuated, in transplant recipients. The discrepancy between the responses of LV myocardial contractility and relaxation to adrenergic stimulation and MIBG scintigraphic findings may provide insight into the reinnervation of transplanted hearts.

Evaluation of the effectiveness of the chronic heart failure therapy using the device cardiac contractility modulation according to the new non-invasive method of the myocardium work analysis

Aim To analyze echocardiographic parameters that reflect left ventricular (LV) myocardial contractility, using a novel method for evaluation of myocardial performance in patients with chronic heart failure (CHF) and atrial fibrillation (AF) during heart contractility modulation (HCM).Material and methods Standard echocardiographic parameters and indexes of myocardial strain and work were analyzed for 66 patients (52 men and 14 women; median age, 60 [54; 66] years). 36 patients had paroxysmal AF and 30 patients had permanent AF. All patients had CHF with a duration of 17 [4; 60] months; duration of AF was 12 [6; 36] months. At baseline, the left ventricular ejection fraction (LV EF) was 33 [27; 37] %.Results After one year of HCM, LV EF significantly increased from 33 [27; 37] to 38 [33; 44] % (р=0.001). Also, there were improvements in the myocardial global longitudinal strain (from -6.00 [ - 8; - 4] to -8 [ - 10; - 6] %; р=0.001) and parameters of myocardial work, including the global work efficiency (from 74 [65; 79] to 80 [73; 87] mm Hg%; р=0.001), global constructive work (from 699 [516; 940] to 882 [714; 1242] mm Hg%; р=0.001), and global myocardial work index (from 460 [339; 723] to 668 [497; 943] mm Hg%; р=0.001). A segmentary analysis of LV work parameters showed positive changes in the myocardial constructive work in the area of the interventricular septal apical segment (at baseline, 844 [614; 1224]; after HCM, 1027 [800; 1520] mm Hg%; р=0.05) and the medium segment of the LV anteroseptal wall (at baseline, 593 [312; 1000]; after HCM, 877 [494; 1145] mm Hg%; р=0.05).Conclusion This method for analysis of the myocardial work provides a more detailed examination of LV structural and functional remodeling and mechanisms for its effects on the LV contractile function in patients with CHF. This method is promising and merits further study in various clinical situations.

Disorganization of intercalated discs in dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a primary myocardial disease, the pathology of which is left ventricular or biventricular dilation and impaired myocardial contractility. The clinical and pathological diagnosis of DCM is difficult, and other cardiac diseases must be ruled out. Several studies have reported pathological findings that are characteristic of DCM, including cardiomyocyte atrophy, nuclear pleomorphism, and interstitial fibrosis, but none of these findings are DCM-specific. In this study, we examined the morphological differences in the intercalated discs (ICDs) between three groups of patients, a DCM group, a chronic heart failure group, and a control group. A total of 22 autopsy cases, including five DCM cases, nine CHF cases and eight control cases, were retrieved from the archives of the Department of Pathology at Akita University, Japan. The morphological differences were examined using multiple methods: macroscopic examination, light microscopy, immunohistochemistry, electron microscopy, and gene expression analyses. We observed disorganized ICDs, clearly illustrated by N-cadherin immunostaining in the DCM group. “Reduction of N-cadherin immunostaining intensity” and “ICD scattering” was DCM-specific. The results suggest that disorganized ICDs contribute to the development of DCM, and that N-cadherin immunostaining is useful for determining the presence of disorganized ICDs and for the pathological diagnosis of DCM.

The modified protocol of transesophageal atrial pacing in stress echocardiography as an alternative way to increase the information value of the method for detection of ischemic wall motion abnormalities

Aim To develop a new, modified protocol for transesophageal atrial electric stimulation (TEAES), which would significantly enhance the diagnostic value of stress echocardiography and reduce the duration of the test in patients with ischemic heart disease (IHD).Material and methods This study included 101 patients (80 men and 21 women aged 55±9 years) with suspected or documented diagnosis of IHD who were divided into two homogenous groups. Group 1 (51 patients) underwent stress echocardiography (stress-EchoCG) according to a standard protocol (SP) for TEAES and group 2 (50 patients), underwent stress-EchoCG according to a modified protocol (MP). In addition to stress-EchoCG with TEAES, selective coronary angiography was performed for all patients. The development of the new method for evaluating occult coronary insufficiency was based on comparison of SP and MP for TEAES with stress-EchoCG with data of coronary angiography.Results In both groups, significant differences in values of systolic and diastolic blood pressure were absent. However, the values of achieved heart rate were significantly different: 141±11 (TEAES SP) and 155±10 (TEAES MP) bpm (p=0.01). There was also a difference in the duration of the TEAES protocols: 15±3 and 5±2 min, respectively (p=0.006). The use of the modified TEAES protocol for detecting transient disorders of left ventricular myocardial local contractility increased the sensitivity, specificity and accuracy of the test from 76 %, 87 %, and 80 % to 83 %, 92 %, and 86 %, respectively. The most significant differences were found in the area supplied by the circumflex artery: the SP and MP sensitivities were 63 % and 75 %, respectively (p&lt;0.05) and the SP and MP accuracies were 81 % and 90 %, respectively (p&lt;0.05).Conclusion Evaluation of occult coronary insufficiency by stress-EchoCG with the TEAES MP as compared to the TEAES SP provides a gentler procedure regimen for the patient due to a shorter duration of the test and at the same time improves the diagnostic significance of this method in IHD patients.

Effects of Cardioprotective Tactics on the Myocardial Perfusion and Contractile Function of the Left Ventricular Myocardium in Cancer Patients with Evidence of Doxorubicin-Induced Cardiotoxicity.

Aim To study the effect of cardioprotective tactics on parameters of left ventricular myocardial perfusion and contractility as per data from single-photon emission computed tomography in oncological patients with signs of anthracycline-induced cardiotoxicity.Material and methods The study included patients with oncological diseases (n=61) referred to polychemotherapy (PCT). For patients with signs of anthracycline-induced cardiotoxicity, a cardioprotective tactics was used, which included changing the PCT schedule and administering beta-blockers and angiotensin-converting enzyme inhibitors. For all patients at baseline, after the first four PCH courses, after initiation of the cardioprotective tactics and the next four PTC courses, the level of N-terminal pro-brain natriuretic peptide was measured and echocardiography and perfusion single-photon emission computed tomography were performed with assessment of left ventricular (LV) perfusion heterogeneity, systolic and diastolic function.Results Following four PTC courses, signs of cardiotoxicity were detected in 13 (21.3 %) patients. On the background of the cardioprotective tactics, a further decrease in LV ejection fraction (EF) by -9±2 % (p&lt;0.01) was observed in 4 (30.8 %) patients. In 9 (69.2 %) patients, LV EF increased by 4±2 % (p&lt;0.01). Standard indexes of LV myocardial perfusion did not significantly change. In 7 patients, the cardioprotective tactics was associated with reduced severity of myocardial perfusion disorder, LV∆σТ = -1.37±1.29 (p&lt;0.05), and in 4 patients, with reduced heterogeneity of myocardial perfusion, LV∆σН = -1.20±0.70 (p&lt;0.05).Conclusion The cardioprotective tactics prevents both further disorder of perfusion and decreases in parameters of left ventricular myocardial contractility in patients with anthracycline-induced cardiotoxicity.

Echocardiography in the Assessment of Postsystolic Shortening of the Left Ventricle Myocardium of the Heart

Echocardiography allows evaluating left ventricular (LV) myocardial contractility; however, the visual assessment of contractility is subjective and requires considerable experience. Modern technologies for assessment of LV myocardial contractility, such as tissue Doppler and speckle-tracking echocardiography, provide quantitative estimation of various parameters of myocardial strain, including the LV postsystolic shortening. Several studies have demonstrated the value of postsystolic shortening for evaluation of myocardial ischemia and "ischemic memory" in patients with cardiovascular diseases. This review analyzes experimental and clinical studies that addressed LV postsystolic shortening.

Неблагоприятное течение тромбоэмболии легочной артерии в течение года наблюдения

Цель исследования: изучение частоты и причины неблагоприятных исходов, а также факторов, с ними связанных, в течение года наблюдения у пациентов с тромбоэмболией легочной артерии (ТЭЛА). Материалы и методы: В одноцентровый регистр проспективного наблюдения методом сплошного включения включены 185 пациентов с ТЭЛА. Проводилось стандартное обследование пациентов, диагноз подтверждался по результатам мультиспиральной компьютерной томографии. Период наблюдения составил 12 мес, в течение которого отслеживали исходы пациентов, выписанных под амбулаторное наблюдение. Конечными точками являлись все случаи смерти и рецидивов ТЭЛА. Статистическую обработку результатов осуществляли с помощью пакета программ MedCalc Version 16.2.1 (Softwa, Бельгия). Результаты: Годовые исходы были определены у 161 пациента. Фатальный исход в течение года после выписки из стационара наступил у 22 (13,6%) больных ТЭЛА: у 45,5% по причине рецидива ТЭЛА, у 22,7% — онкологической патологии, у 13,6% — из-за острого нарушения мозгового кровообращения (ОНМК). Развитие летальных исходов было ассоциировано с такими факторами, как пожилой возраст, наличие ишемической болезни сердца, злокачественных новообразований, застойной сердечной недостаточности, ОНМК, а также со снижением глобальной сократимости миокарда левого желудочка, высоким риском по шкале PESI (англ. Pulmonary Embolism Severity Index) и отказом от антикоагулянтной терапии в течение первых 6 мес. Рецидив ТЭЛА в течение года наблюдения выявлен в 11,2% случаев и был связан с наличием тромбоза глубоких вен нижних конечностей, нижней полой вены и подвздошных вен, застойной сердечной недостаточностью и дилатацией правых отделов сердца. Установлено, что отказ от антикоагулянтной терапии в течение 11 мес после первичного эпизода повышает риск развития рецидива ТЭЛА. Заключение: У пациентов с ТЭЛА в течение первого года наблюдения летальный исход развился в 13,6% случаев, а рецидив ТЭЛА — в 11,2%. Наиболее значимым неблагоприятным фактором, связанным с данными конечными точками, являлся отказ от антикоагулянтной терапии ранее 6 мес после эпизода ТЭЛА. Objectives: to study the incidence, causes and factors associated with adverse outcomes in patients with pulmonary embolism (PE) during the year of observation. Patients/Methods: The single-center prospective follow-up register included 185 patients with PE. Standard examination was carried out; the diagnosis was confirmed by multispiral computed tomography. During follow-up period of 12 months we tracked outpatient outcomes. The endpoints were all-cause mortality and PE relapses. Statistical analysis was performed by MedCalc Version 16.2.1 software package (Softwa, Belgium). Results: Twelve-month outcomes were determined in 161 patients. Post-discharge fatal outcome within a year occurred in 22 (13.6%) patients with PE: in 45.5% due to PE relapse, in 22.7% due to oncological pathology, in 13.6% because of acute stroke. Lethal outcomes were associated with elderly age, ischemic heart disease, malignant neoplasms, congestive heart failure, stroke, reduction of left ventricular global myocardial contractility, a high risk according to PESI (Pulmonary Embolism Severity Index) scale and the refusal of anticoagulant therapy during the first 6 months. Within a year of observation PE relapse was detected in 11.2% of patients and was associated with deep vein thrombosis of the lower limbs, inferior vena cava and iliac veins, congestive heart failure and dilatation of right heart compartments. Refusal of anticoagulant therapy within 11 months after the initial episode increased the risk of PE relapse. Conclusions: In patients with PE during the first year of observation a fatal outcome occurred in 13.6% patients with PE and PE relapse — in 11.2%. Refusal of anticoagulant therapy earlier than 6 months after the episode of PE was the most significant adverse factor associated with these endpoints.

Preoperative Factors Influencing the Results of Coronary Artery Bypass Grafting with Reduced Left Ventricular Myocardial Contractility

Myocardial infarction remains one of the most common causes of disability in patients. Prior myocardial infarction in 15–30% of cases leads to decrease in left ventricle (LV) contractility. Isolated drug therapy is ineffective in most cases – impressions of the coronary arteries require revascularization, including coronary artery bypass grafting. Data on the choice of optimal tactics in such patients is also limited. In addition, there is no consensus on the prognosis of mortality and management of this group of patients.&#x0D; Materials and methods. The study included 190 patients with the left ventricular ejection fraction (EF LV) of 35% or less, who underwent CABG at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine in the period from 01.01.2015 to 31.12.2018. The age of patients ranged from 29 to 83 years (61.13 ± 8.87). There were 170 men (89.47%) and 20 women (10.53%). Our data suggests that patients with low EF LV have complications typical of coronary artery bypass grafting, but the incidence of these complications is higher and increases with the EF LV decrease (except for the central nervous system (CNS) complications where there is no correlation). At the same time, such indicators as the duration of mechanical ventilation, the number of days of stay in the intensive care unit and the total number of days of stay in the hospital are increasing. The following complications most often arose in the postoperative period: acute heart failure, respiratory failure, renal failure.&#x0D; Based on our data, we came to the following conclusions: in patients with reduced LV myocardial contractility, the main complications after coronary artery bypass grafting were congestive heart failure, respiratory failure, renal failure and CNS complications. Among them, regardless of the level of EF LV, the most common were acute heart failure and complications of the respiratory system. The most significant factors of preoperative condition of patients with reduced LV myocardial contractility, which increase the risk of postoperative complications and increased mortality are: EF LV 30% and below, patient age over 60 years, creatinine rise to &gt;200 mmol/L, pulmonary hypertension over 50 mmHg. Concomitant mitral regurgitation (moderate or severe) requires obligatory intraoperative correction.

Experimental validation of the prestretch-strain relationship as a non-invasive index of left ventricular myocardial contractility.

BackgroundThe slope of the relationship between segmental PreS and total systolic shortening (S) has been proposed as a non-invasive index of left ventricular contractility. The aim of this study was to correlate this novel parameter to invasive gold standard measurements of contractility and to investigate how it is influenced by afterload.MethodsIn domestic pigs, afterload was increased by either balloon inflation in the aorta or by administration of phenylephrine while contractility was increased by dobutamine infusion. During all interventions, left ventricular pressure-volume measurements and trans-diaphragmatic two-dimensional echocardiographic images were acquired. The PreS-S slope was constructed from 18 segmental strain curves obtained by speckle tracking analysis and compared to the slope of the end systolic PV relationship (Emax) and the pre-load recruitable stroke work (PRSW).ResultsSixteen datasets of increased contractility and afterload were analyzed. During dobutamine infusion, the LV volumes decreased (p<0.05) while ejection fraction increased (p<0.05). Emax, PRSW and the slope of the intra-ventricular PreS-S relation increased significantly during dobutamine infusion. Afterload increase led to increase in systolic blood pressure (105±16mmHg vs. 138±25mmHg; p<0.01) and decrease of LV stroke volume and ejection fraction (p<0.01). The PreS-S slope was not influenced by loading conditions in concordance with the PRSW findings. The absolute values of the PreS-S slope did not correlate with Emax or PRSW. However, the change of the PreS-S slope in relation with different interventions demonstrated good correlation with changes in PRSW or Emax, (r = 0.66, p<0.05 and r = 0.69, p<0.05).ConclusionsThe slope of the PreS-S relationship is sensitive to changes in inotropy and is less load-dependent than conventional non-invasive parameters of left ventricular function. The magnitude of the change of this slope correlates well with changes in invasive contractility measurements making it an attractive parameter to assess contractile reserve or contractile changes during longitudinal follow-up of patients.

Механизмы взаимодействия сердечно-сосудистой и дыхательной систем

In this review we discuss the mechanisms of cardio-pulmonary interaction during spontaneous respiration and mechanical lung ventilation. We noted the interrelations between the changes of the intrathoracic pressure, venous return and cardiac output; the changes of the intrathoracic pressure and pulmonary hemodynamics; the values of the intrathoracic pressure and right and left ventricular myocardial contractility; the changing of respiratory phases and heart rate; the changes of respiratory muscles contraction and circulatory system. The phasic changes of the venous flow (it increases during respiration and decreases during expiration) are caused by the changes of both the intrathoracic and transdiaphragmatic pressures. However, the sucking thoracic effect is practically absent to the mean values of the venous return. During phasic respiratory changes the shifts of the venous return and pulmonary artery flow are opposite to the changes of the cardiac output and arterial pressure as a result of the changes of capacitance and resistance of the pulmonary vessels. In case of positive end expiratory pressure ventilation the changes of the cardiac output are dependent from the interrelations of the venous return, right ventricular myocardial contractility, pulmonary veins outflow and left ventricular myocardial contractility. The reflectory neurogenic influences on the heart and vessels from the pulmonary and respiratory muscles receptors are important during the cardio-pulmonary interaction.

P785 Left ventricular geometry and myocardial contractility modulate impact of statins on prognosis in patients with acute heart failure

Abstract Funding Acknowledgements N/A Background/Introduction: The benefit of statins in patients with heart failure (HF) remains controversial and the mechanism of action is largely speculative. We investigated whether survival benefit with statins differs according to left ventricular (LV) geometry and myocardial contractility in acute HF patients. Methods We enrolled 1792 acute HF patients receiving statins and 2296 patients not receiving statins admitted from 2009 to 2016. The LV and right ventricular (RV) global longitudinal strain (GLS) was assessed as a measure of myocardial contractility. Patients were classified into 2 groups based on ischemic etiology of HF and further divided into 4 subgroups according to the median values of LV-GLS or RV-GLS. The primary outcome was 5-year all-cause mortality. The study protocol was approved by the ethics committee at each institute and complied with the Declaration of Helsinki. The need for written informed consent was waived. Results During the 5-year follow-up, 1740 (40.4%) patients died and they had more unfavorable baseline characteristics. Statin therapy was significantly associated with improved survival in overall patients and in both groups with and without ischemic etiology (all p &amp;lt;0.001). Patients with concentric remodeling/hypertrophy and eccentric hypertrophy demonstrated survival benefit with statin therapy (P = 0.033, 0.004, and 0.008, respectively), while those with normal geometry did not (p = 0.123). In the non-ischemic HF group, survival benefit with statin therapy was confined to patients with low LV-GLS (p = 0.045) or those with low RV-GLS p = 0.003). On the contrary, in ischemic HF group, survival benefit with statin therapy was observed in all patients regardless of the values of LV-GLS or RV-GLS. Significant interactions were present between statin use and diabetes mellitus and IHD (p for interaction = 0.027 and 0.003, respectively) regarding mortality. Conclusions LV geometry and myocardial contractility may modulate the effects of statins in patients with acute HF. These echocardiographic measures can provide prognostic information to guide tailored statin treatment in this population. Our findings may also help to develop more well-designed prospective studies, in terms of a more homogenous study population, to confirm survival benefit with statin therapy. Abstract P785 Figure. Multivariate Cox survival curves

Radiomics of Non-Contrast-Enhanced T1 Mapping: Diagnostic and Predictive Performance for Myocardial Injury in Acute ST-Segment-Elevation Myocardial Infarction.

ObjectiveTo evaluate the feasibility of texture analysis on non-contrast-enhanced T1 maps of cardiac magnetic resonance (CMR) imaging for the diagnosis of myocardial injury in acute myocardial infarction (MI).Materials and MethodsThis study included 68 patients (57 males and 11 females; mean age, 55.7 ± 10.5 years) with acute ST-segment-elevation MI who had undergone 3T CMR after a percutaneous coronary intervention. Forty patients of them also underwent a 6-month follow-up CMR. The CMR protocol included T2-weighted imaging, T1 mapping, rest first-pass perfusion, and late gadolinium enhancement. Radiomics features were extracted from the T1 maps using open-source software. Radiomics signatures were constructed with the selected strongest features to evaluate the myocardial injury severity and predict the recovery of left ventricular (LV) longitudinal systolic myocardial contractility.ResultsA total of 1088 segments of the acute CMR images were analyzed; 103 (9.5%) segments showed microvascular obstruction (MVO), and 557 (51.2%) segments showed MI. A total of 640 segments were included in the 6-month follow-up analysis, of which 160 (25.0%) segments showed favorable recovery of LV longitudinal systolic myocardial contractility. Combined radiomics signature and T1 values resulted in a higher diagnostic performance for MVO compared to T1 values alone (area under the curve [AUC] in the training set; 0.88, 0.72, p = 0.031: AUC in the test set; 0.86, 0.71, p002). Combined radiomics signature and T1 values also provided a higher predictive value for LV longitudinal systolic myocardial contractility recovery compared to T1 values (AUC in the training set; 0.76, 0.55, p < 0.001: AUC in the test set; 0.77, 0.60, p < 0.001).ConclusionThe combination of radiomics of non-contrast-enhanced T1 mapping and T1 values could provide higher diagnostic accuracy for MVO. Radiomics also provides incremental value in the prediction of LV longitudinal systolic myocardial contractility at six months.