Longitudinal Left Ventricular Research Articles

1674 Is Arterial hypertension an intermediate step to heart failure with preserved ejection fraction?

Abstract Background Arterial hypertension (HT) is one of the main risk factors for the development of heart failure with preserved ejection fraction (HFpEF). The evaluation of cardiorespiratory fitness during the exercise may provide a clearer insight into this association. Purpose We assessed the hemodynamic, respiratory and metabolic characteristics of HT subjects and patients with HFpEF and HT (HFpEF-HT), combining cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE). Methods We studied 170 consecutive subjects, undergoing a symptom-limited graded ramp bicycle CPET-ESE: 52 stable (NYHA I-III) outpatients with HFpEF-HT (69 ± 13 years; 44 males, 85%) on optimal medical therapy, 86 well-controlled HT subjects (66 ± 10 years; 72 males, 84%) and 32 age and sex-matched healthy controls (59 ± 15 years; 24 males, 75%). Oxygen consumption (VO2), left ventricular (LV) ejection fraction (EF), global longitudinal strain (GLS), E/e’ and LV compliance (expressed as end-diastolic volume [EDV] / E/e’ ratio) were measured during exercise, including rest and peak lung ultrasound for B-lines evaluation. Results HT patients showed peak VO2 values (18.7 ± 2 ml/min/kg) higher than HFpEF-HT (15.2 ± 2 ml/min/kg, p < 0.0001) but lower than controls (24.4 ± 7.3 ml/min/kg, p < 0.0001). Regardless of a similar EF, HT subjects had lower low-load (at 4 min of effort) GLS (18.2 ± 3%) than controls (20.9 ± 3%, p < 0.0001), but higher than HFpEF-HT (16.8 ± 5%, p = 0.04). Likewise, peak diastolic function (E/e’ and LV compliance) was altered in HT patients (9.1 ± 2 and 13.4 ± 2) when compared to controls (6.2 ± 1 and 17.8 ± 2, all p < 0.0001), but less than in HFpEF (12.7 ± 3, p < 0.0001 and 12.1 ± 3, p = 0.003), as confirmed by peak B-lines (HFpEF-HT: 16 [interquartile range (IQR): 10 – 22], HT: 8 [IQR: 4 – 10] and controls: 0 [IQR: 0 – 2]; p < 0.0001). LV hypertrophy was reported in 37 patients (27%); it was more common in HFpEF (24/37, 65%) and associated with a significantly worse peak VO2 and systo-diastolic profile (all p < 0.05). Conclusions HT subjects represent an intermediate step from healthy subjects to HFpEF, showing altered functional capacity and systo-diastolic profile (Figure). LV hypertrophy characterises the clinical stage and portends a more severe cardiorespiratory fitness impairment. Abstract 1674 Figure

Left ventricular apical pacing in children: feasibility and long-term effect on ventricular function

Left ventricular apical pacing (LVAP) has been reported to preserve left ventricular (LV) function in chronically paced children with complete atrioventricular block (CAVB). We sought to evaluate long-term feasibility of LVAP and the effect on LV mechanics and exercise capacity as compared to normal controls. Thirty-six consecutive paediatric patients with CAVB and LVAP in the absence (N = 22) or presence of repaired structural heart disease (N = 14, systemic LV in all) and 25 age-matched normal controls were cross-sectionally studied after a median of 3.9 (interquartile range 2.1-6.8) years of pacing using echocardiography and exercise stress testing. Pacemaker implantation was uneventful and there was no death. Probability of the absence of pacemaker-related surgical revision (elective generator replacement excluded) was 89.0% at 5 years after implantation. Left ventricular apical pacing patients had lower maximum oxygen uptake (P = 0.009), no septal to lateral but significant apical to basal LV mechanical delay (P < 0.001) which correlated with decreased LV contraction efficiency (P = 0.001). Left ventricular ejection fraction and global longitudinal LV strain were, however, not different from controls. Results were similar in both the presence and absence of structural heart disease. Left ventricular apical pacing is technically feasible with a low reintervention rate. Mechanical synchrony between LV septum and free wall is maintained at the price of an apical to basal mechanical delay associated with LV contraction inefficiency as compared to healthy controls. Global LV systolic function is, however, not negatively affected by LVAP.

Assessment of Left Ventricular Asynchrony after Permanent Cardiac Pacing by Using Speckle Tracking Echocardiography

AbstractBackground: Echocardiography is important in assessing Left Ventricular (LV) Mechanical Dysynchrony (LVMD) and left ventricular function after permanent pacemaker. At present, Real-Time Three Dimensional Echocardiography (RT3DE) and tissue Doppler imaging (TDI) are the most sensitive and commonly used techniques for the quantification of LVMD. Global longitudinal strain (GLS) and LV dyssynchrony as-sessment enables us to detect early signs of LV dysfunction after cardiac pacing.Aim of Study: To evaluate LV mechanical dyssynchrony and LV function in different pacing modes after permanent cardiac pacing by using TDI and speckle tracking echocardi-ography and to correlate these changes with other clinical, electrocardiographic and echocardiographic data.Patients and Methods: Seventy patients were enrolled in this prospective cross sectional observational study, (mean age 60.99±13.77 years, 42 females), in Mansoura Specialized Medical Hospital over a period of 1 year from April 2018 to April 2019. All patients were assessed by thorough history taking, clinical examination, 12 lead surface ECG, echocar-diography, 2D speckle tracking echocardiography STE to assess GLS and tissue Doppler imaging TDI.Results: Regarding diastolic function by pulsed wave Doppler PWD: There was significant decrease in E/e¢ ratio (p<0.001 *), significant increase in myocardial performance index Tei index (p<0.001 *). Regarding internal dimensions and systolic function: There was significant increase in the following: Left Atrial Dimension (LAD) (p=0.001*), Left Ventricular End Systolic Dimension LVESD (p<0.001*) and Left Ventricular End Diastolic Dimension LVEDD (p<0.001 *) while there was significant decrease in ejection fraction EF (p<0.001 *) and fractional shortening FS (p<0.001 *). Regarding parameters of LV dysynchrony: There was significant increase in the following: Aortic preejection delay APED (p<0.001*), interventricular mechanical delay (p<0.001 *) and septal posterior wall motion delay SPWMD by M mode (p<0.001 *). Regarding parameters assessed by tissue synchronization imaging TSI: There was significant increase in the following: SD-Ts (p=0.001 *) and all segments Max delay (p=0.027*). Regarding parameters assessed by STE: There was significant decrease in global longitudinal strain GLS (p=0.034*) while there was significant increase in TP-SD by STE (p<0.001*).Also, there was significant decrease in global longitudinal strain GLS (p<0.001*) and significant increase in TP-SD by STE (p=0.001*) in DDD group. While there was significant decrease in global longitudinal strain GLS (p<0.001 *) and significant increase in TP-SD by STE (p<0.001*) in VVI group.Conclusion: GLS and 2D STE can help in the detection of subclinical left ventricular dysfunction after permanent pacemaker implantation before appearance of symptoms. Also, cardiac pacing leads to LVMD whatever the pacing mode is which may needs later on upgrading to cardiac resynchronization therapy CRT.

Assessment of Biventricular Function by Three-Dimensional Speckle Tracking Echocardiography in Adolescents and Young Adults with Human Immunodeficiency Virus Infection: A Pilot Study

Background: The purpose of the study was to assess biventricular parameters of wall deformation with three-dimensional speckle tracking echocardiography (3DSTE) in adolescents and young adults with human immunodeficiency virus (HIV) infection on antiretroviral therapy in order to detect a possible subclinical myocardial dysfunction. Methods: Twenty-one patients aged 12–39 years with HIV, 21 normal controls of the same age and sex, and 21 patients with idiopathic nonischemic dilated cardiomyopathy (DCM) were studied with 3DSTE. All HIV patients were stable in terms of HIV infection, with no history of heart disease or other chronic systemic disease except HIV infection, and were on highly active antiretroviral therapy with good immunological control. Standard echocardiographic measures of left ventricular (LV)-right ventricular (RV) function were assessed. 3D LV global longitudinal strain (GLS), circumferential strain, radial strain, and LV twist were calculated. Global area strain (GAS) was calculated by 3DSTE as percentage variation in surface area defined by the longitudinal and circumferential strain vectors. 3D RV global and free-wall longitudinal strain (FWLS) were obtained. Results: LV GLS and GAS were lower in HIV patients compared to normal controls (p = 0.002, and p = 0.01, respectively). There were no significant differences in LV ejection fractions between the groups. There was a weak positive correlation between LV GLS and age (r = 0.215, p = 0.034) and a weak negative correlation between LV GLS and nadir-CD4 T-cells count (r = 0.198, p = 0.043). DCM patients had more marked and widespread reduction in LV GLS and GAS compared to controls (p < 0.001), whereas in HIV patients LV strain impairment (p < 0.05) was more localized in basal and apical regions. RV FWLS was significantly reduced in HIV patients when compared with the control group (p = 0.03). No patient had pulmonary systolic pressure higher than 35 mm Hg. Conclusions: 3DSTE may help to identify HIV patients at high cardiovascular risk allowing early detection of biventricular dysfunction in the presence of normal LV ejection fraction and in the absence of pulmonary hypertension. LV strain impairment in HIV patients is less prominent and widespread compared to DCM patients.

Dynamic changes of heart structural and functional condition in patients with acute myocarditis

Diagnosis and prognosis of myocarditis course, which is an inflammatory heart muscle disease, has been and remains one of the most urgent, complex and unresolved problem in modern cardiology. The purpose of the study – to investigate the dynamic changes in the structural and functional heart state in patients with acute myocarditis and reduced left ventricular ejection fraction. Materials and methods. In total, 74 patients with clinically suspected acute myocarditis (AM) with reduced left ventricular (LV) ejection fraction (EF) ≤40 % and NYHA heart failure (HF) functional class II or higher were examined three times: in the first month of myocarditis debut, after 6 and 12 months of observation. All the patients underwent echocardiography and speckle-tracking echocardiography, Holter electrocardiogram monitoring and cardiac magnetic resonance imaging (MRI). Results. It was found that the debut of AM was characterized by the presence of active inflammatory process according to the cardiac MRI - edema and hyperemia of the myocardium were detected in 54.0 % and 70.2 % of cases, respectively, followed by LV dilation and systolic dysfunction as well as by a significant decrease in longitudinal and circumferential LV global systolic strain. After 12 months of observation, there was a significant increase in LV EF, decrease in end-diastolic volume index and an improvement in the parameters of longitudinal and circumferntial LV systolic strain by 30.8 % and 36.8 %, respectively, (P < 0.01), the frequency of active inflammatory changes in the myocardium was significantly reduced, herewith in 41.8 % of cases, delayed enhancement was noted, indicating fibrotic changes in the myocardium. The presence of delayed enhancement in cardiac MRI after 12 months since myocarditis onset was correlated with the presence of unstable ventricular tachycardia episodes (r = 0.62; P < 0.02) and with the frequency of ventricular extrasystoles (r = 0.53; P < 0.05). A significant influence of fibrotic changes in the myocardium on the presence of unstable ventricular tachycardia episodes in 12 months after the disease onset was confirmed by determining Fisher's exact test, its value was: P = 0.016 (P < 0.05). Conclusions. It was established that the debut of myocarditis was characterized by a significant violation of the structural and functional heart state: an active inflammatory process in the myocardium causedLV dilatation and contractile dysfunction. After 12 months, a decrease in detection of active inflammatory myocardial changes followed by regression ofLV dilation and its contractile function improvement was observed. It was proved that the presence of fibrotic changes in the myocardium in patients with myocarditis was associated with the persistence of ventricular rhythm disorders.

P2488The 2013 ACC/AHA pooled cohort equations and insulin resistance status for detection of early-stage heart failure in the community

Abstract Objectives Detection of heart failure (HF) in its subclinical phase would allow timely initiation of preventive measures that counter its pathophysiology. Here, we assessed the usefulness of traditional cardiovascular (CV) risk assessment and insulin resistance status to detect early-stage HF. Methods In 984 participants (mean age, 57.0 years, 52.3% women), we derived echocardiographic indexes of left ventricular (LV) structure and function and calculated the 10-year risk for a first atherosclerotic CV disease (ASCVD) using the 2013 ACC/AHA risk score. We assessed the discriminatory value of this risk score to detect LV maladaptation and the improvements in reclassification by insulin resistance status (HOMA-IR). Results The probability for LV maladaptation rose progressively with the 10-year ASCVD risk increasing. Participants at high 10-year ASCVD risk (&gt;7.5%) had indeed significantly higher odds for LV concentric remodeling (odds ratio, 4.84), LV hypertrophy (OR, 5.93), abnormal LV longitudinal strain (OR, 2.04) and LV diastolic dysfunction (OR, 25.3) as compared to those at low ASCVD risk (&lt;2.5%; P≤0.0003). Adding markers of insulin resistance to the ACC/AHA risk score moderately improved the integrated discrimination and net reclassification of all LV maladaptive phenotypes (P≤0.022) except LV diastolic dysfunction (P≥0.059). LV remodeling and abnormal LS was particularly more likely in insulin-resistant participants with a 10-year ASCVD risk between 5% and 15% than in their insulin-sensitive counterparts. Prediction of early-stage HF profiles 2013 ACC/AHA risk score Addition of insulin resistance status to the 2013 ACC/AHA risk score AUC (95% CI) Integrated Discrimination Improvement Net Reclassification Improvement Absolute IDI (%) P value NRI (95% CI) P value LV concentric remodeling 0.70 (0.66 to 0.74) 0.0083 (11.3%) 0.022 0.23 (0.067 to 0.39) 0.0058 LV hypertrophy 0.70 (0.66 to 0.74) 0.017 (20.7%) 0.0033 0.27 (0.11 to 0.43) 0.0011 Abnormal LV LS 0.56 (0.53 to 0.62) 0.022 (202.0%) &lt;0.0001 0.33 (0.18 to 0.49) &lt;0.0001 LV diastolic dysfunction 0.82 (0.78 to 0.86) 0.0007 (0.45%) 0.84 0.093 (−0.11 to 0.30) 0.38 ≥2 LV abnormalities 0.76 (0.72 to 0.80) 0.0087 (7.3%) 0.071 0.22 (0.042 to 0.40) 0.016 The integrated discrimination improvement (IDI) and net reclassification improvement (NRI) reflect the improvements in classification by adding insulin resistance (by HOMA-IR) to the 2013 ACC/AHA risk score. HOMA-IR, Homeostatic Model for Assessment of Insulin Resistance; LS, longitudinal strain; LV, left ventricular. Risk enhancers of LV maladaptation Conclusions The 2013 ACC/AHA risk score adequately captured the risk for echocardiographic phenotypes of early-stage HF. As risk enhancer, insulin resistance might improve risk stratification of subclinical HF in subjects at intermediate risk. Acknowledgement/Funding The European Union, European Research Council and the Flanders Scientific Research Fund supported this study.

P4353Global longitudinal strain is a measure of subclinical left ventricular dysfunction in chronic inflammatory autoimmune conditions

Abstract Background Myocardial deformation indices are proposed to be a more sensitive marker of subclinical dysfunction compared to standard measures of left ventricular (LV) systolic function. We hypothesize that subclinical myocardial dysfunction is present in chronic inflammatory autoimmune diseases such as Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA), despite both conditions being mediated by different pro-inflammatory modulators. Purpose Identify subclinical myocardial dysfunction through assessment of global longitudinal strain in two different chronic autoimmune conditions, SLE and RA. Methods Consecutive patients admitted to our institution with known history of SLE or RA (&gt;1 year disease activity) were examined. Patients with preexisting cardiac disease, LVEF &lt;50% and those without comprehensive transthoracic echocardiograms (TTE) were excluded. Mean longitudinal LV strain was performed offline using vendor-independent software (TomTec v4.6) and compared to age- and gender-matched controls with normal LV function and no history of cardiac disease. Results Of the 86 patients examined (mean age 53.01±21.74, 85.4% female), 51 (59.3%) had SLE and 35 (40.7%) had RA. No significant difference in BMI, hypertension, hypercholesterolemia, diabetes, obesity, obstructive sleep apnea and stroke was observed between controls and patients with SLE or RA. While there was no significant difference in LVEF between RA patients and matched controls, there was a significantly lower GLS in the RA cohort. Conversely, patients with SLE had significantly lower LVEF and GLS when compared to matched controls, despite LVEF being in the normal range. See Table 1. Receiver operator curve analysis revealed that mean GLS is a better discriminator for autoimmune disease with an area under the curve of 0.829 (95% CI, 0.77 to 0.89; p&lt;0.01) compared to LVEF with an area under the curve of 0.632 (95% CI, 0.55 to 0.72; p&lt;0.01). Echocardiographic Parameters SLE (n=51) Controls (n=51) Sig (p value) RA (n=35) Controls (n=35) Sig (p value) LVEDV (mls) 102±30 85±20 &lt;0.01 84±28 89±30 0.43 LVESV (mls) 36±17 29±9 0.02 26±14 30±12 0.24 Biplane LVEF % 59±6 63±4 &lt;0.01 62±6 62±5 0.81 LV Mass (grams/m2) 96±34 72±20 &lt;0.01 79±26 82±23 0.67 LV Mean GLS % 16.7±2.8 21.3±2 &lt;0.01 17.8±1.7 19.1±2.5 0.02 Conclusions Our results suggest that chronic inflammatory conditions (SLE and RA) are associated with subclinical cardiac dysfunction. Impaired GLS may reflect early myocardial damage and be used as a tool for screening of patients with inflammatory conditions. Acknowledgement/Funding None

P3437Impact of epicardial adipose tissue on global longitudinal strain: a study in patients with normal left ventricular ejection fraction

Abstract Background Epicardial adipose tissue (EAT) locates anatomically and functionally contiguous to the myocardium and coronary arteries. It has been suggested that EAT accumulation is associated with cardiac remodeling and impaired cardiac performance. However, its role in left ventricular (LV) wall strain remains unclear. Purpose In this study, we aimed to clarify: whether EAT accumulation is related to global longitudinal (GLS), circumferential (CS) and radial strain (RS); and if so, in which extent or by which amount of EAT are required to deteriorate these strain. Methods Total 180 patients who had no obstructive coronary artery disease (CAD) on multi-detector computed tomography (MDCT) coronary angiography and normal left ventricular ejection fraction (LVEF) on conventional echocardiography were recruited. Cardiac CT was used to quantify EAT volume (EATV) and echocardiographic speckle tracking was used to measure the GLS, CS and RS. EATV index (EATV/Body surface area) was determined as: EAT volume, the sum of the EAT area from the base to the apex of the heart (cm3)/body surface area (m2). Adipose tissue was determined as the density range between −190 and −30 Hounsfield unit. According to the median value (68 cm3/m2), patients were divided into lower and higher EATV index two groups. Results In higher EATV index group (95±19 cm3/m2), mean age, body mass index (BMI), prevalence of hyperlipidemia and prevalence of CAD were larger than in lower EATV index group (48±14 cm3/m2). Male gender, hypertension, diabetes, smoking and LV mass index were comparable between two groups. Patients in higher EATV index had lower GLS than those in lower EATV index (−19.4±1.2% vs. −18.8±1.3%, p=0.002). However, there were no significant difference between two groups regarding to the CS and RS. Linear regression analysis showed that there was strong correlation between EATV index and GLS (R=0.216, p=0.004); whereas, both RS and CS were strongly associated with the interventricular septum thickness (RS: R=0.248, p=0.003; CS: R= −0.192, p=0.023) and relative wall thickness (RS: R=0.178, p=0.036; CS: R= −0.184, p=0.030) but not with EATV; on multiple regression analysis, EATV was a predictor of GLS independent of age, male gender, BMI, diabetes, hyperlipidemia, hypertension and CAD (Adjusted R2=0.238, p&lt;0.001). Conclusion EATV is independently associated with GLS despite the preserved LVEF and lacking of obstructive CAD, and may play a significant role in estimating impaired longitudinal LV performance.

1201Cardiac function, structure, and speckle-tracking echocardiography-derived parameters after distal and conventional renal denervation: a double-blind randomized study

Abstract Background/Introduction Distal renal denervation (RD) of the segmental branches beyond the bifurcation of the main renal artery is considered more effective treatment than conventional RD of the trunk renal artery. Evidence accumulated over the last decade has shown that global longitudinal strain (GLS) from speckle-tracking analysis of 2-dimensional echocardiography may represent a sensitive parameter of the left ventricular (LV) dysfunction. Purpose We compared cardiac function, structure, and GLS parameters after distal and conventional RD in the double-blind randomized prospective study. Methods The study (NCT01499810) compromised 55 patients who met criteria for resistant hypertension and signed informed consent. Patients were randomized to either endovascular conventional RD of the main renal artery (group 1, n=27) or to distal treatment applied to the segmental branches after the bifurcation of the main renal artery (group 2, n=28). Parameters of GLS from speckle-tracking echocardiography, ejection fraction, thickness of the interventricular septum (IVS) and LV posterior wall (PW), as well as the parameters of the diastolic function of the heart were assessed at baseline and at 12-months follow-up. Reference echocardiographic values were adapted from the ASE/ESC guidelines. Baseline parameters of heart and drug intake did not significantly differ between patients at the time of randomization. Results Drug treatment consisted in combination therapy in the maximum tolerated doses. Patients used different types of drugs, but the number of drug classes did not significantly differ between groups (4.1 in group 1 vs. 4.2 in group 2). Reduction of systolic blood pressure was significantly greater after distal RD vs. conventional RD: −22.1 vs. −11.5 mm Hg, respectively (p&lt;0.05). Decrease in the LV wall thickness was significantly greater after distal RD then after conventional RD, namely: changes in the IVS thickness were −0.21 (−0.39; 1.2) mm after distal RD vs. 1.21 (−0.44; −2.64) mm after conventional RD, p=0.023; changes in the PW thickness were −0.87 (−2.6; −0.62) mm after distal RD vs. 0.07 (−0.45; 1.25) mm after conventional RD, p=0.021. Normalization of diastolic function was found in 13% ((group 1) and 26% ((group 2) in patients with first and second degrees of LV diastolic dysfunction. Speckle-tracking parameters of the left ventricle and some parameters of the left atrium (reduced size by 18% vs 27% of patients) also improved after DRD. Conclusion(s) Compared to conventional RD, distal RD treatment applied to the segmental branches beyond the bifurcation of the main renal artery significantly greater attenuated the LV wall thickness and the number of patients with diastolic dysfunction. At 12-month follow up, the global longitudinal LV function also improved in distal RD patients.

P888Left ventricular diastolic function and left atrial longitudinal function during exercise correlate with exercise capacity in patients with hypertrophic cardiomyopathy

Abstract Background The clinical course of hypertrophic cardiomyopathy (HCM) is heterogeneous and the development of heart failure (HF) is difficult to predict. Exercise echocardiography can provide information about mechanisms involved in the occurrence of HF symptoms: development of intraventricular obstruction, increase in mitral regurgitation (MR) severity, impaired left ventricular (LV) and left atrial (LA) function. Purpose To analyse the changes in LV and LA function during exercise and to identify the main correlates of exercise capacity in patients (pts) with HCM, in sinus rhythm and with normal LV ejection fraction. Methods We have prospectively enrolled 32 pts (48±17 years, 15 men) with HCM and no obstruction at rest. A symptom limited exercise echocardiogram was performed in all pts using a table ergometer. Maximum LV wall thickness (LVWT), indexed left atrial volume (LAVi), septal E', E/septal E' ratio, were measured at rest (r) and during exercise (e). Global longitudinal LV strain (GLS) and LA strain (LAɛ) were assessed by speckle tracking echocardiography at rest and during exercise. The peak LV outflow tract gradient, systolic pulmonary artery pressure (PAP), and MR degree were recorded at rest and during exercise. Exercise-related symptoms, peak exercise heart rate (HR) and exercise capacity calculated in metabolic equivalents (METs) were also recorded. Results The mean value of achieved METs was 5.9±1.4, the peak HR was 124±25 bpm, representing 72±12% of maximal HR, during a mean of 8.5±2.5 minutes of exercise. Thirteen pts developed LV gradients &gt;30 mmHg. Fifteen pts were asymptomatic, while 17 pts reported dyspnea during exercise. There were no significant differences between pts with and without symptoms regarding: age, rE', rE/E', rGLS, rLAɛ, rMR, rPAP, LAVi, eE/e', eGLS, eMR, ePAP (p&gt;0.05 for all). Symptomatic pts had lower values for eE' (p=0.01), eLAɛ (p=0.03) and tended to have higher values for LVWT (p=0.06) and a higher prevalence of eLV outflow tract obstruction (p=0.13) compared to asymptomatic pts. In symptomatic group of pts, E' (p=0.004), PAP (p&lt;0.001) and GLS (p=0.04) significantly increased and LAɛ tended to decrease (p=0.18) during exercise. Age (r=−0.44, p=0.01), rE' (r=0.40, p=0.02), eE' (r=0.46, p=0.01), ePAP (r=−0.35, p=0.04) and LVWT (r=−0.32, p=0.07) significantly correlated with achieved METs in HCM pts overall. In multivariate analysis, eE' (β=0.60, 95% CI 0.122 to 0.009, p=0.003) was the only parameter independently correlated with exercise capacity (expressed in METs). Conclusions Symptomatic pts had a worse LV diastolic function (as expressed by E') and a severe LA longitudinal dysfunction (as expressed by LAɛ) during exercise. E' during exercise was the only parameter independently correlated with exercise capacity in pts with HCM. These suggest that a detailed analysis of LV and LA function during exercise could provide additional information to predict the occurrence of HF in HCM pts.

Cardiac maladaptation in obese pregnant women at term.

Obesity is an increasing problem worldwide, with well recognized detrimental effects on cardiovascular health; however, very little is known about the effect of obesity on cardiovascular adaptation to pregnancy. The aim of the present study was to compare biventricular cardiac function at term between obese pregnant women and pregnant women with normal body weight, utilizing conventional echocardiography and speckle-tracking assessment. This was a prospective case-control study of 40 obese, but otherwise healthy, pregnant women with a body mass index (BMI) of ≥ 35 kg/m2 and 40 healthy pregnant women with a BMI of ≤ 30 kg/m2 . All women underwent a comprehensive echocardiographic examination and speckle-tracking assessment at term. Obese pregnant women, compared with controls, had significantly higher systolic blood pressure (117 vs 109 mmHg; P = 0.002), cardiac output (6.73 vs 4.90 L/min; P < 0.001), left ventricular (LV) mass index (74vs64 g/m2 ;P < 0.001)andrelativewall thickness (0.43 vs 0.37; P < 0.001). Diastolic dysfunction was present in five (12.5%) controls and 16 (40%) obese women (P = 0.004). In obese women, compared with controls, LV global longitudinal strain (-15.59 vs -17.61%; P < 0.001), LV endocardial (-17.30 vs -19.84%; P < 0.001) and epicardial (-13.10 vs -15.73%; P < 0.001) global longitudinal strain as well as LV early diastolic strain rate (1.05 vs 1.24 /s; P = 0.006) were all significantly reduced. No differences were observed in the degree of LV twist and torsion between the two groups. Morbidly obese, but otherwise healthy, pregnant women at term had significant LV hypertrophy with evidence of diastolic dysfunction and impaired deformation indices compared with pregnant women of normal weight. These findings are likely to represent a maladaptive response of the heart to volume overload in obese pregnancy. The impact of theses changes on pregnancy outcome and long-term maternal outcome is unclear. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Clinical Course and Predictors of Ischemic Mitral Regurgitation in Patients with Myocardial Infarctions of Different Localizations

to assess the clinical course of ischemic mitral regurgitation (IMR) in patients with myocardial infarction of different localizations and reveal its mechanisms and predictors. We enrolled in this study patients with first inferoposterior myocardial infarction (IPMI) (n=77), and anteroseptal MI (ASMI) (n=79) revascularized within 12 hours after symptoms onset, as well as age, sex and weight matched healthy control subjects (n=50). Parameters of mitral structures and mitral annulus areas (MAA), left ventricular (LV) volumes (LVV) and sphericity index (SI), global (G) and segmental (S) longitudinal LV strain (GLS, SLS), papillary muscles (PM) LS (PMLS) and PM systolic dyssynchrony (PMSD) were measured by echocardiography on the 7th and 180th days of follow up. On the 7th day of follow up IMR was diagnosed more frequently in IPMI vs. ASMI (42 vs. 28%, р&lt;0.001). In both groups patients with TIMI 0 flow before angioplasty had highest, while those with TIMI 3 flow - lowest incidence of IMR. Presence of IMR depended on collateral flow availability in vascular bed of infarct related artery. Wall motion abnormalities (WMA) of infarcted segments, MAA, posteromedial PM posterior displacement (PPMPD), SLS, PMLS, PMSD correlated with IMR in patients with IPMI on the 7th day of follow up. VLV, GLS and MAA correlated with IMR in patients with ASMI on the 7th day follow up. Patients with IPMI without IMR in 7th day did not develop IMR for 180 days of follow up while IMR developed in 19.3% of patients with ASMI without IMR at initial examination. Among patients with IPMI and ASMI 37.5% and 45.5%, respectively, of those with IMR at initial examination had no IMR after 180 days of follow up. Patients with IPMI more frequently had eccentric IMR than patients with ASMI (78 and 24%, respectively, p&lt;0.002). At examination after 6 months WMA, MAA, PMSD, PPMPD, SLS, PMLS, PMSD correlated with IMR in patients with IPMI, while VLV, AMA, PM apical displacement (PMAD), GLS and PMSD correlated with IMR in patients with ASMI. AMA, PMAD and PMSD were predictors of IMR in patients with MI of both localizations. In addition, in patients with ASMI VLV and SI were also predictors of IMR.

Associations of Electrocardiographic Parameters with Left Ventricular Longitudinal Strain and Prognosis in Cardiac Light Chain Amyloidosis

A 12-lead ECG is a simple and less costly measure to assess cardiac amyloidosis and may reflect the infiltrative nature of cardiac amyloidosis and have prognostic value for predicting overall survival in patients with cardiac AL amyloidosis. Therefore, we investigated the associations of surface ECG parameters with left ventricular (LV) global longitudinal strain (GLS) and prognosis in patients with cardiac AL amyloidosis. We performed a multi-center, retrospective analysis of 102 biopsy-proven cardiac AL amyloidosis patients. Baseline studies included 12-lead surface ECG and echocardiography, with two-dimensional strain analysis performed within one month of diagnosis. From the Kaplan-Meier survival analysis, patients with prolonged QTc (≥483 msec) had significantly poorer survival. ECG scores were assigned according to presence of prolonged QTc (≥483 msec) and abnormal QRS axis, and the study participants were divided into three groups according to ECG score. Mean absolute value of LV GLS and regional LV longitudinal strain (LS) differed significantly among the three groups and decreased in a stepwise manner as ECG score increased. Log NT-proBNP increased in a stepwise manner as ECG score increased. Prolonged QTc (≥483 msec) and abnormal QRS axis showed significant incremental values in addition to the revised Mayo stage. The presence of prolonged QTc (≥483 msec) and abnormal QRS axis showed significant incremental values for overall mortality rates. In addition, ECG scores consisting of presence of prolonged QTc (≥483 msec), and abnormal QRS axis showed good association with longitudinal LV dysfunction and NT-proBNP. ECG finding may provide prognostic additional information regarding prognosis of AL amyloidosis with cardiac involvement.

The Prognostic Value of Myocardial Deformation in Adult Patients With Corrected Tetralogy of Fallot

Adult patients with repaired tetralogy of Fallot (ToF) are at risk for complications such as heart failure and sudden cardiac death, and identifying high-risk patients is important. Reduced left ventricular (LV) and right ventricular (RV) function has been identified as a predictor of outcomes. However, LV ejection fraction is often preserved, and RV function is difficult to assess. With the introduction of strain analysis, an easy and more sensitive parameter became available. The aim of this study was to investigate the association between strain variables and cardiovascular events in patients with ToF. Stable adult patients with repaired ToF were consecutively included in a prospective observational study between 2011 and 2013 (N=151; median age, 33.2years [interquartile range, 25.5-42.0years]; 61.6% men). For the left ventricle, global longitudinal strain and apical and basal rotation were measured, and longitudinal strain was measured for the right ventricle. The primary endpoint was a composite of death or heart failure. The secondary endpoint was a composite of death, heart failure, arrhythmia, reintervention, or hospitalization for cardiac reasons. During a median follow-up period of 71.5months (interquartile range, 64.0-75.3months), the primary and secondary endpoints occurred in 14 (9%) and 62 (41%) patients, respectively. After adjusting for LV ejection fraction and LV global longitudinal strain, RV longitudinal strain remained independently associated with the primary endpoint in a ridge regression analysis. LV apical rotation remained independently associated with the secondary end point (adjusted hazard ratio, 0.72; 95% CI, 0.52-0.98; P=.035) after adjusting for age, New York Heart Association functional class, QRS duration, LV ejection fraction, RV longitudinal strain, and LV global longitudinal strain. Myocardial deformation variables of both the left and right ventricles were associated with cardiovascular events in patients with ToF. LV and RV longitudinal strain and LV rotation should become part of the routine assessment of patients with ToF.

Порівняльний аналіз структурно-функціонального стану серця у хворих із хронічним міокардитом та дилатаційною кардіоміопатією

The aim – to establish differences in the structural and functional state of the heart in patients with chronic myocarditis and dilated cardiomyopathy and to investigate their associations with the presence of cardiac rhythm disorders.Materials and methods. We included 95 patients who were divided into two groups: the first group consisted of 55 patients with chronic myocarditis (CM), the second group included 40 patients with dilated cardiomyopathy (DCM). All patients had heart failure (HF) II or higher functional class (FC) according to the classification of the New York Heart Association (NYHA) and a reduced left ventricular (LV) ejection fraction (EF). All patients underwent the echocardiography (EchoCG) with speckle tracking (ST), Holter electrocardiogram monitoring and cardiac magnetic resonance (CMR) imaging. Results and discussion. A comparative analysis of the EchoCG data revealed that CM was characterized by lower values of LV end-diastolic and end-systolic volume indexes (by 21.7 and 28.6 %, respectively, p&lt;0.01) and by 16.8 % (p&lt;0.05) higher value of LV EF compared to DCM; when studying the results of ST EchoCG, it was found that in patients with CM, the absolute values of the longitudinal, circumferential and radial global systolic LV strain were by 25.0; 23.7 and 28.5 %, respectively, higher compared with patients with DCM (p&lt;0.05–0.01). The obtained data were confirmed by the results of 6-minute walking test, so patients with DCM demonstrated the lower tolerance to physical exercise comparing with CM. When performing CMR in patients with CM, along with inflammatory changes in the myocardium (edema and hyperemia), fibrotic changes were present, while DCM was characterized only by diffuse fibrotic changes of the heart. The association between the presence of delayed enhancement on CMR and episodes of unstable ventricular tachycardia was proved for both CM and DCM – the result of Fisher’s exact test was p=0.019 and p=0.027 respectively.Conclusions. In patients with DCM compared with CM we found more significant impairment of the structural and functional state of the heart, that was manifested by the presence of the worst heart failure functional class and a lower tolerance to exercise test. It has been established that fibrotic changes of the myocardium both in CM and in DCM are associated with the presence of ventricular arrhythmias, including such potentially dangerous ones as episodes of unstable ventricular tachycardia.

ESTIMATION OF LEFT VENTRICULAR FILLING PRESSURE BY LEFT ATRIAL MYOCARDIAL DEFORMATION IMAGING IN PATIENTS WITH SEVERE MITRAL ANNULAR CALCIFICATION

The presence of mitral annular calcification (MAC) makes the assessment of left ventricular (LV) diastolic function difficult. We thus investigated the association between left atrial global longitudinal strain (LAGLS) and LV filling pressure. Patients with severe MAC who had undergone a Doppler

Abstract WP267: Lower Left Ventricular Longitudinal Contraction is Associated With Early-onset Cryptogenic Ischemic Stroke

Introduction: At least one third of ischemic strokes at a young age (&lt;50 years) remain cryptogenic after complete diagnostic work-up. We hypothesized that based on their neuroimaging presentation majority of these strokes may originate from the heart and that advanced cardiac ultrasound imaging might reveal hints from underlying left ventricular pathology. Methods: We prospectively recruited 26 patients aged 18-49 with cryptogenic ischemic stroke and 26 age- and sex-matched stroke-free controls. We examined all participants with transthoracic echocardiography and analyzed the left ventricular (LV) ejection fraction (LVEF) with 3-dimensional volumetry. We used speckle-tracking imaging in three planes (apical 4-chamber, 3-chamber and 2-chamber views), to determine LV global longitudinal strain (GLS), and only patients with visibility allowing analysis of all 18 LV segments were included. Tissue Doppler velocity imaging was used to determine the mitral annular plane systolic excursion (MAPSE), as a mean of six annular points in the 3 apical planes. Measurements were normally distributed and group-level differences were analyzed by paired-samples T-tests. Results: A total of 26 pairs had adequate visibility to examine LVEF, 20 to assess GLS, and 25 to examine MAPSE. There was no significant difference in LV ejection fraction between patients and controls (mean 59.0 vs 61.4 (%); P=0.300). LV global longitudinal strain was significantly lower in patients compared with controls (mean 18.0 vs 19.9 (%); P=0.012). Furthermore, MAPSE was lower in patients (mean 13.3 vs 14.2(mm); P=0.044). Conclusion: Young patients with cryptogenic ischemic stroke had lower longitudinal LV contraction than stroke-free individuals of the same age—without differences in LVEF—suggesting that subclinical LV systolic dysfunction may play a role in cryptogenic strokes.

Exercise Training Improved Longitudinal Intrinsic Left Ventricle Function in Heart Failure with Preserved Ejection Fraction.

Exercise improves morbidity, fatality rate, and quality of life in heart failure with low ejection fraction, but fewer data available in heart failure with preserved ejection fraction (HFPEF). The purpose of this study is to test the hypothesis that exercise training might improve the longitudinal intrinsic left ventricular (LV) function in HFPEF patients. This quasi-experimental study had recruited 30 patients with HFPEF. Exercise training program had been performed for a month with a total of 20 times exercise sessions and evaluated every 2 weeks. Echocardiography was performed before sessions, second week and fourth week of exercise training. Six-minute walk tests (6MWTs) and quality-of-life variables using Minnesota living with HF scoring and the 5-item World Health Organization Well-Being Index scoring were measured before and after exercise as well. Left ventricular filling pressure, represented by the ratio of early diastolic mitral flow velocity/early diastolic annular velocity and left atrial volume index, improved during exercise. The longitudinal intrinsic LV function, represented by four-chamber longitudinal strain, augmented during exercise ( p < 0.001). Aerobic capacity, measured by 6MWT, increased significantly ( p = 0.001). Quality of life improved significantly during exercise ( p < 0.001). Exercise training was suggested to improve the longitudinal intrinsic LV function and quality of life in HFPEF. Clinical Trial Registration: ACTRN12614001042639.

Longitudinal Shortening of the Left Ventricle by Cine-CMR for Assessment of Diastolic Function in Patients with Aortic Valve Disease.

BackgroundDiastolic dysfunction, commonly evaluated by echocardiography, is an important early finding in many cardiomyopathies. Cardiac magnetic resonance (CMR) often requires specialized sequences that extends the test time. Recently, feature-tracking imaging has been made available, but still requires expensive software and lacks clinical validation.ObjectiveTo assess diastolic function in patients with aortic valve disease (AVD) and compare it with normal controls by evaluating left ventricular (LV) longitudinal displacement by CMR.MethodsWe compared 26 AVD patients with 19 normal controls. Diastolic function was evaluated as LV longitudinal displacement in 4-chamber view cine-CMR images using steady state free precession (SSFP) sequence during the entire cardiac cycle with temporal resolution < 50 ms. The resulting plot of atrioventricular junction (AVJ) position versus time generated variables of AVJ motion. Significance level of p < 0.05 was used.ResultsMaximum longitudinal displacement (0.12 vs. 0.17 cm), maximum velocity during early diastole (MVED, 0.6 vs. 1.4s-1), slope of the best-fit line of displacement in diastasis (VDS, 0.22 vs. 0.03s-1), and VDS/MVED ratio (0.35 vs. 0.02) were significantly reduced in AVD patients compared with controls, respectively. Aortic regurgitation showed significantly worse longitudinal LV shortening compared with aortic stenosis. Higher LV mass indicated worse diastolic dysfunction.ConclusionsA simple linear measurement detected significant differences on LV diastolic function between AVD patients and controls. LV mass was the only independent predictor of diastolic dysfunction in these patients. This method can help in the evaluation of diastolic dysfunction, improving cardiomyopathy detection by CMR, without prolonging exam time or depending on expensive software.

Characterization of Left Ventricular Dysfunction by Myocardial Strain in Critical Pulmonary Stenosis and Pulmonary Atresia After Neonatal Pulmonary Valve Balloon Dilation

Transient left ventricular (LV) dysfunction occurs in some infants born with critical pulmonary stenosis (PS) or membranous pulmonary atresia with intact ventricular septum (PAIVS) after pulmonary valve (PV) balloon dilation (BD). The cause for this is not well understood. We sought to characterize this LV dysfunction by investigating regional differences in this cohort using myocardial strain imaging. Patients who underwent neonatal (<2 weeks age) PV BD for critical PS or PAIVS from Jan, 2007 to March, 2014 with echocardiographic images suitable for strain analysis were identified; infants with ≥moderate post-BD LV dysfunction (ejection fraction <40%, n = 8) were matched 1:1 with controls who underwent PV BD but did not develop LV dysfunction. Longitudinal and circumferential global and segmental strain were analyzed before and after PV BD. For the 8 LV dysfunction cases, LV global longitudinal strain worsened after PV BD (-16% pre- vs -8% post-PV BD, p = 0.008) with similar impairment in global LV circumferential strain (-17% vs -8%, p = 0.008); there was no significant change in RV global or segmental longitudinal strain pre- vs post-PVBD. No significant pre/post-BD differences in global or circumferential strain were found in control pts. Segmental analysis of longitudinal and circumferential LV strain before and after balloon dilation in cases demonstrated decreased strain in all segments, but more pronounced and statistically significant in septal segments as compared with the free wall. In conclusion, transient LV dysfunction post-PV BD for critical PS/PAIVS is characterized by impaired global longitudinal and circumferential LV strain, with the most significant reductions in strain at the interventricular septum; longitudinal RV strain remains unchanged. These findings suggest that the mechanism of LV dysfunction post-PV BD is adverse ventricular-ventricular interactions specifically involving the interventricular septum.