Left Ventricular Longitudinal Strain Research Articles

S-29-5: EARLY CHANGES IN LEFT ATRIAL STRAIN AND GLOBAL VENTRICULAR FUNCTION IN HYPERTENSIVE PATIENTS WITH HEART FAILURE WITH PRESERVED EF

Background: Hypertension is one of leading causes in heart failure with preserved ejection fraction (HFpEF).Left atrial (LA) maximal volume and index (LAVI) had a prognostic value in patients with heart failure and incidence of atrial fibrilation (AF). Recently, LA mechanical function and LA strain have been introduced as alternative methods to assess LA performance more accuratly. Aim: To evaluate the relation between early changes in LA function and strain (PALS) and correlate the association with global left ventricular (LV) function and longitudinal strain (GLS) in patients with HFpEF.and arterial hypertension. Methods: We evaluated 152 subjects in sinus rhythm: 22 normals (31y ± 5), and 70 pts with HFpEF (65y ± 12), 60 pts HFrEF (64 y ± 10). Echocardiography was performed in all patients and follow up after 12 monts and analyzed offline in order to extract the global and segmental strain values of the LV and LA and LA volume and LAVI. Results: The two groups of patients were comparable for most of clinical variables. LV volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. The LA diameter and maximal volume were higher in HFrEF group. The GLS is significantly reduced in HFrEF group. LV GLS is the main parameter for myocardial dysfunction, which changed significantly in the HFrEF (p < 0,001) at 12mFU. Reduced PALS in HFrEF was associated with impairment of all measures of LV systolic and diastolic function and events of atrial fibrilation / 33 % in HFrEF and 12 % in HFpEF/ and the correlation between global longitudinal strain and PALS was highly significant (p < 0.001; r = 0.71). At 12mFU, PALS was significantly associated with lower global longitudinal strain in group with HFrEF (p < 0.001, r = 0.61), LAVI > 28 ml/m2 (p < 0.01,r = 0.57) and slightly decreased in HFpEF /p < 0.5, r = 0.34/. ROC analysis shows the cut of value of 29 % for PALS which correlated with AF events. Conclusions: PALS and GLS are significantly reduced in HFpEF patients and decreased in HFpEF. PALS provides additional,prognostic value beyond LA volume and LAVI. Severe LV myocardial dysfunction and reduced GLS and decreased PALS, even still normal LAVI is a prognostic index for AF.

Multimodality strategy for cardiac damage assessment in falciparum malaria: A preliminary study

Malaria caused by the Plasmodium falciparum (P.f) parasite can result in life-threatening complications. Traditionally, cardiac involvement has not been included as a frequent cause of morbidity and mortality. Cardiac damage in P.f infection is probably underdiagnosed. To analyze the hypothesis of cardiac damage in apparently uncomplicated P.f infection with a multimodality strategy unavailable in most endemic countries. Cardiac biomarkers, ECG and 24 h ECG recording, transthoracic echocardiography with global strain analysis, and complete CMR analysis, including T2 (Fig. 1) and T1 mapping and extracellular volume quantification (ECV), were performed in patients hospitalized for malaria in a French tertiary center. Ten cases (sex ratio: 1 – mean age: 45 ± 13 years) imported from sub-Saharan Africa were prospectively included. Mean P.f parasitemia was 1.6 ± 1.7%. Hs-c Troponin T and NT pro BNP were mildly increased respectively in 1 and 2 patients. 24-h ECG recording revealed > 500 ventricular premature beats in 2 patients. Imaging revealed normal left and right ventricular systolic function, diastolic function and longitudinal global strain in all but one patient. CMR revealed 2 cases of focal late gadolinium enhancement consistent with the diagnosis of acute myocarditis in 1 case. ECV value was increased in 1 case (dilated cardiomyopathy). All patients were treated with piperaquine + dihydroartemisine and had a favorable outcome. Multimodality strategy reveals some cardiac abnormalities (ventricular ectopy, myocarditis) in patients hospitalized for falciparum malaria. Specificity of such findings remains questionable in this preliminary study. Further investigation is required to conclude about the hypothesis of a significant malaria-induced cardiac.

Impaired Speckle-Tracking-Derived Left Ventricular Longitudinal Strain Is Associated with Transposition of Great Arteries in Neonates: A Single-Center Study.

The transposition of great arteries (TGA) is one of the most frequent and severe congenital heart diseases. After newborn stabilization and while pending surgical correction, echocardiographic monitoring with a careful evaluation of left ventricle (LV) performance is warranted. In this study, our objectives were (i) to compare myocardial function, assessed via speckle-tracking echocardiography, between neonates with TGA and neonates without TGA and (ii) to identify a strain parameter with a good discriminatory ability for TGA. We conducted a retrospective, single-center study. A total of 90 neonates were examined, of whom 66 were included (16 comprised the TGA group and 50 comprised the control group). The results of a bivariate analysis showed that classic echocardiography parameters displayed no significant differences between the two studied groups (p = 0.785 for EF, p = 0.286 for MAPSE and p = 0.315 for TAPSE). We found a statistically significant difference between the two groups for the mean values of the LVpGLS parameter (adjusted p = 0.0047), with impaired LV myocardium function being observed in the TGA group after adjusting for other covariates. Regarding segmental strain, the mean medial and apical inter-ventricular septum strain values were found to be significantly lower in the neonates with TGA than in the controls (95% CI for difference in means: [-6.45, -0.65], [-8.56, -1.97]). The results of an ROC analysis showed that LVpGLS had a significant ability to differentiate between neonates with TGA and controls (AUC = 0.712, 95% CI: [0.52, 0.903], p = 0.011). In conclusion, LVpGLS is a parameter with a significant discriminatory ability for LV dysfunction, and it is useful in the evaluation of ventricular myocardial function in newborns with TGA.

Mid- and Long-Term Atrio-Ventricular Functional Changes in Children after Recovery from COVID-19.

Background: Although most children may experience mild to moderate symptoms and do not require hospitalization, there are little data on cardiac involvement in COVID-19. However, cardiac involvement is accurately demonstrated in children with MISC. The objective of this study was to evaluate cardiac mechanics in previously healthy children who recovered from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in a long-term follow-up by means of two-dimensional speckle-tracking echocardiography (STE). Methods: We analyzed a cohort of 157 paediatric patients, mean age 7.7 ± 4.5 years (age range 0.3−18 years), who had a laboratory-confirmed diagnosis of SARS-CoV-2 infection and were asymptomatic or mildly symptomatic for COVID-19. Patients underwent a standard transthoracic echocardiogram and STE at an average time of 148 ± 68 days after diagnosis and were divided in three follow-up groups (<180 days, 180−240 days, >240 days). Patients were compared with 107 (41 females—38%) age- and BSA-comparable healthy controls (CTRL). Results: Left ventricular (LV) global longitudinal strain (post-COVID-19: −20.5 ± 2.9%; CTRL: −21.8 ± 1.7%; p < 0.001) was significantly reduced in cases compared with CTRLs. No significant differences were seen among the three follow-up groups (p = NS). Moreover, regional longitudinal strain was significantly reduced in LV apical-wall segments of children with disease onset during the second wave of the COVID-19 pandemic compared to the first wave (second wave: −20.2 ± 2.6%; first wave: −21.2 ± 3.4%; p = 0.048). Finally, peak left atrial systolic strain was within the normal range in the post-COVID-19 group with no significant differences compared to CTRLs. Conclusions: Our study demonstrated for the first time the persistence of LV myocardial deformation abnormalities in previously healthy children with an asymptomatic or mildly symptomatic (WHO stages 0 or 1) COVID-19 course after an average follow-up of 148 ± 68 days. A more significant involvement was found in children affected during the second wave. These findings imply that subclinical LV dysfunction may also be a typical characteristic of COVID-19 infection in children and are concerning given the predictive value of LV longitudinal strain in the general population.

Correlating decline in left ventricular ejection fraction and longitudinal strain in pediatric cancer patients.

Left ventricular ejection fraction (LVEF) is routinely used to monitor cardiac function in cancer patients. Global longitudinal strain (GLS) detects subclinical myocardial dysfunction. There is no consensus on what constitutes a significant change in GLS in pediatric cancer patients. We aim to determine the change in GLS associated with a simultaneous decline in LVEF in pediatric cancer patients. This is a retrospective longitudinal study of pediatric cancer patients treated with anthracyclines between October 2017 and November 2019. GLS was measured by 2-dimensional speckle tracking. The study outcome was a decline in LVEF, defined as a decrease in LVEF of ≥ 10% points from baseline or LVEF < 55%. We evaluated two echocardiograms per patient, one baseline, and one follow-up. The follow-up echocardiogram was either (1) the first study that met the outcome or (2) the last echocardiogram available in patients without the outcome. Statistical analyses included receiver operator characteristic curves and univariable and multivariable Cox proportional hazards regression. Out of 161 patients, 33 (20.5%) had a decline in LVEF within one year of follow-up. GLS reduction by ≥ 15% from baseline and follow-up GLS >-18% had sensitivities of 85% and 78%, respectively, and specificities of 86% and 83%, respectively, to detect LVEF decline. GLS reduction by ≥ 15% from baseline and follow-up GLS >-18% were independently associated with simultaneous LVEF decline [hazard ratio (95% confidence intervals): 16.71 (5.47-51.06), and 12.83 (4.62-35.63), respectively]. Monitoring GLS validates the decline in LVEF in pediatric cancer patients.

517 RIGHT ATRIAL THROMBUS IN A PATIENT WITH CARDIAC AMYLOIDOSIS: A MULTIMODALITY IMAGING APPROACH

Abstract Case Presentation A 47-year-old man was referred to our outpatient clinic for dyspnea and chest pain. His past medical history was remarkable for an admission of acute congestive heart failure, occurred two weeks before presentation. On that occasion, the patient was discharged after a few days of diuretic therapy. Diagnostic Workup at presentation, the patient was symptomatic for dyspnea with signs of systemic congestion. The ECG showed sinus rhythm, inferolateral negative T waves and absent progression of R wave in precordial leads. Transthoracic echocardiography revealed markedly thickened left ventricular (LV) walls (maximum interventricular septum dimension 19 mm) with a granular-sparkling appearance of the myocardium, bi-atrial enlargement, preserved LV ejection fraction, restrictive mitral flow pattern thickened interatrial septum and atrio-ventricular valves. No significant valvular regurgitations were detected. Global LV longitudinal strain was significantly reduced (-9.4%), with relative apical sparing. Given the high suspicion for infiltrative disease we performed further investigations. The cardiac computed tomography (CCT) excluded significant coronary artery disease, but it raised the suspicion of a thrombus at the level of the right atrial appendage, that was confirmed by a transesophageal echocardiography showing a mobile round mass of 14×12 mm. Finally, tissue characterization by cardiac magnetic resonance exhibit a diffuse myocardial delayed enhancement, with a dark blood pool and, an increase in extracellular volume and T1 mapping values (1266.3 ms). Laboratory tests showed increased levels of creatinine, BNP and, lambda light chains. Bone scintigraphy imaging didn't identify any uptake of radiotracers at myocardial level. These findings were suggestive for cardiac light-chain (AL) amyloidosis. Accordingly, a treatment with warfarin, beta-blockers, steroid, and diuretics was initiated. Conclusions cardiac amyloidosis is an infiltrative disease characterized by the deposition of aggregates of amyloid fibrils in the myocardium. Multimodality imaging is pivotal to determine the diagnosis, assess the potential complications, and stratify the patients’ prognosis. Our case demonstrates that cardiac AL amyloidosis is associated with an increased thromboembolic risk, irrespective of the presence of atrial fibrillation. Moreover, although the left atrial appendage is most frequently the site of thrombus formation, it is advised to look for them also in uncommon sites as the right atrial appendage.

228 PD-1-TARGETED T-CELL CHECKPOINT INHIBITORS-RELATED MYOCARDITIS COMPLICATED BY COMPLETE ATRIOVENTRICULAR BLOCK: A CASE SERIES OF SUCCESSFUL MANAGEMENT

Abstract Background Immune checkpoint inhibitors (ICI) have revolutionized the clinical management of a broad spectrum of solid and hematopoietic malignancies over the past decade. ICI are associated with several Immune-related Adverse Events, among which myocarditis and atrioventricular blocks are uncommon but potentially fatal toxicities. Material and Methods We describe two patients undergoing treatment with PD-1 checkpoint inhibitors for metastatic cancers who developed myositis and myocarditis complicated by complete atrioventricular block (CAVB). The first patient had a history of metastatic sarcomatoid urothelial carcinoma treated with Pembrolizumab. After two cycles, he developed eyelid ptosis and was hospitalized for syncopal episodes due to CAVB associated with ICI myocarditis. The second patient had a history of metastatic melanoma and was hospitalized for myocarditis and myositis after the second infusion of Nivolumab. Results In the first case, high-dose corticosteroid therapy was promptly initiated, with subsequent rapid recovery of sinus rhythm and rapid resolution of symptoms. The second patient, despite high-dose corticosteroid therapy, developed CAVB requiring implantation of a definitive PM. After initiation of mycophenolate mofetil and intravenous immunoglobulin therapy, gradual recovery was observed. Both patients had normal left ventricular function with no wall motion abnormalities. However, speckle tracking echocardiography revealed a normal global longitudinal left ventricular strain (GLS) of -19.8% in patient 1 and a depressed GLS of -14.7% in patient 2, consistent with the different evolution of the two myocarditis. Conclusions We recommend a high degree of caution and awareness to all physicians when treating immunotherapy patients. Myocarditis is a relatively rare but potentially fatal event due to its early onset, non-specific clinical presentation and fulminant progression. GLS may be useful in detecting myocardial damage in these patients. Discontinuation of ICI, cardiac pacing, treatment with high-dose corticosteroids and immunosuppressive agents may improve the outcome.

558 BIVENTRICULAR PERIOPERATIVE TAKOTSUBO CARDIOMIOPATHY

Abstract Introduction Perioperative Takotsubo cardiomyopathy (pTC) represents a rare and still not well characterized disease. Biventricular involvement is an uncommon manifestation of TC and is associated with a more severe clinical presentation. Case report A 72-year-old male, hospitalized for a laparoscopic left hemicolectomy, was transferred to ICU after having developed severe bradycardia, treated with Adrenalin, and cardiogenic shock during induction of general anesthesia. EKG showed complete atrio-ventricular block, so a temporary PMK was placed. Troponin was raised. Echocardiogram showed severe biventricular disfunction (LVEF 25%, TAPSE 12 mm) with akinesia of medio-apical segments, suggesting a biventricular pTC. Also, there was a reduction of 3D LV longitudinal strain (- 5,8%), particularly of the medio-apical portion, and RV free wall longitudinal strain (- 11%). Coronary angiography resulted negative. Patient's hemodynamic was supported with Noradrenalin and a cycle of Levosimendan, allowing to reach stability. Further echocardiogram showed improvement of biventricular function and longitudinal strain values. Due to the persistency of atrio-ventricular block, a definitive PMK was placed. Patient was discharged after therapy optimization. Discussion pTC is a little-known disease, as incidence and etiology are not well definite. Literature suggests a relation between pTC and physical or emotional stress due to surgery to promote an increase of catecholamine release. Other potential factors may be inadequate depth of anesthesia or tracheal manipulation during intubation and catecholaminergic drugs administration. On the other hand, the use of anesthetic volatile agents seems to have a cardioprotective effect. PTC is more common during general anesthesia and when occurs intraoperatively has a worse clinical presentation. Biventricular involvement, which is a rare and severe manifestation of TC, has been reported frequently among pTC patients. To date, due to the lack of a systematic review, there is little knowledge about potential risk factors, prevention strategies and management of pTC. Conclusions Despite multiple cases of pTC have been reported, several characteristics of this entity are not fully understood. However, it must be considered as a part of differential diagnosis in patients with anaesthesia-related decompensation. Biventricular involvement represents an infrequent presentation and its commonly associated with life-threating hemodynamic impairment.

The Early Effects of Bariatric Surgery on Cardiac Structure and Function: a Systematic Review and Meta-Analysis.

This meta-analysis was performed to investigate how cardiac structures and functions change in the very early stage after bariatric surgery. We thoroughly searched the PubMed, Embase, Cochrane Library, and Web of Science databases for articles including patients who underwent bariatric surgery and examined the changes of their cardiac indices. Results were pooled by using Review Manager 5.1 and Stata 12.0. Weighted mean differences (WMDs) with 95% confidence intervals (CIs) were obtained. The I-squared (I2) test was used to determine the heterogeneity between studies. To identify publication bias, funnel plots and Egger's test were utilized. The leave-one-out method was used to conduct sensitivity analysis. In this meta-analysis, 24 research including 942 patients were considered. According to our findings, most cardiac indices changed 3-6months following bariatric surgery. An improvement in cardiac geometry was reflected by a reduction in left ventricular mass (LVM) (WMD = - 22.06, 95% CI = (- 27.97, - 16.16)). The left ventricular diastolic function improved, as reflected by the decrease in the E/e' ratio (WMD = - 0.90, 95% CI = (- 1.83, - 0.16)). Left ventricular ejection fraction (LVEF) did not show an obvious change (WMD = 0.94, 95% CI = (- 0.19, 2.07)), while a more sensitive indicator of left ventricular systolic function, left ventricular longitudinal strain (LV LS), increased (WMD = - 2.43, 95% CI = (- 3.96, - 0.89)). This meta-analysis includes the newest and most comprehensive cardiac indices to prove that cardiac structures and functions are improved early after bariatric surgery, which has not been reported by any other studies.

Left Ventricular Functions Assessment by Speckle Tracking in Comparison with The Two-Dimensional (2D) Echocardiography in Patients with Fragmented QRS

Background and Aim: Fragmented QRS (fQRS) are electrocardiographic signals reflecting altered ventricular conduction around regions of a myocardial scar and/or ischemia. However, it could be presented in normal healthy individuals. But, its incidence and its role in prediction of cardiac disease is not yet addressed. This study aiming to assess the left ventricular (LV) functions in patients with apparent normal LV functions with fQRS using two-dimensional (2D) speckle tracking echocardiography. Patients and Methods: This cross-sectional study take place from March to October 2020. Fifty non cardiac patients who undergo preoperative cardiac assessment of non-cardiac surgery at cardiology department were included. All subjects are submitted to full history taking, complete general and local examinations, twelve lead ECG searching for fQRS complex and exclude ischemia and arrhythmia, and transthoracic echocardiography to assess LV functions as described previously. Results: 36% fQRS complex was in anterior lead, 50% were in Inferior lead and only 14 % was in Lateral lead. Mean EF was 58.9 ± 5.8%, ranging from 55 to 65, FS was 26.7±1.9%, with range of 24 to 40%. LVEDD 4.5±0.7cm, LVESD was 3.3±0.4cm, Intraventricular septum was 10.1±0,6 mm and Posterior wall thickness 9.6±07 mm. Left ventricular longitudinal strain in 2 chamber apical view was 16.4±3.3%, 4 chamber apical view was 16.7±3%, apical long axis view was 17.7±3.5% and average LV GLS was 18.1±2.9%. There were 15 cases abnormal LV diastolic function according to E/e` ratio and 9 cases according to LV-GLS. There was statistically significant different between assessment of LV function by 2D echocardiography and speckle tracking. Conclusion: The presence of fQRS on standard electrocardiography in apparently healthy people with preserved EF is associated with some sort of subclinical LV dysfunction and two-dimensional speckle tracking is more accurate and sensitive than two-dimensional echocardiography in detection of those patients.

Pediatric Normal Values and Z Score Equations for Left and Right Ventricular Strain by Two-Dimensional Speckle-Tracking Echocardiography Derived from a Large Cohort of Healthy Children

Strain values vary with age in children and are both vendor and platform specific. Philips QLAB 10.8 and TomTec AutoSTRAIN are two widely used strain analysis platforms, and both incorporate recent European Association of Cardiovascular Imaging/American Society of Echocardiography/Industry Task Force to Standardize Deformation Imaging guidelines. The aims of this study were to establish normal strain values and Z scores for both platforms using a large data set of healthy children and to compare values among these two platforms and a previous version, QLAB 10.5, which predated the task force guidelines. Echocardiograms from 1,032 subjects <21years old with structurally and functionally normal hearts were included. Images were obtained on the Philips EPIQ platform. Left ventricular (LV) and right ventricular (RV) strain was analyzed using QLAB 10.8 and AutoSTRAIN, and measurement reliability was assessed. Z score equations were derived as a function of age for QLAB 10.8 (LV longitudinal and circumferential strain) and AutoSTRAIN (LV and RV longitudinal strain). A subset (n=309) was analyzed using QLAB 10.5. Strain values were compared among the three platforms. For both of the newer platforms, strain varied with age, with magnitude reaching a maximum at 4 to 5years. For LV longitudinal strain, the largest differences in value were observed in the youngest patients when using QLAB 10.5; the other two platforms were similar. LV circumferential strain measurements (QLAB 10.5 vs QLAB 10.8) were different for all ages, as were measurements of RV longitudinal strain (QLAB 10.8 vs AutoSTRAIN). Reliability was greater for AutoSTRAIN than for QLAB 10.8 and greater for LV than for RV strain. Normal RV and LV strain values and Z scores were generated from a large cohort of children for two commonly used platforms in pediatric echocardiography laboratories. Following the incorporation of task force guidelines, the greatest improvement in standardization was seen in infants. Small differences persist between modern platforms; however, these results support the cautious consideration of comparing interplatform measurements.

Machine learning approach in diagnosing Takotsubo cardiomyopathy: The role of the combined evaluation of atrial and ventricular strain, and parametric mapping

BackgroundCardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) is a key diagnostic tool in the differential diagnosis between non-ischemic cause of cardiac chest pain. Some patients are not eligible for a gadolinium contrast-enhanced CMR; in this scenario, the diagnosis remains challenging without invasive examination. Our purpose was to derive a machine learning model integrating some non-contrast CMR parameters and demographic factors to identify Takotsubo cardiomyopathy (TTC) in subjects with cardiac chest pain. Material and methodsThree groups of patients were retrospectively studied: TTC, acute myocarditis, and healthy controls. Global and regional left ventricular longitudinal, circumferential, and radial strain (RS) analysis included were assessed. Reservoir, conduit, and booster bi-atrial functions were evaluated by tissue-tracking. Parametric mapping values were also assessed in all the patients. Five different tree-based ensemble learning algorithms were tested concerning their ability in recognizing TTC in a fully cross-validated framework. ResultsThe CMR-based machine learning (ML) ensemble model, by using the Extremely Randomized Trees algorithm with Elastic Net feature selection, showed a sensitivity of 92% (95% CI 78–100), specificity of 86% (95% CI 80–92) and area under the ROC of 0.94 (95% CI 0.90–0.99) in diagnosing TTC. Among non-contrast CMR parameters, the Shapley additive explanations analysis revealed that left atrial (LA) strain and strain rate were the top imaging markers in identifying TTC patients. ConclusionsOur study demonstrated that using a tree-based ensemble learning algorithm on non-contrast CMR parameters and demographic factors enables the identification of subjects with TTC with good diagnostic accuracy. Translational outlookOur results suggest that non-contrast CMR features can be implemented in a ML model to accurately identify TTC subjects. This model could be a valuable tool for aiding in the diagnosis of subjects with a contraindication to the contrast media. Furthermore, the left atrial conduit strain and strain rate were imaging markers that had a strong impact on TTC identification. Further prospective and longitudinal studies are needed to validate these findings and assess predictive performance in different cohorts, such as those with different ethnicities, and social backgrounds and undergoing different treatments.

Abstract 9764: Simultaneous Assessment of Coronary Flow Reserve and Left Ventricular Strain During Vasodilator Stress Measured by 13 N-ammonia Positron Emission Tomography/Magnetic Resonance Imaging

Introduction: Hybrid positron emission tomography (PET)/magnetic resonance imaging (MRI) is able to yield important information regarding molecular and functional imaging in a one-stop examination. The aim of this study was to investigate the relationship between coronary flow reserve (CFR) and left ventricular longitudinal strain (LVLS) using simultaneous acquisitions on hybrid 13 N-ammonia PET/MRI. Methods: Thirty-eight patients with suspected coronary artery disease (CAD) who underwent 13 N-ammonia PET/MRI were enrolled. Vasodilator stress was induced by intravenous injection of adenosine. CFR was calculated from dynamic acquisition of 13 N-ammonia PET. LVLS was evaluated by feature-tracked MRI. Myocardial flow reserve (MFR) and LVLS values were based on a 17-segment model and three coronary territories, left anterior descending artery (LAD), left circumflex artery (LCx), and right coronary artery (RCA). Results: We analyzed 577 myocardial segments in the left ventricle. LVLS under vasodilator stress was significantly increased compared with LVLS at rest in myocardial segments with MFR ≥2.0 (P&lt;0.01), whereas there were no changes between LVLS under stress and LVLS at rest in the segments with MFR &lt; 2.0 (P=0.24). Similarly, regional values of LVLS under vasodilator stress were significantly increased compared with those measured at rest in the coronary territories of LAD (P&lt;0.01), LCx (P&lt;0.01), and RCA (P&lt;0.01) with MFR ≥ 2.0, whereas there were no differences between LVLS at rest and LVLS under stress in those territories with CFR &lt; 2.0 (P=0.45). These data revealed that left ventricular strain under vasodilator stress was impaired in segments with lower CFR. Conclusion: Simultaneous assessment of regional CFR and LV strain was feasible using by 13 N-ammonia PET/MRI. 13 N-ammonia PET/MRI was able to detect not only impaired CFR but also morphological abnormalities, which may improve diagnostic and predictive capacity in patients with CAD.

Abstract 14802: Influence of Coronary Artery Anomalies on Left Ventricle Function After Arteries Switch Operation: A Two-Dimensional Speckle Tracking Echocardiography Study

Background: This study aimed to assess the influence of the complexity of coronary arteries (CA) anomalies and high-risk CA on Left ventricular (LV) function after arterial switch operation (ASO) using two-dimensional speckle-tracking echocardiography. Methods: Sixty patients with transposition of the great arteries after ASO who underwent echocardiography performed between January 2007 and June 2021 and thirty controls were studied. Patients after ASO were categorized into three subgroups: usual CA group ( n = 30), low-risk CA group ( n = 22), and high-risk CA group ( n = 8). LV longitudinal strain (LS) at the apical four-chamber view was analyzed. Results: Compared with controls, age at echocardiography examination (5.5 ± 3.1 years vs. 7.5 ± 3.9 years, P = 0.008) and body surface area (median 0.8 m 2 vs. 1.0 m 2 , P = 0.033) were smaller in ASO group. Patients after ASO had significantly lower septal e’ (10.9 ± 1.3 cm/s vs. 13.7 ± 2.2 cm/s, P &lt; 0.001), a’ (5.3 ± 0.8 cm/s vs. 7.2 ± 1.6 cm/s, P &lt; 0.001), and s’ (5.9 ± 0.9 cm/s vs. 8.4 ± 1.5 cm/s, P &lt; 0.001), and greater E/e’ (10.3 ± 2.4 vs. 8.0±1.7, P &lt; 0.001) than controls. Patients after ASO had normal and comparable LV ejection fraction (63.3 ± 4.7% vs. 63.0 ± 5.1%, P = 0.771), while LV LS were significantly lower (-20.9 ± 2.4% vs. -24.2 ± 2.0%, P &lt; 0.001) to controls. LV ejection fraction was similar among usual, low-risk, and high-risk CA groups (64.2 ± 4.6% vs. 62.3 ± 4.8% vs. 62.9 ± 4.8%, P = 0.557), while LV LS was significantly lower in high-risk CA group (-18.3 ± 2.6% vs. -21.5 ± 2.1% vs. -21.1 ± 2.2%, P &lt; 0.001). LV LS was negatively correlated with the level of complexity of CA anatomy ( r = -0.288, P = 0.026) and positively correlated with septal E/e’ ( r = 0.268, P = 0.038). Conclusion: LV systolic and diastolic function were generally normal, however, significantly lower in patients at 5 years after ASO than in healthy peers. Patients with high-risk CA are associated with greater impairment of ventricular systolic myocardial deformation.

Abstract 14737: Right Heart Remodeling After Pulmonary Valve Replacement in Patients With Pulmonary Atresia With Intact Ventricular Septum and Critical Pulmonary Stenosis

Background: Patients with pulmonary atresia with intact ventricular septum (PA/IVS) and critical pulmonary stenosis (CPS) managed to a biventricular circulation may eventually require pulmonary valve replacement (PVR) for pulmonary regurgitation (PR). Right ventricular (RV) remodeling after PVR has been well described in tetralogy of Fallot (TOF); we sought to investigate RV volumetric and functional changes in PA/IVS using CMR. Methods: A retrospective cohort of PA/IVS and CPS patients who underwent PVR at Boston Children’s Hospital from 1995-2021 with CMR before and after PVR was matched 1:3 with TOF patients by age at PVR. Patients with initial intervention &gt;2 weeks of age or 1.5 ventricle circulation were excluded. Median regression modeling accounting for matching was performed with reduction in indexed right ventricular end diastolic volume (RVEDVi) post PVR as the primary outcome, adjusting for covariates including tricuspid regurgitation (TR) and PVR valve size. Results: Twenty PA/IVS or CPS patients (cases) were matched with 60 TOF (controls), with median age at PVR 14 years; at median follow-up 8 years post PVR, 95% were NYHA Class I. Pre-PVR RVEDVi was similar between groups (165 vs 167 ml/m 2 , p=0.7), although cases had higher RV EF (51.4 vs 48.6%, p=0.03), TR fraction (23 vs 9%, p=0.008), and a trend toward lower RV mass; PR fraction, LV volumes and EF were similar. Pre-PVR RV free wall and LV longitudinal strain were similar, although LV circumferential strain was worse in cases (-15.6 vs -17.1, p=0.01). At median 2 years after PVR, RVEDVi was similarly reduced from 166 to 118 ml/m 2 (p=0.73), although cases had higher RV EF (52.3% vs 46.9%, p=0.007) with less reduction in indexed RV mass (Δ4.5 vs 9.6 g/m 2 , p=0.02); LV volumes and EF were similar. Post PVR, RV and LV longitudinal strain remained unchanged both within and between groups; LV circumferential strain was similar post PVR and remained lower in cases vs controls. Conclusion: Patients with PA/IVS after PVR demonstrate similar RV remodeling to TOF patients, with lesser reduction in RV mass and comparatively better post RV EF. CMR strain imaging found no significant pre-post differences in RV or LV systolic parameters. Further investigation is needed to evaluate for changes in diastolic parameters.

Abstract 13860: Heart Failure With Preserved Ejection Fraction Induced by Amyloid Light Chain Amyloidosis: A Case Report

Introduction: Cardiac amyloidosis is a clinical disorder defined as an extracellular deposition of protein in the heart. Typically, signs and symptoms of heart failure develop in the advanced disease. High index of suspicion is required for the diagnosis of this disorder. Results: A 62 years old male came to the cardiology clinic due to lower extremity edema, fatigue, dyspnea on exertion. He had a 3 month history of progressive lower leg edema. On physical examination he had a positive S4; lung sounds were diminished and there was dullness to percussion over the lower two thirds; and bilateral lower extremity edema. Hospital admission was decided for management of decompensated heart failure. On admission, the surface ECG showed normal sinus rhythm with low QRS voltage in the limb leads, a RBBB and LPFB. Initial laboratory reported elevated NT-proBNP: 13,816 pg/mL. Chest x-ray demonstrated right interstitial infiltration and bilateral pleural effusion. The echocardiogram revealed severe concentric hypertrophy of the left ventricle, an apical sparing left ventricle longitudinal strain, and an ejection fraction of 68%. A cardiac MRI showed concentric biventricular hypertrophy associated with extensive diffuse late gadolinium enhancement, suggestive of cardiac amyloidosis. Screening resulted in a Perugini score of 1 on Tc-PYP scintigraphy, elevated Kappa and Lambda light chains on serum, and kidney biopsy positive for amyloidosis. Hematology-oncology consultation was done and a daratumumab-CyBorD protocol was started. Conclusions: This case elucidated a stepwise diagnostic approach of cardiac amyloidosis in a patient presenting with signs and symptoms of heart failure. Amyloid AL cardiac amyloidosis and its repercussions are severe because it not only compromises by being infiltrative but also by its toxic capacity. A high index of suspicion and a multidisciplinary approach is needed in order to improve quality of life and prolong survival.

Abstract 12797: Obesity Predisposes Pediatric Cancer Patients Treated With Anthracyclines to Subclinical Cardiac Dysfunction Detectable by Strain Echocardiography

Introduction: Anthracyclines are used in &gt; 60% of pediatric cancer cases yet are associated with a life-long risk of cardiomyopathy. Strain echocardiography is currently the standard of care for cardiac surveillance in adult cardio-oncology. However, strain has yet to be widely evaluated in the pediatric population. Hypothesis: Strain analysis on echocardiograms from anthracycline-exposed pediatric patients will identify dysfunction that is overlooked by left ventricular ejection fraction (LVEF) alone and which will be associated with identifiable cardiovascular risk factors. Methods: All anthracycline-exposed cancer patients &lt; 18 years old with an initial visit to Duke University between 2013-2019 were identified. Subjects with cancer relapses, congenital heart disease, or inadequate imaging for analysis were excluded. Peak longitudinal left ventricular strain was calculated from the 4-chamber view on all adequate surveillance studies for each patient using the TOMTEC AutoSTRAIN software. Univariate and multivariate Cox proportional hazards models were created to identify risk factors for abnormal LVEF (&lt;50%) or abnormal longitudinal strain (&gt;-16%). Results: The cohort included 101 subjects (52% male) with 606 echocardiograms for analysis. Median age at diagnosis was 12 years (IQR = 3-15), and median anthracycline dose was 201 mg/m 2 (IQR = 120-284). Median follow-up duration was 3.7 years (IQR = 2.3-5.3). Abnormal LVEF was identified in 5 subjects, while abnormal strain was identified in 16 subjects. All subjects with abnormal LVEF also had abnormal strain. When adjusting for dose, BMI, and family history of cardiovascular disease, anthracycline dose &gt; 250 mg/m 2 and BMI &gt; 25 at diagnosis were predictors of abnormal strain with hazards ratios of 3.3 (p =.02, CI = 1.2-8.9) and 3.2 (P = .03, CI = 1.1-9.5), respectively. Anthracycline dose was the only significant predictor of abnormal LVEF. Conclusions: Longitudinal strain is more sensitive than LVEF alone in identifying subclinical cardiac dysfunction in pediatric cancer patients, and those with a BMI &gt; 25 at diagnosis are at an increased risk of dysfunction. Multi-center studies should further explore the link between obesity, early subclinical dysfunction, and subsequent cardiomyopathy.

Abstract 9390: Cardiac Geometry, Function, and Mechanics in Biventricular Takotsubo Syndrome

Introduction: Approximately 30% of patients with Takotsubo syndrome have biventricular involvement (BiV-TTS), which confers an increased morbidity. This study aimed to detail cardiac geometry, function and mechanics in BiV-TTS. Methods: Twenty-five patients diagnosed with BiV-TTS according to the InterTAK diagnostic criteria between 2006 to 2020 were retrospectively identified and analyzed with 2-dimensional and speckle-tracking strain echocardiography. An independent t-test, Mann-Whitney U-test, or Kruskal-Wallis test were used for the statistical analyses. Results: Mean age was 71.1 ± 17.9 years, and 56% were female. The LV ejection fraction was decreased (31.4 ± 12.2%), chamber size was increased (end-systolic volume index: 41.3 ± 10.2 ml/m2), and 48% had concentric remodeling. The right ventricular (RV) size was upper normal (40.6 ± 4.1 mm), and tricuspid annular plane systolic excursion was decreased (12.0 ± 2.6 mm). Sixteen patients had suitable images for speckle-tracking analysis. Global LV longitudinal strain was impaired (-7%, IQR -9.6 to -4.5), with significant differences between basal (-7.1%), mid (-4.3%), and apical (-0.2%) territories (P=0.001). Segmental strain within the LV base statistically varied, with the anteroseptum most impaired (-3.1%) and the inferolateral segments most preserved (-11%) (p=0.01). RV free wall strain was impaired (-9.9% ± 4.7), and differed between basal (-14.6%), mid (-11.9%), and apical (-5.4%) territories (P&lt;0.001). Females had worse global LV (-4.6 vs. -9.5%, p=0.02) and similar RV free wall strain (-9.6 vs. -10.2%, p=0.78) impairment compared with males. Conclusions: Chamber remodeling, dysfunction, and mechanical impairment characterize BiV-TTS. Important differences exist in territorial and segmental strain values, and between genders.

Prognostic value of right ventricular strain and peak oxygen consumption in heart failure with reduced ejection fraction.

Our purpose is to evaluate the combined predictive value of cardiopulmonary exercise testing (CPET) and echocardiographic evidence of left ventricular (LV) and right ventricular (RV) strain in predicting mortality and heart transplant (HTx) in a series of outpatients with heart failure with reduced ejection fraction (HFrEF). A retrospective cohort study of 66 patients with HFrEF (median age, 57years; 51% women) who underwent CPET and echocardiography (up to 90days apart) to assess prognosis. The primary outcome was a composite of death and need for HTx. At a median follow-up of 27 [20-39] months, 19 patients (29%) experienced the primary outcome. In unadjusted analysis, most echocardiographic and CPET parameters were associated with the primary outcome, including percentage of predicted peak oxygen consumption (ppVO2), VE/VCO2 slope, LV ejection fraction, and LV and RV longitudinal strain. After adjusting for other clinical, echocardiographic and CPET variables, RV free wall longitudinal strain and ppVO2 remained significantly associated with the primary outcome. Kaplan-Meier survival curves for death and HTx, based on the best cutoff values, showed lower survival rates in patients with impairment in both ppVO2 and RV FW-LS than in those with one or neither parameter impaired (p < 0.001). RV dysfunction and low cardiorespiratory fitness were independent markers of death and need for HTx. Impairment of both ppVO2 and RV FW-LS had a strong additive impact on prognostic assessment in this cohort of patients with HFrEF.

Post-PCI corrected TIMI Frame Count predicts left ventricular global longitudinal strain at 90 days post-STEMI in thrombolysis-treated patients: A pre-specified analysis of the MIRTOS study

IntroductionTicagrelor has been established as the P2Y12-inhibitor of choice in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI); however, its use has not been adequately studied in the context of thrombolysis. In the present study, we sought to investigate whether the administration of ticagrelor together with thrombolysis could result in a greater degree of left ventricular systolic function recovery compared to clopidogrel, at 90 days post-STEMI, as well as to evaluate post-PCI corrected TIMI Frame Count (CTFC) as a predictive marker of myocardial recovery in thrombolysis-treated patients. Material and methodsIn this pre-specified analysis of the MIRTOS trial, the degree of change in left ventricular ejection fraction (ΔLVEF) and left ventricular longitudinal strain (ΔLV-GLS) from baseline to 90 days post-randomization in all patients who underwent conventional and speckle-tracking echocardiography at both timepoints was compared between the ticagrelor and clopidogrel groups. In addition, speckle-tracking echocardiographic measurements were evaluated for any correlations to post-PCI CTFC. ResultsNo statistically significant differences were detected between the ticagrelor and clopidogrel groups for ΔLVEF (+3.61 ± 5.08 % versus +2.21 ± 4.78 %; P = 0.18) and ΔLV-GLS (−1.53 ± 2.7 % versus −1.21 ± 3.05 %; P = 0.73). A strong negative correlation was found between post-PCI CTFC and the absolute value of LV-GLS at 90 days post-randomization (r = −0.33, P = 0.014). ConclusionsOur work suggests that both P2Y12-inhibitors are accompanied with a similar degree of myocardial recovery in the context of lytic therapy. Importantly, post-PCI microvascular integrity is a predictor of 3-month left ventricular systolic function in STEMI patients initially treated with thrombolysis.