Systolic Left Ventricular Ejection Fraction Research Articles

Study of Right Ventricular Function in Post COVID Syndrome in Recovered Mild Severity COVID-19 Patients Using Conventional and Speckle Tracking Echocardiography

Abstract Background Many patients seek medical help for COVID-19’s longer term physical and mental effects. The term post COVID syndrome is used by the World Health Organization (WHO) to identify individuals with a history of probable or confirmed COVID-19 infection, usually 3 months from the onset of infection with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Symptoms may be due to persistent chronic inflammation, sequelae of organ damage, and hospitalization and social isolation. These symptoms may persist from the initial infection, or appear after a period of recovery. RV dimensions (RVD) and RV function (RVF) are closely correlated to symptom occurrence and to exercise capacity in many clinical conditions. Consequently, a comprehensive and accurate evaluation of the RV is essential. Echocardiography is the modality of choice for the assessment of RVD and RVF in clinical practice owing to its numerous advantages. It is widely available, relatively cheaper than other modalities, non-invasive, and doesn’t require radiation or contrast injection. Nevertheless, the RV special anatomy, its retrosternal position and its complex architecture pose a challenge to conventional echocardiographic imaging. Novel modalities of echocardiography, such as myocardial deformation imaging by speckle tracking echocardiography (STE), provide the solution to overcome most of these challenges owing to the fact that it is independent of cardiac translation, angle-independent and load-independent. Aim and Objectives The aim was to study RV function in post COVID syndrome in recovered mild severity COVID-19 patients using 2D RV STE and correlate these findings with the patients’ symptomatology. Patients and Methods This study included 96 subjects divided into 3 age and gender matched groups; the first group consisted of 32 mild severity COVID-19 patients 3-6 months after recovery and not complaining of post COVID-19 syndrome, the second group consisted of 32 mild severity COVID-19 patients 3-6 months after recovery and complaining of post COVID-19 syndrome and the third group consisted of 32 healthy controls who didn’t get COVID-19. This study was conducted at Ain Shams University Hospitals. The patients were recruited from the outpatient ECHO clinic in the cardiology department during the period from March 2022 to August 2022. The entire study population was evaluated via 2D conventional echocardiography and STE imaging. Results Our study assessed RV functions at 3-6 months after recovery from mild severity COVID-19 disease. At the follow-up, TAPSE, RV-FAC, RV S’, RV-GLS and RV-FWLS parameters were significantly lower in patients with mild severity COVID-19 disease than healthy controls. They also showed lower values in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.032, 0.034, 0.003, 0.010 and 0.029 respectively. In addition, RV diameters (longitudinal, mid and basal RVEDD), RV MPI and sPAP values were significantly higher in patients with mild severity COVID-19 disease than healthy controls. They also showed higher values in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.043, 0.026, 0.014, 0.000 and 0.025 respectively. LV-GLS showed lower value in patients with post COVID syndrome than control group with P-value = 0.002. It also showed lower value in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.018. We also found that the most common symptom in post COVID syndrome was fatigue, with a percentage of 65.6%, followed by palpitations (40.6%) and chest pain (31%). These three symptoms showed a significant negative relation with RV 2D STE parameters. Additionally, a negative correlation between inflammatory markers including CRP, TLC, PLT, ferritin and D-dimer levels during active infection and long term echocardiographic parameters such as RV-GLS, RV-FWLS and LV-GLS was detected in our study. Conclusion We concluded that RV-GLS and RV-FWLS decreased at 3-6 month follow-up of patients with history of mild severity COVID-19 disease especially those complaining of post COVID syndrome. Additionally, it is demonstrated that increased CRP, TLC, PLT, ferritin and D-dimer levels during acute infection is related to RV-GLS, RV-FWLS and LV-GLS values. 2D STE may be used for both detection and follow-up for possible long term right ventricular dysfunction after mild severity COVID-19 disease. Key words: Post-COVID Syndrome, Speckle Tracking Echocardiography, RV-GLS, RV-FWLS, LV-GLS Abbreviations. Abbreviations: RV Right Ventricle STE Speckle Tracking Echocardiography 2D 2-Dimensional TAPSE Tricuspid Annular Plane Systolic Excursion RV-FAC Right Ventricular Fractional Area Change RV-GLS Right Ventricular Global Longitudinal Strain RV-FWLS Right Ventricular Free Wall Longitudinal Strain LV-GLS Left Ventricular Global Longitudinal Strain RVEDD Right Ventricular End Diastolic Dimension RV MPI Right Ventricular Myocardial Performance Index sPAP Systolic Pulmonary Artery Pressure CRP C – Reactive Protein TLC Total Leucocytic Count PLT Platelets WHO World Health Organization LVEDD Left Ventricular End Diastolic Dimension LVESD Left Ventricular End Systolic Dimension FS Fractional Shortening EF Ejection Fraction

Prospective benchmarking of an observational analysis in the SWEDEHEART registry against the REDUCE-AMI randomized trial

Prospective benchmarking of an observational analysis against a randomized trial increases confidence in the benchmarking process as it relies exclusively on aligning the protocol of the trial and the observational analysis, while the trials findings are unavailable. The Randomized Evaluation of Decreased Usage of Betablockers After Myocardial Infarction (REDUCE-AMI, ClinicalTrials.gov ID: NCT03278509) trial started recruitment in September 2017 and results are expected in 2024. REDUCE-AMI aimed to estimate the effect of long-term use of beta blockers on the risk of death and myocardial following a myocardial infarction with preserved left ventricular systolic ejection fraction. We specified the protocol of a target trial as similar as possible to that of REDUCE-AMI, then emulated the target trial using observational data from Swedish healthcare registries. Had everyone followed the treatment strategy as specified in the target trial protocol, the observational analysis estimated a reduction in the 5-year risk of death or myocardial infarction of 0.8 percentage points for beta blockers compared with no beta blockers; effects ranging from an absolute reduction of 4.5 percentage points to an increase of 2.8 percentage points in the risk of death or myocardial infarction were compatible with our data under conventional statistical criteria. Once results of REDUCE-AMI are published, we will compare the results of our observational analysis against those from the trial. If this prospective benchmarking is successful, it supports the credibility of additional analyses using these observational data, which can rapidly deliver answers to questions that could not be answered by the initial trial. If benchmarking proves unsuccessful, we will conduct a “postmortem” analysis to identify the reasons for the discrepancy. Prospective benchmarking shifts the investigator focus away from an endeavour to use observational data to obtain similar results as a completed randomized trial, to a systematic attempt to align the design and analysis of the trial and the observational analysis.

Discordance interpretation of left ventricular size between echocardiography and cardiac magnetic resonance in pediatric patients with aortic/mitral regurgitation

PurposeThis study investigated discordance between echocardiography (echo) and cardiac magnetic resonance (CMR) measurements of the left ventricle (LV) in pediatric patients with aortic and/or mitral regurgitation (AR/MR).MethodsRetrospective cohort study of pediatric patients. The cohorts were comprised of patients with AR/MR vs. non-AR/MR. Left ventricular end diastolic volume (LVEDV) by CMR and left ventricular internal diameter diastolic (LVIDd) by echo were obtained from clinical reports then echo images were reviewed to remeasure LVEDV by bullet method. Left ventricular internal diameter systolic (LVIDs) and left ventricular ejection fraction (LVEF) measurements by echo and LVEF by CMR were obtained from clinical reports. Fractional shortening (FS%) was recalculated. Z-scores were calculated using normative data. Correlation between echo and CMR LV measurements was assessed using correlation coefficients. Bland-Altman plots assessed bias between imaging modalities. Receiver operator characteristic (ROC) analysis was performed for detection of LV enlargement and LV dysfunction.ResultsAR/MR patients had greater discrepancy in LV size interpretation by Z-score compared to non-AR/MR patients. This discrepancy persisted when the bullet method short axis measurements were incorporated. There was negative bias in echo-based measurements compared to CMR. The diagnostic performance of echo in identifying moderate LV enlargement was worse for AR/MR pediatrics patients.ConclusionThe discordant interpretation of LV size by echo compared to CMR is worse in pediatric patients with AR/MR when compared to patients without AR/MR even when short axis measurements are incorporated. This finding suggests non-uniform geometrical changes in the LV as it enlarges due to AR/MR.

Outcomes of COMBO therapy for severe mitral regurgitation compared with transcatheter edge-to-edge repair.

There are different types of transcatheter mitral valve repair (TMVr) currently in clinical use, including leaflet approximation, annular cinching, and restoration of the chordal apparatus of the mitral valve (MV). While the concomitant combination (COMBO) therapy of mitral transcatheter edge-to-edge repair (M-TEER) with another TMVr concept has been proven feasible, potentially offering patient-tailored treatment for severe mitral regurgitation (MR), a comparison with M-TEER alone has not been made. To evaluate the procedural and clinical outcome of COMBO therapies compared with M-TEER alone. We included consecutive patients undergoing COMBO and M-TEER between March 2015 and April 2018 at our Heart Valve Center, while excluding patients presenting a case of redo or with previous MV surgery. Procedural outcomes and all-cause mortality were compared between COMBO therapy vs. M-TEER alone. A total of 357 patients (mean age 78.9 ± 7.0 years, 53.2% male, M-TEER n = 322, COMBO n = 35; COMBO: MitraClip and the Carillon mitral contour system n = 26, MitraClip and Cardioband n = 5, and MitraClip and NeoChord n = 4) were analyzed. Patients with COMBO therapy had larger left chamber sizes, a lower left ventricular systolic ejection fraction (LVEF; COMBO: 37.4 ± 13.8%, M-TEER: 47.9 ± 14.3%, p < 0.001), and a more severe MR grade (p < 0.001). There were no significant differences in the prevalence of residual MR ≧2+. However, the need for re-intervention, always employing M-TEER, was more common in the COMBO group. During a mean 3.6-year long-term follow-up, there was no significant difference of all-cause mortality between both groups (Log rank p = 0.921). COMBO therapy may still be a beneficial therapy option for patients with severe MR who already have a more dilated left ventricle (LV), a more severe MR, and a more pronounced LV systolic dysfunction. The higher need for re-intervention in the COMBO group may signal more complex anatomies and possibly underlines the necessity of treating significant MR earlier. Future research is required to establish the COMBO approach as a toolbox-like treatment option, thus offering a patient-tailored approach depending on the individual anatomy and pathology.

Effect of Cardiac Rehabilitation on the Psychological Changes in Post Myocardial Infarction Patients

Abstract Objectives To assess the effect of cardiac rehabilitation on the psychological changes in post myocardial infarction (MI) patients. Background Cardiac rehabilitation (CR) is a acceptable treatment strategy adding to the basic medical plan for the patients with coronary artery disease. Subjects and methods A prospective study that was conducted on 60 myocardial infarction patients and they were subdivided into 2 groups; group 1 included 30 myocardial infarction patients who underwent cardiac rehablitation and group 2: included 30 myocardial infarction patients who didn’t undergo cardiac rehablitation. All the included subjects underwent full history taking, full examination and echocradiography and psychological evaluation tests (state–trait anxiety inventory (STAI), Beck depression inventory (BDI) and hospital anxiety and depression scale (HADS)), before and after cardiac rehablitation. Results Comparison between the 2 groups regarding cardiac changes on follows up, there was significant difference between 2 groups regarding Left ventricular end diastolic diameter (LVEDD), Left ventricular end systolic diameter (LVESD) and ejection fraction (EF) (P-value = 0.0001, 0.0082 &amp; 0.0261). Comparison between the 2 groups regarding psychiatric changes on follows up revealed that there was significant difference as regard STAI, BDI and HADS (P-value = 0.0001, 0.0.0001 &amp; 0.0001). Conclusion Cardiac rehabilitation in post-MI patients could have beneficial effects on cardiac function without adversely affecting LV remodeling or causing serious cardiac complications. Participating in a cardiac rehablitation beneficially contributed to a decrease in depression and anxiety manifestations in post-MI patients. Abbreviations A-state: State-anxiety A-trait, Trait-anxiety; BDI: Beck depression inventory; BP: Blood pressure; CAD: Coronary artery disease; HADS: Hospital Anxiety and Depression Scale; HF: Heart failure; LVEF: Left ventricular ejection fraction; MI: Myocardial infarction; STAI: State–trait anxiety inventory

Correlation between tissue Doppler-derived left ventricular systolic velocity (S’) and left ventricle ejection fraction in sepsis and septic shock: a retrospective cohort study

BackgroundTissue Doppler-derived left ventricular systolic velocity (mitral S’) has shown excellent correlation to left ventricular ejection fraction (LVEF) in non-critically patients. However, their correlation in septic patients remains poorly understood and its impact on mortality is undetermined. We investigated the relationship between mitral S’ and LVEF in a large cohort of critically-ill septic patients.MethodsWe conducted a retrospective cohort study between 01/2011 and 12/2020. All adult patients (≥ 18 years) who were admitted to the medical intensive care unit (MICU) with sepsis and septic shock that underwent a transthoracic echocardiogram (TTE) within 72 h were included. Pearson correlation test was used to assess correlation between average mitral S’ and LVEF. Pearson correlation was used to assess correlation between average mitral S’ and LVEF. We also assessed the association between mitral S’, LVEF and 28-day mortality.Results2519 patients met the inclusion criteria. The study population included 1216 (48.3%) males with a median age of 64 (IQR: 53–73), and a median APACHE III score of 85 (IQR: 67, 108). The median septal, lateral, and average mitral S’ were 8 cm/s (IQR): 6.0, 10.0], 9 cm/s (IQR: 6.0, 10.0), and 8.5 cm/s (IQR: 6.5, 10.5), respectively. Mitral S’ was noted to have moderate correlation with LVEF (r = 0.46). In multivariable logistic regression analysis, average mitral S’ was associated with an increase in both 28-day ICU and in-hospital mortality with odds ratio (OR) 1.04 (95% CI 1.01–1.08, p = 0.02) and OR 1.04 (95% CI 1.01–1.07, p = 0.02), respectively.ConclusionsEven though mitral S’ and LVEF may be related, they are not exchangeable and were only found to have moderate correlation in this study. LVEF is U-shaped, while mitral S’ has a linear relation with 28-day ICU mortality. An increase in average mitral S’ was associated with higher 28-day mortality.Graphical

Dark papillary muscles sign: a novel prognostic marker for cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: None. Background the prognostic role of left ventricular (LV) papillary muscle abnormalities in patients with preserved LV systolic ejection fraction (LVEF) is unknown. Aim to evaluate the prevalence and the clinical and prognostic impact of papillary muscle abnormalities by CMR in patients with ventricular arrhythmias, preserved LVEF with no cardiac disease. Methods 391 patients with &amp;gt;500/24h premature ventricular complexes and/or with non-sustained ventricular tachycardia (NSVT), preserved LVEF and no cardiac disease, were enrolled. Different features of LV papillary muscles were considered: supernumerary muscles, papillary thickness, the attachment, late gadolinium enhancement (LGE). The end-systolic hypointensity was defined when its measured signal intensity (SI) was lower than the SI of the septum in early post-contrast cine CMR images. Dark-Paps was defined when both the main papillary muscles had systolic hypointensity. Mitral valve prolapse, mitral annular disjunction (MAD), myocardial LGE were considered. The outcome of hard cardiac events was define as a composite of cardiac death, resuscitated cardiac arrest, and appropriate implantable cardioverter defibrillator (ICD) shock, sustained ventricular tachycardia (lasting ≥30 s at ≥100 beats/min). Results Dark-Paps was found in 79 (20%) patients and was more frequent in females. It was associated with higher prevalence of mitral valve prolapse and MAD. During a median follow-up of 2534 days, 22 hard cardiac events occurred. At Kaplan-Meier curve (Figure) analysis patients with Dark-Paps were at higher risk of events than those without (p&amp;lt;0.0001). Dark-Paps was significantly associated with hard cardiac events in all the multivariate models performed. Dark-Paps improved prognostic estimation when added to NSVT (p = 0.0006), to LGE (p = 0.005) and to a model including NSVT+LGE (p = 0.014). Dark-Paps allowed a significant net reclassification when added to NSVT (NRI 0.30, p =0.03), to LGE (NRI 0.25, p =0.04), and to NSVT + LGE (NRI 0.32, p =0.02). Conclusions Dark-Paps sign could be considered a novel imaging prognostic marker in patients with ventricular arrhythmias and preserved ejection fraction.

Dark papillary muscles sign: a novel prognostic marker for cardiac magnetic resonance

ObjectivesThe prognostic role of left ventricular (LV) papillary muscle abnormalities in patients with preserved LV systolic ejection fraction (LVEF) is unknown. We sought to evaluate the prognosis role of LV papillary muscle abnormalities by CMR in patients with ventricular arrhythmias, preserved LVEF with no cardiac disease.MethodsA total of 391 patients with > 500/24 h premature ventricular complexes and/or with non-sustained ventricular tachycardia (NSVT), preserved LVEF, and no cardiac disease were enrolled. Different features of LV papillary muscles were considered: supernumerary muscles, papillary thickness, the attachment, late gadolinium enhancement (LGE). Dark-Paps was defined as end-systolic signal hypointensity of both papillary muscles in early post-contrast cine CMR images. Mitral valve prolapse, mitral annular disjunction (MAD), and myocardial LGE were considered.ResultsDark-Paps was found in 79 (20%) patients and was more frequent in females. It was associated with higher prevalence of mitral valve prolapse and MAD. During a median follow-up of 2534 days, 22 hard cardiac events occurred. At Kaplan-Meier curve analysis, patients with Dark-Paps were at higher risk of events than those without (p < 0.0001). Dark-Paps was significantly associated with hard cardiac events in all the multivariate models. Dark-Paps improved prognostic estimation when added to NSVT (p = 0.0006), to LGE (p = 0.005) and to a model including NSVT+LGE (p = 0.014). Dark-Paps allowed a significant net reclassification when added to NSVT (NRI 0.30, p = 0.03), to LGE (NRI 0.25, p = 0.04), and to NSVT + LGE (NRI 0.32, p = 0.02).ConclusionsIn LV papillary muscles, Dark-Paps is a novel prognostic marker in patients with ventricular arrhythmias and preserved ejection fraction.Key Points• Papillary muscle abnormalities are seen in patients with ventricular arrhythmias and preserved left ventricular ejection fraction.• Early post-contrast hypointensity of papillary muscles in end-systolic cine images (Dark-Paps) is a novel prognostic marker in patients with ventricular arrhythmias and preserved ejection fraction.• Dark-Paps had an additive prognostic role over late gadolinium enhancement and non-sustained ventricular tachycardia.

Identification of early cardiac dysfunction and heterogeneity after pressure and volume overload in mice by high-frequency echocardiographic strain imaging.

Aortic stenosis and regurgitation are clinically important conditions characterized with different hypertrophic types induced by pressure or volume overload, respectively, but with comparable cardiac function in compensated stage. Speckle-tracking based strain imaging has been applied to assess subtle alterations in cardiac abnormality, but its application in differentiating these two types of ventricular hypertrophy is still sparse. Here, we performed strain imaging analysis of cardiac remodeling in these two loading conditions. C57BL/6J mice were subjected to transverse aortic constriction (TAC)-induced pressure overload or aortic regurgitation (AR)-induced volume overload. Conventional echocardiography and strain imaging were comprehensively assessed to detect stimulus-specific alterations in TAC and AR hearts. Conventional echocardiography did not detect significant changes in left ventricular systolic (ejection fraction and fractional shortening) and diastolic (E/E') function in either TAC or AR mice. On the contrary, global strain analysis revealed global longitudinal strain and strain rate were remarkably impaired in TAC while preserved in AR mice, although global radial, and circumferential strain and strain rate were significantly reduced in both models. Regional strain analysis in the long axis demonstrated that longitudinal strain and strain rate in all or most segments were decreased in TAC but maintained or slightly dented in AR mice, while radial strain and strain rate indicated overt decline in both models. Moreover, decreased radial and circumferential strain and strain rate were observed in most segments of TAC and AR mice in the short axis. Strain imaging is superior to conventional echocardiography to detect subtle changes in myocardial deformation, with longitudinal strain and strain rate indicating distinct functional changes in pressure versus volume overload myocardial hypertrophy, making it potentially an advanced approach for early detection and differential diagnosis of cardiac dysfunction.

Comparison of Midterm and Long-Term Effects of Cord Protection Methods on Left Ventricular Function in Mitral Valve Replacement Surgery

Introduction: Our study aimed to determine the effects of cord protection methods applied in Mitral valve replacement (MVR) surgery on left ventricular function. Materials and Methods: MVR surgery was performed on 634 patients using either single or combined procedures. Of these patients, 358 (56.5%) underwent conventional MVR surgery, 121 (19.1%) underwent total chordal protection, and 155 (24.4%) underwent posterior chordal preservation. All patients were evaluated as class 3 and 4 according to the New York functional classification (NYHA). Left ventricular diastolic end-diameter (SVDSD), left ventricular systolic end-diameter (SVSSD), end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) were compared between groups. Results: The degree of valve insufficiency was 3 and 4 in patients with mitral insufficiency. The mortality risk for patients undergoing conventional surgical operations was 4.257 times higher (OR:4.25; 95%CI:1.22-14.76). The study showed positive effects of chordal protection on the clinical status and echocardiographic parameters of undergoing MVR surgery (p&lt;0.01). Conclusion: We believe cord protection methods positively affect left ventricular function after MVR. In particular, total chordal protection will positively affect left ventricular function.

769 EFFECT OF GLUCOSE LOWERING AGENTS ON CARDIAC AUTONOMIC FUNCTION AND STRUCTURE IN TYPE 2 DIABETES MELLITUS

Effects of novel glucose-lowering agents on cardiac autonomic function and structure in type 2 diabetes Ilaria Cavallari, Ernesto Maddaloni, Francesco Veneziano, Carla Indennidate, Maria Valeria Giaccari, Dario Tuccinardi, Silvia Pieralice, Nicola Napoli, Raffaella Buzzetti, Francesco Grigioni Background Novel glucose-lowering agents, such as sodium glucose co-transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, have the potential to reduce major adverse cardiovascular events among people with type 2 diabetes. However, mechanisms behind their cardiovascular protection and the implications of positive chronotropic effects of GLP-1 receptor agonists are not fully understood. Purpose To elucidate and compare the effects of novel glucose-lowering agents on cardiac autonomic function and structure. Methods This prospective observational study included subjects with type 2 diabetes and either a history of established cardiovascular disease or multiple risk factors and early initiation (within 2 weeks) of a SGLT-2 inhibitor or a GLP-1 receptor agonist on top of standard of care. Patients were followed for a median of 2 months. As per study protocol, background medical therapy should have remained stable for the entire duration of the study. Cardiac autonomic reflex tests (heart rate response to a deep breathing and to standing) and echocardiography were performed in all patients at baseline and at the end of follow-up. Endpoints were changes from baseline of E/I ratio, 30:15 ratio and indices of cardiac structure and function. Results A total of 37 patients completed follow-up, of whom 20 were on SGLT-2 inhibitors and 17 on GLP-1 receptor agonists. Mean age was 69 years, mean disease duration was 14 years and mean HbA1c value was 7.5%. Cardiac autonomic dysfunction, defined as at least an abnormal test, was found in 19% of patients (n=7). At a median follow-up of 2 months, there were no differences from baseline in heart rate response to a deep breathing test (p=0.92) and to standing (p=0.86). No differences were found when patients were stratified according to drug class. Among echocardiographic parameters, significant reductions of left ventricular mass (300.5±73.3 vs 280.4±68.3 g/m2, p=0.048) and left atrial volume (61.3±29.4 vs 54.7±18.0 ml, p=0.034) were found with no interaction by drug class. Left ventricular end-diastolic and systolic volumes, ejection fraction, filling pressures and pulmonary artery pressure did not substantially change. Conclusions In a population of patients with type 2 diabetes, short-term treatment with novel glucose-lowering agents significantly reduced left ventricular mass and left atrial volume but did not affect cardiac autonomic function.

Synergistic and Attenuating Effect of Electroacupuncture on Aconitine in Improving Heart Failure and Its Calcium Regulation Mechanism.

Objective The objective is to observe the synergistic and attenuating effect of electroacupuncture (EA) on aconitine (ACO) in improving heart failure (HF) and to explore its underlying mechanism for calcium regulation. Methods Twenty-four male Sprague-Dawley rats were randomly divided into four groups: normal control (NC) (n = 6), HF(n = 6), ACO (n = 6), and ACO + EA (n = 6). The maximum rates of left ventricular pressure rising and declining (±dp/dtmax), arrhythmia, the left ventricular systolic pressure (LVSP), ejection fraction (LVEF), and fractional shortening (LVFS) were measured by physiological recorder and ultrasound, respectively. Protein expressions of sarcoplasmic/endoplasmic reticulum Ca2+ ATPase (SERCA2a), phospholamban (PLB), and Na+-Ca2+ exchange (NCX1) in the left ventricle tissue were detected by fluorescence immunoblotting. Results Compared with the NC group, LVSP, ±dp/dtmax, LVEF, and LVFS were decreased in the HF group; compared with the HF group, LVSP, ±dp/dtmax, LVEF, and LVFS were significantly increased in the ACO + EA group. Compared with the ACO group, the incidence and the degree of arrhythmia were significantly reduced in the ACO + EA group. Compared with the NC group, the activity of SERCA2a was decreased, and the expression of PLB and NCX1 was enhanced in the HF group; compared with the HF group and ACO group, the activity of SERCA2a was increased, and the expression of PLB and NCX1 was significantly attenuated in the ACO + EA group. Conclusions EA plays a synergistic and attenuated role in ACO improving HF, and the mechanism may be related to the enhancement of the SERCA2a activity and the decrease of the expression of PLB and NCX1 in cardiomyocytes.

Correlation between obstructive sleep apnea and ventricular function: a cross-sectional hospital-based study

Background Obstructive sleep apnoea (OSA) is a major cause of cardiovascular morbidity and mortality worldwide. Previous studies showed high prevalence of OSA in heart failure. We aimed to evaluate the association of OSA with cardiac dysfunction and the importance of myocardial performance index (Tei) in identifying cardiac dysfunction. Methods Participants with OSA and sinus rhythm were included, while participants with arrhythmia, debilitating disease, or significant valvular heart disease were excluded. Thirty participants were enrolled, consecutively allocated in a single group, and underwent nocturnal polysomnography, electrocardiogram, and transthoracic echocardiography. Results The prevalence of hypertension, diabetes, and smoking in the study population was 50%, 30%, and 23.3%, respectively. The mean body mass index and apnoea-hypopnoea index (AHI) of the study population was 40.11 ± 7.5 kg/m2 and22.12 ± 13.54 events/h, respectively. There were statistically significant differences between mild, moderate, and severe OSA regarding the left ventricular end diastolic diameter, left ventricular end systolic diameter, ejection fraction, and fractional shortening (p = 0.006, p = 0.002, p = 0.014 and p = 0.011),respectively. There were statistically significant regular positive correlations between the AHI and the right and left Tei (r = 0.447, p = 0.001 and r = 0.391, p = 0.003),respectively. Conclusions The prevalence of OSA was more in patients with comorbidities especially hypertension and diabetes. OSA was significantly associated with ventricular remodelling and cardiac dysfunction. A significant regular positive correlation was observed between the severity of OSA and worsening cardiac function as measured by Tei. Echocardiographic evaluation of the right and left ventricles and the right and left Tei could be considered as potentially valid, reproducible, and clinically applicable non-invasive methods for estimation of ventricular global function in patients with OSA.

Venoarterial extracorporeal membrane oxygenation support for acute fulminant myocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute fulminant myocarditis (AFM) may be life threatening. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide an effective cardiocirculatory support. Purpose This study aims to evaluate the clinical course and the prognosis of patients (P) with fulminant myocarditis supported by VA-ECMO. Methods Observational retrospective single-center study of 15 consecutive P (73% women; 45,6±11,6 years; body mass index 26,7±2,23kg/m2) admitted to an intensive care unit (ICU) for AFM managed by peripheral VA-ECMO between 2008 and 2018. Were included P with diagnosis of myocarditis, recent onset of symptoms and severe hemodynamic compromise within 7 days following hospital admission. P were followed during 29,4±8,4 months after discharge to identify rehospitalization due to cardiovascular causes (re-hosp), recurrence of myocarditis or death. Results The P had previous history of hypertension (20%), diabetes (13%), dyslipidemia (20%), autoimmune disease (7%), previous acute myocarditis (7%), 20% were former smokers and 7% active smoker. The main clinical presentation was chest pain (27%), dyspnea /heart failure (47%) and epigastric pain/nausea (13%). The media between symptom onset and hospitalization was 14,9±6,5 days. The total hospital length of stay was 37±6,9 days, with 18,7±16,1 days in the ICU. During hospitalization, arrhythmias were documented in 40%: atrial fibrillation/flutter (13%), complete atrioventricular block (13%), ventricular tachycardia (13%), ventricular fibrillation (7%), asystole (7%) and electrical storm (7%). Medical therapy included corticosteroids in 47% of P, immunosuppressive therapy in 13% and intravenous immunoglobulin in 13%. The mean duration of VA-ECMO support was 8,5±6,2 days. 27% had preserved left ventricular systolic ejection fraction (LVEF), 13% left ventricular dilation, 13% pericardial effusion and 13% late gadolinium enhancement. The mean LVEF was 23±8,2%. Endomyocardial biopsy was diagnostic for 3 out of 4P in which was performed. The etiology of myocarditis was identified in 60% of P: viral (33%), autoimmune (7%) and pheochromacitoma (20%). During hospitalization 5P (33%) died (3 in the ICU). The P who died had higher liver sequential organ failure assessment (SOFA) and kidney SOFA scores before starting ECMO, both being predictors of mortality (liver SOFA:Cramér’sV 0,76;95%CI 0,009-0,014;p=0,01;kidney SOFA:Cramér’sV 0,79;95% CI 0,03-0,04; p=0,031). At discharge, the survival rate was 67% and the recovery of LVEF ocurred in 47% of P. During follow-up, there were no re-hosp, recurrence of myocarditis or deaths and 53% of P had preserved LVEF. Conclusion AFM is associated with high mortality rates. Percutaneous VA-ECMO is a highly effective haemodynamic support that can be used as a "bridge to recovery". Once a patient recovers, the subsequent clinical outcome seems favourable.

Successful Heart Transplantation in a Patient with Neonatal Marfan Syndrome

<h3>Introduction</h3> Neonatal Marfan syndrome (NMS) is a rare subtype of Marfan syndrome associated with more pronounced clinical characteristics. Patients with NMS often have more severe cardiac involvement, including atrioventricular valve prolapse and insufficiency and aortic root pathology. The development of a concurrent myopathy syndrome has not been described. We describe a case of a teenage girl with NMS who developed inotrope-dependent heart failure secondary to dilated cardiomyopathy requiring heart transplantation. <h3>Case Report</h3> The patient is a 16-year-old female with NMS, mitral valve prolapse and regurgitation, and aortopathy who underwent mitral valvuloplasty and valve-sparing aortic root replacement 5 years prior to presentation. Since that time, she had asymptomatic, progressively declining left ventricular systolic ejection fraction without progressive aortic valve or mitral disease. Her left ventricular ejection fraction was 20-25% at its nadir. Additionally, she had severe kyphosis requiring surgery three months prior to presentation and was dependent on GJ feeds for weight management. She presented in winter of 2020 with new onset heart failure requiring admission for milrinone which was unable to be weaned off due to a low cardiac output state and was listed for heart transplant on day 13 of admission. An acceptable heart became available, and she was transplanted on day 17 of admission. Her post-operative course was relatively uncomplicated. She developed ectopic atrial tachycardia, which is well-controlled with atenolol and propafenone. Whole exome sequencing confirmed that she is heterozygous for a ∼13.8 KB deletion within the <i>FBN1</i> gene, confirming her NMS diagnosis, as well as an additional novel deletion of exons 18 to 28 within <i>FBN1.</i> She has had no rejection and marked improvement in her quality of life evident by weaning off tube feedings, exercising regularly with long distance walking and attending senior year of high school. <h3>Summary</h3> The cardiac involvement in NMS and typical Marfan syndrome has generally been described as valve prolapse and aortopathy, although cardiomyopathy in the latter has been reported. Our teenage patient with NMS developed progressive LV systolic heart failure ultimately requiring a heart transplant. We believe patients with NMS that develop end-stage heart failure without treatment options should be considered for heart transplantation.

Embolic stroke of undetermined source and atrial cardiopathy: Towards a personalized antithrombotic strategy for secondary stroke prevention

An 82-year-old hypertensive woman with a history of myocardial infarction is admitted with aphasia and weakness of the right arm and leg. Admission electrocardiogram shows sinus rhythm. During telemetry at the stroke unit, no episodes of atrial fibrillation (AF) are detected. Using transthoracic echocardiography, mitral valve prolapse, moderate-severe aortic stenosis, reduced left ventricular systolic ejection fraction and regional akinesia of the left ventricular wall are identified. Would you consider one of these findings as the cause of her stroke? If yes, which one? Carotid ultrasound reveals a left carotid plaque causing a 40% stenosis without signs of ulceration.

Assessment of late cardiotoxic effects in patients treated for cancer in childhood.

Graphical AbstractThe aim was to assess the late cardiotoxic effects in young adults treated for various cancer types in childhood using echocardiography and 24-h ECG Holter monitoring.

Fully automated quantification of cardiac chamber and function assessment in 2-D echocardiography: clinical feasibility of deep learning-based algorithms

We aimed to compare the segmentation performance of the current prominent deep learning (DL) algorithms with ground-truth segmentations and to validate the reproducibility of the manually created 2D echocardiographic four cardiac chamber ground-truth annotation. Recently emerged DL based fully-automated chamber segmentation and function assessment methods have shown great potential for future application in aiding image acquisition, quantification, and suggestion for diagnosis. However, the performance of current DL algorithms have not previously been compared with each other. In addition, the reproducibility of ground-truth annotations which are the basis of these algorithms have not yet been fully validated. We retrospectively enrolled 500 consecutive patients who underwent transthoracic echocardiogram (TTE) from December 2019 to December 2020. Simple U-net, Res-U-net, and Dense-U-net algorithms were compared for the segmentation performances and clinical indices such as left atrial volume (LAV), left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), LV mass, and ejection fraction (EF) were evaluated. The inter- and intra-observer variability analysis was performed by two expert sonographers for a randomly selected echocardiographic view in 100 patients (apical 2-chamber, apical 4-chamber, and parasternal short axis views). The overall performance of all DL methods was excellent [average dice similarity coefficient (DSC) 0.91 to 0.95 and average Intersection over union (IOU) 0.83 to 0.90], with the exception of LV wall area on PSAX view (average DSC of 0.83, IOU 0.72). In addition, there were no significant difference in clinical indices between ground truth and automated DL measurements. For inter- and intra-observer variability analysis, the overall intra observer reproducibility was excellent: LAV (ICC = 0.995), LVEDV (ICC = 0.996), LVESV (ICC = 0.997), LV mass (ICC = 0.991) and EF (ICC = 0.984). The inter-observer reproducibility was slightly lower as compared to intraobserver agreement: LAV (ICC = 0.976), LVEDV (ICC = 0.982), LVESV (ICC = 0.970), LV mass (ICC = 0.971), and EF (ICC = 0.899). The three current prominent DL-based fully automated methods are able to reliably perform four-chamber segmentation and quantification of clinical indices. Furthermore, we were able to validate the four cardiac chamber ground-truth annotation and demonstrate an overall excellent reproducibility, but still with some degree of inter-observer variability.

Effect of Sacubitril/Valsartan or enalapril on left ventricular longitudinal strain in patients with hematologic malignancies after bone marrow transplantation

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Hellenic Association of Lipidiology, Atherosclerosis and Vascular disease Background and Aims Chemotherapy is known for its potential adverse effects on myocardium. Optimal medical treatment for heart failure may reverse myocardial dysfunction in the early stages of toxicity development. We hypothesized that early initiation of treatment with enalapril or sacubitril/valsartan could prevent cardiotoxicity. Patients and methods 60 patients (mean age 44,8± 14,1 years old, 34 male) with preserved ejection fraction, who suffered from hematologic malignancies (lymphoma, leukemia) and underwent bone marrow transplantation, were randomized to receive sacubitril/valsartan 24/26 mg bid daily or enalapril 5 mg bid daily or placebo. We measured at baseline, before transplantation, after three and after six months: i) Global Longitudinal Strain of left ventricle (LV) (GLS), ii) Left Ventricular End Diastolic Volume, Left Ventricular End Systolic Volume and Left Ventricular Ejection Fraction (LVEF Simpson’s Method). Results The three treatment groups had similar age, sex, atherosclerotic risk factors and cardiotoxic medication before, and after bone marrow transplantation. Compared to baseline, patients treated with sacubitril/valsartan did not show a deterioration of LV GLS at three and six months follow up (GLS=-20.2 ± 3.1% vs -19.8 ± 3.1%, p = 0.551 vs -19.6 ± 3.2%, p = 0.452, respectively). Similarly, compared to baseline, patients treated with enalapril did not show a deterioration of LV GLS at three and six months follow up (GLS=-20.7 ± 3.0% vs -20.5 ± 2.8%, p = 0.772 vs -20.3 ± 3.2%, p = 0.730, respectively). Conversely, patients treated with placebo, presented a significant impairment of LV GLS, at three and six months follow up (GLS=-20,5 ± 1.9% vs -18.5 ± 2.4%, p = 0.003 vs -18.6 ± 2.9%, p = 0.018, respectively). No significant changes were found in LVEF after treatment with sacubitril/valsartan (57,9 ± 5,6% vs 57,6 ± 6,1%, p = 0,733) or enalapril (59.2 ± 6.3% vs 60.4 ± 7.7%, p = 0.464) vs placebo (60,1 ± 5,6% vs 57,8 ± 6,6%, p = 0,166) at six months follow up. Conclusions Treatment with sacubitril/valsartan or enalapril prevented deterioration of myocardial deformation six months after bone marrow transplantation in patients with hematologic malignancies and preserved ejection fraction.

Abstract 11069: Nutritional Risk Index is a Predictive Factor of Anthracycline-Induced Cancer Therapeutics-Related Cardiac Dysfunction

Background: It has been reported that nutritional risk index (NRI) is one of prognostic factors in cardiovascular diseases, but little is known about its relation to the onset of cancer therapeutics-related cardiac dysfunction (CTRCD). Methods and Results: Consecutive 202 cancer patients planed for anthracycline treatment were enrolled and followed up for 12 months in our hospital from February 2017 to June 2019. The patients were divided into 2 groups based on NRI value at 100 before chemotherapy (high NRI group, n=141, 110.5 [104.7-115.6]; low NRI group, n=61, 93.7 [89.6-97.6]). Baseline left ventricular end systolic volume index and left ventricular ejection fraction (LVEF) before chemotherapy were similar between two groups. After chemotherapy, the occurrence of CTRCD was higher in low NRI group than in high NRI group (14.8% vs. 3.5%, P=0.012). Furthermore, there was a correlation between the severity of NRI categories and the development of CTRCD. When we set the cut-off value of baseline NRI from ROC analysis at 100.8, sensitivity, specificity, and area under the curve to predict the occurrence of CTRCD were 71.4%, 70.7%, and 0.698, respectively. Multivariable logistic regression analysis revealed that baseline NRI value was an independent predictor of the development of CTRCD (odds ratio 0.935, 95% CI [0.881-0.992], P=0.026). The value of net reclassification index and integrated discrimination improvement for detecting CTRCD reached statistical significance when baseline NRI value was added to the regression model including known risk factors such as age, female gender, the presence of hypertension, chronic kidney disease, cumulative anthracycline dose, the usage of HER2 inhibitor, and radiation therapy; 0.872 (95% CI [0.421-1.323], P&lt;0.001) for net reclassification index and 0.035 (95% CI [0.002-0.067], P=0.033) for integrated discrimination improvement. Conclusion: Baseline NRI is a novel parameter to predict anthracycline-induced CTRCD.