LV GLS Research Articles

Effects of sacubitril/valsartan on atrial function and structure as treatment response indicators in patients with heart failure with reduced ejection fraction: an observational prospective study

Abstract Funding Acknowledgements Type of funding sources: None. Background Sacubitril/valsartan (Sac/Val) has been shown to improve mortality and reduce hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF), also through reverse cardiac remodeling. However, temporal changes of functional and structural left atrial parameters, including speckle tracking (ST) analysis, have not been comprehensively characterized yet. Purpose This prospective study sought to: (1) evaluate the impact of Sac/Val on echo parameters, focusing on left atrial function and structure metrics, at two timepoints, 6 and 12 months, after treatment initiation; (2) assess the predictive role of these factors on Sac/Val response at 12 months, including LVEF and biomarker outcomes. Methods From January 2020 to September 2021, HFrEF patients from Policlinico Universitario Agostino Gemelli IRCSS outpatient HF service with indication to Sac/Val treatment were prospectively enrolled; subjects with history of atrial fibrillation and more than moderate mitral regurgitation were excluded. Echocardiographic evaluation was performed before Sac/Val, at 6 and 12 months after treatment initiation. Patients with improvement in left ventricular ejection fraction (LVEF) ≥ 35% and with N-terminal pro-b-type natriuretic peptide (NT pro-BNP) reduction below 1000 pg/mL were considered responders. Results Sixty-six patients (50 males, 16 females) with an age of 64 ± 12 years were finally enrolled, of which 41% were affected by chronic ischemic heart disease. At enrollment, 19 subjects were in New York Heart Association class III-IV, median NT-proBNP was 3063.00 pg/mL and mean LVEF was 30.3±7.7%. LA-EF was 27.8±12.8%, while Left Atrio-ventricular coupling index (LACi) was 0,30±0,12. At ST echocardiography, LV GLS was -8,2±3,0% and LA reservoir strain (LARS) 11,60%. All structural and functional LA parameters significantly improved at T1 and T2: at T2, LARS was 22,51%, LA-EF 37,4±15,8% and LACi 0,28±0,12 (respectively p <0,001, p = 0,05, p = 0,018 compared to baseline). No differences were detected according to dysfunction etiology. Improvements were larger among patients who achieved the pre-specified outcome. LA reservoir strain was the best predictor of positive changes in LVEF and NT-proBNP. Conclusions Precise characterization of LA structural and functional parameters, including ST analysis, may help identifying patients experiencing the highest benefit from Sac/Val, therefore guiding treatment in the HFrEF population.

Antioxidant Genetic Variants Modify Echocardiography Indices in Long COVID.

Although disturbance of redox homeostasis might be responsible for COVID-19 cardiac complications, this molecular mechanism has not been addressed yet. We have proposed modifying the effects of antioxidant proteins polymorphisms (superoxide dismutase 2 (SOD2), glutathione peroxidase 1 (GPX1), glutathione peroxidase 3 (GPX3) and nuclear factor erythroid 2-related factor 2, (Nrf2)) in individual susceptibility towards the development of cardiac manifestations of long COVID-19. The presence of subclinical cardiac dysfunction was assessed via echocardiography and cardiac magnetic resonance imaging in 174 convalescent COVID-19 patients. SOD2, GPX1, GPX3 and Nrf2 polymorphisms were determined via the appropriate PCR methods. No significant association of the investigated polymorphisms with the risk of arrhythmia development was found. However, the carriers of variant GPX1*T, GPX3*C or Nrf2*A alleles were more than twice less prone for dyspnea development in comparison with the carriers of the referent ones. These findings were even more potentiated in the carriers of any two variant alleles of these genes (OR = 0.273, and p = 0.016). The variant GPX alleles were significantly associated with left atrial and right ventricular echocardiographic parameters, specifically LAVI, RFAC and RV-EF (p = 0.025, p = 0.009, and p = 0.007, respectively). Based on the relation between the variant SOD2*T allele and higher levels of LV echocardiographic parameters, EDD, LVMI and GLS, as well as troponin T (p = 0.038), it can be proposed that recovered COVID-19 patients, who are the carriers of this genetic variant, might have subtle left ventricular systolic dysfunction. No significant association between the investigated polymorphisms and cardiac disfunction was observed when cardiac magnetic resonance imaging was performed. Our results on the association between antioxidant genetic variants and long COVID cardiological manifestations highlight the involvement of genetic propensity in both acute and long COVID clinical manifestations.

P274 LEFT ATRIAL STRAIN RESPONSE TO HEART RATE IN PATIENTS AFFECTED OR NOT BY CHRONIC HEART FAILURE: CLINICAL CORRELATES

Abstract Background and aim of the study. Left atrium (LA) is poorly understood in many pathological conditions and it is often considered a passive bystander of these pathophysiologic alterations. In the setting of impaired heart rate related LV response, the LA function could play a relevant role. The relevance of LA has been also recently demonstrated by studies which have evaluated its function by using new echocardiographic techniques such as two–dimensional speckle tracking evaluation (2D–STE). The aim of this study was to evaluate the relationship between changes in LV and LA function, assessed by 2D–STE, in response to the increase of heart rate (HR) in a group of patients carrying a pacemaker (PM) or an implantable cardioverter defibrillator (ICD). Methods We enrolled 45 patients. Among them, 38 were evaluated with LA strain. 31 patients were affected by CHF, among whom 18 with implanted cardioverter defibrillator (ICD), 13 with ICD and cardiac resynchronization therapy (ICD–CRT) and 7 without CHF who had a PM implanted. All were in clinically stable conditions for at least 30 days and in conventional medical therapy. Starting from basal values, HR was increased by 10 beats/min programming the implantable devices at higher atrial stimulation frequencies to max 90 beats/min. At each HR, echocardiography was performed and for left atrium the strain of reservoir (LAr), strain of conduit (LAcd) and contraction (LAct) were calculated (figure 1). Changes in left ventricle global longitudinal strain (LVGLS) were also calculated. Results The LAr shows a significant reduction from baseline at a heart rate of 90 bpm in conjunction with a significant change in the LAcd. No variation in LAct was observed at the various frequencies. Among the 38 patients, 29 showed a worsening of LVGLS and 9 no worsening with increasing heart rate. We demonstrated a close relationship between LV and LA function assessed by longitudinal strain measures (figure 2). A significant decrease in LAr was observed in patients with worsening LV–GLS that was not evident in patients with no or improvement. Conclusions Our study demonstrates that, in chronic HF outpatients, HR increase has different and heterogeneous effects on the LA function, assessed by STI and this response is more frequent among patients with LV systolic dysfunction. These results could be useful for guiding the optimal heart rate responsiveness of the implanted devices.

C56 ACCURACY OF TWO–DIMENSIONAL SPECKLE TRACKING PARAMETERS REFLECTING LEFT ATRIAL FUNCTION IN PREDICTING OUTCOME AMONG OUTPATIENTS AFFECTED BY HEART FAILURE

Abstract Background The two–dimensional speckle tracking analysis (2D–ST) is a new useful tool in order to evaluate both atrial and ventricular function. Aim of the study. To evaluate the accuracy of the 2D–ST measures reflecting atrial and ventricular function in predicting the outcome among outpatients affected by chronic heart failure (CHF). Methods We enrolled 212 outpatients (age 64±13 years, 77% males, mean left ventricular ejection fraction, LVEF, 38±11%, NYHA class 2.4±0.5) affected by CHF in conventional therapy (sacubitril/valsartan or ACE–inhibitors or Angiotensin II receptor blockers in 85%, beta–blockers in 94%, mineralcorticoid receptor antagonists in 74%, diuretics in 72%, SGLT2 inhibitors in 20%). All patients underwent a medical visit, an ECG and an echocardiographic examination. The following 2D–ST parameters reflecting atrial and ventricular function were analyzed: global longitudinal left ventricular strain (LV–GLS, mean –11.4±3.9%), global longitudinal right ventricular strain (RV–GLS, mean –15.2±5.2%), free wall right ventricular longitudinal strain (RV–fwLS, mean –20.2±5.8%); left atrial reservoir (LAr, mean 19±10.8%), conduit (LAcd, mean –10.–8±6.8) and contraction (LAct, mean –8.1±8.2). Moreover, the early diastolic peak at pulsed Doppler (E) and at the level of septal (e’s) and lateral (e’l) mitral annulus by Tissue Doppler Imaging (TDI) were also evaluated. Then the ratio between E and e’s (E/es, mean 13.9±6.4) and between E and the mean of e’s and e’l (E/em, mean 11.1±5.4) were also calculated. Finally, the ratio between LAr and E/es (LAr/Ees, mean 1.98±1.65) and E/em (LAr/Eem, mean 2.51±1.95) were computed. During follow–up the progression of heart failure, defined as heart failure hospitalization or cardiovascular death, were evaluated. Results During a mean follow–up of 13±6, 32 patients experienced death (13) and/or hospitalization (25) for heart failure worsening. The table shows the relationship among echocardiographic variables and outcome At Cox univariate regression analysis and the relative C–index. LAR/Ees showed the greater accuracy (C–index) in predicting heart failure progression. Conclusions 2D–ST is an echocardiographic approach able to more accurately assess both left ventricular and atrial function. In our series, among the 2D–ST parameters, the ratio between LAr and E/es is characterized by the greater accuracy in predicting heart failure progression.

C14 CASE REPORT: MULTIMODALITY IMAGE–CHALLENGE IN PRIMARY CARDIAC DIFFUSE LARGE B–CELL LYMPHOMA

Abstract A 76–year–old Caucasian woman presented to our hospital with progressive exertional fatigue and weight–loss over 2 months.Her past medical history revealed a recent local–hospital admission because of atrioventricular third–degree block, requiring permanent pacemaker implan­tation. At presentation her cardiovascular exam was normal.Laboratory studies revealed elevated LDH and PCR; electrolytes, cardiac biomarkers and complete blood count were normal. ECG demonstrated AF and ventricular stimulation.Transtoracich echocardiography showed LV hypertrophy in the basal segments, with normal ejection fraction and a reduced LV–GLS with a relative apical sparing pattern.There was a large, well–circumscribed mass arising from the right atrium, with a contextual moderate pericardial effusion (Fig1).Vasculitic, thrombophilic and infectious work–up were negative.The patient was immunocompetent. CMR was proposed but could not be performed due to patient claustrophobia. ECG gated cardiac CT was carried out for a better differential diagnosis of the mass, as well as to look for possible embolization or primary tumours, in the hypothesis of cardiac metastases. A CT total body showed a large ill–defined mass invading the interatrial and interventricular septum with projections into the left ventricle. Not enlarged lymph nodes were detected with neither hepatosplenomegaly nor abdominal lymphadenopathy. A total body 18FDG PET revealed significant tracer uptake in the heart and pericardium without extracardiac uptake, consistent with a malignant cardiac mass (Fig2).LV endomyocardial biopsy was attempted: pathology revealed large B–cell lymphoma expressing CD20, Bcl–2, Bcl–6, Mum–1, C–myc and with a high Ki67 proliferation rate. The patient underwent six cycles of chemotherapy(R–POCH).Echocardiography imaging after the second cycle showed significant reduction in myocardial wall thickness and concomitant improvement in LV–GLS. Repeated PET–CT scans 6 months post–chemotherapy showed complete remission with no evidence of FDG–avid lymphoma (Fig3). Primary cardiac lymphoma (PCL) is an extranodal non–Hodgkin’s B–cell lymphoma exclusively located in the heart or pericardium, accounting for 1–2% of primary cardiac tumours. PCL often presents with non–specific clinical symptoms making the diagnosis challenging. Multimodality approach and myocardial biopsy are essential in the diagnostic work–up. Early diagnosis and treatment are crucial since a good response to chemotherapy is expected.

Echocardiographic Findings in Asymptomatic Mediastinal Lymphoma Survivors Years after Treatment Termination.

Patients treated due to mediastinal lymphomas are at risk of cardiovascular complications, as they receive chemotherapy, usually containing anthracyclines, often combined with thoracic radiotherapy. The aim of this prospective study was to assess early asymptomatic cardiac dysfunction using resting and dobutamine stress echocardiography (DSE) at least 3 years after the end of mediastinal lymphoma treatment. Two groups of patients were compared: those treated with chemoradiotherapy and those exclusively treated with chemotherapy. Left ventricular contractile reserve (LVCR) during DSE was assessed using changes in LV ejection fraction (LVEF), LV global longitudinal strain (LV GLS), and a novel parameter-Force, which is the ratio of the systolic blood pressure to the LV end-systolic volume. The study included 60 patients examined at a median of 89 months after the end of treatment. Resting echocardiography showed normal LVEF of 58.9 ± 9.6%, borderline LV GLS of -17.7 ± 3%, decreased mean stroke volume (SV) of 51.4 ± 17 mL, and indexed SV of 27.3 ± 8 mL/m2, and the right ventricular free wall longitudinal strain (LS) was impaired in some patients but not in all. There were no significant differences between the groups, with the exception of arterial hypertension, which was more common in the chemotherapy group (32% vs. 62.5%, p = 0.04). In resting echocardiography, only LV posterior wall LS differed significantly and was impaired in patients treated with chemotherapy (-19.1 ± 3.1% vs. -16.5 ± 5.1%, p = 0.04). DSE, performed in 21 patients after a median of 166 months from the end of cancer treatment, detected new contractility disorders in 1 patient (4.8%) and decreased LVCR in the majority of patients when determined using changes in LVEF or LV GLS, and in all patients when assessed with changes in Force. Conclusions: Most asymptomatic mediastinal lymphoma survivors showed preserved ventricular function on resting echocardiography. However, all of them showed impaired LV contractile reserve on DSE, as assessed with a simple parameter-Force. This may indicate subtle LV dysfunction and confirms the need for long-term monitoring of patients with potentially cardiotoxic cancer treatment.

Global longitudinal strain analysis application for prediction of left ventricular dysfunction in breast cancer under sequential therapy

Transthoracic echocardiography (TEE) plays a major role in the baseline assessment and follow-up of cardio-oncology patients. While left ventricular ejection fraction (LVEF) still has its place in cardiac monitoring, new modalities like myocardial deformation imaging with speckle tracking strain analysis has been validated for early detection of subclinical LV dysfunction. We conducted a longitudinal prospective study including all the breast cancer patients treated with anthracyclines and trastuzumab from January 2017 to March 2022. All patients underwent baseline TEE, and were followed-up every 3 months after that, with GLS assessment whenever it was possible. We evaluated the frequency of GLS drop and its correlation to LVEF reduction. Out of a total of 1583 patients, 677 had available LV GLS assessment. Among them, 83 (12.3%) decreased their GLS during follow-up, 67% of which had no concomitant drop in LVEF. In these patients, impaired LV GLS values were noted at 3 months after chemotherapy and at 6, and 12 months compared with baseline (−22.3 ± 1.8% at baseline, −18.1 ± 2.3% at 3 months, −17.7 ± 2.1% at 6 months, and −16.9 ± 2.1% at 12 months). LV GLS at 3 months was strongly correlated to cardiotoxicity (LVEF < 50%) at 12 months (P < 0.05). A cut-off LV GLS value of −16.9% was then retained to identify LVEF alteration at the end of follow-up. Finally, our study found that GLS at 3 months and 6 months had a prognostic value, since the lower GLS was, the poorest the patient's clinical outcome was, with further development of symptomatic heart failure. Our study demonstrates that myocardial deformation analysis enables detection of early and progressive subclinical cardiac dysfunction, and GLS at 3 months was positively correlated to LVEF drop at 12 months.

Value of echocardiography in estimating functional status and event-risk in patients with hypertrophic cardiomyopathy

The prognosis in patients with hypertrophic cardiomyopathy (HCM) remains complicated to estimate. Exercise testing is recommended. We sought to assess whether the echocardiographic evaluation could help in best understanding the clinical consequences and the event-risk of patients referred for HCM. In total, 302 HCM-patients (57.4 ± 16.8 years old) were analysed. All patients underwent transthoracic rest and stress echocardiography for the evaluation of size and function including strain measurements. A cardiopulmonary exercise test (CPET) was performed by all the patients at the time of echocardiography. The patients were followed for 3.4 years for the occurrence of a composite endpoint including heart failure requiring hospitalization, syncope, ventricular tachycardia (VT) sustained or not, atrial heart rate episode registered by pacemaker or implanted defibrillator, symptomatic supraventricular tachycardia, asymptomatic supraventricular tachycardia detected by Holter, defibrillator implantation, myomectomy/septal alcoholising, or HCM related death. Mean VO2 peak for all patients was 21.57 ± 7.6 mL/kg/min. The best predictors of peak VO2 were increased exercise mean E/Ea (9.17 [6.30–12.9]), decreased resting TAPSE (22.5 ± 4.99 mm) and decreased exercise LV GLS (−17.6 ± 3.97%). Among the 302 patients, 132 (43.8%) met the composite endpoint. Among clinical, CPET and echocardiographic parameters recorded, PLAS was the best predictor of event with linear association. The decrease in PLAS was strongly associated with the risk of event. It takes over CPET results. On top of this prognostic value, echocardiographic evaluation was demonstrated extremely relevant for our daily evaluation of HCM-patients.

Echocardiographic Features Beyond Ejection Fraction and Associated Outcomes in Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction.

Heart failure (HF) guidelines recommend assessment of left ventricular ejection fraction (LVEF) to classify patients and guide therapy implementation. However, LVEF alone may be insufficient to adequately characterize patients with HF, especially those with mildly reduced or preserved LVEF. Recommendations on additional testing are lacking, and there are limited data on use of echocardiographic features beyond LVEF in patients with heart failure with mildly reduced or preserved LVEF. In patients with HF with mildly reduced or preserved LVEF identified in a large US health care system, the association of the following metrics with mortality was evaluated: LV global longitudinal strain (LV GLS>-16), left atrial volume index (>28 mL/m2), left ventricular hypertrophy (LVH), and E/e´>13 and e´<9. A multivariable model for mortality was constructed including age, sex, and key comorbidities followed by stepwise selection of echocardiographic features. Characteristics and outcomes of subgroups with normal versus abnormal LV GLS and LVEF were evaluated. Among 2337 patients with complete echocardiographic data assessed between 2017 and 2020, the following features were associated with all-cause mortality on univariate analysis over 3 years of follow-up: E/e´+e´, LV GLS, left atrial volume index (all P<0.01). In the multivariable model (C-index=0.65), only abnormal LV GLS was independently associated with all-cause mortality (HR, 1.35 [95% CI, 1.11-1.63]; P=0.002). Among patients with LVEF>55%, 498/1255 (40%) demonstrated abnormal LV GLS. Regardless of specific LVEF, patients with abnormal LV GLS demonstrated a higher burden of multiple comorbidities and higher event rates compared with patients with normal LV GLS. In a large, real-world HF with mildly reduced or preserved LVEF population, echocardiographic features, led by LV GLS, were associated with adverse outcomes irrespective of LVEF. A large proportion of patients demonstrate adverse myocardial function by LV GLS despite preserved LVEF and may represent a key cohort of interest for HF medical therapies and future clinical studies.

Left ventricular assessment in patients with significant mitral incompetence: a multi-modality imaging study

Background: Detection of the deleterious effect of MR on LV is crucial in guiding the surgical decision. Aim of the study: Comprehensive assessment of LV with significant primary MR using (2D, 3D echo and CMR). Methods: 40 patients with significant MR have been recruited in a prospective study. Patients underwent 2D and 3D echo and CMR studies. LV volumes, function and GLS were calculated. Results: End diastolic and systolic volumes were significantly larger when measured by CMR (all p &lt; 0.001). EDV measures were strongly correlated with CMR and 3D echocardiography. Conclusion: It’s important to identify early deleterious LV changes.

There is more than just longitudinal strain: Prognostic significance of biventricular circumferential mechanics.

Despite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning its prognostic value on long-term mortality. Accordingly, our study aimed to assess both left (LV) and right ventricular (RV) global longitudinal (GLS) and global circumferential strain (GCS) using three-dimensional echocardiography (3DE) to determine their prognostic importance. Three hundred fifty-seven patients with a wide variety of left-sided cardiac diseases were retrospectively identified (64 ± 15 years, 70% males) who underwent clinically indicated 3DE. LV and RV GLS, and GCS were quantified. To determine the prognostic power of the different patterns of biventricular mechanics, we divided the patient population into four groups. Group 1 consisted of patients with both LV GLS and RV GCS above the respective median values; Group 2 was defined as patients with LV GLS below the median while RV GCS above the median, whereas in Group 3, patients had LV GLS values above the median, while RV GCS was below median. Group 4 was defined as patients with both LV GLS and RV GCS below the median. Patients were followed up for a median of 41 months. The primary endpoint was all-cause mortality. Fifty-five patients (15%) met the primary endpoint. Impaired values of both LV GCS (HR, 1.056 [95% CI, 1.027-1.085], p < 0.001) and RV GCS (1.115 [1.068-1.164], p < 0.001) were associated with increased risk of death by univariable Cox regression. Patients with both LV GLS and RV GCS below the median (Group 4) had a more than 5-fold increased risk of death compared with those in Group 1 (5.089 [2.399-10.793], p < 0.001) and more than 3.5-fold compared with those in Group 2 (3.565 [1.256-10.122], p = 0.017). Interestingly, there was no significant difference in mortality between Group 3 (with LV GLS above the median) and Group 4, but being categorized into Group 3 versus Group 1 still held a more than 3-fold risk (3.099 [1.284-7.484], p = 0.012). The impaired values of both LV and RV GCS are associated with long-term all-cause mortality, emphasizing the importance of assessing biventricular circumferential mechanics. Reduced RV GCS is associated with significantly increased risk of mortality even if LV GLS is preserved.

Evaluation of subclinical left ventricular systolic dysfunction in patients with acute-phase Kawasaki disease by hematological indices, layer-specific left ventricular longitudinal strain and global myocardial work.

To evaluate subclinical LV systolic dysfunction in aKD patients by hematological indices, global layer-specific LV longitudinal strain and myocardial work (MW). Forty-three normal controls and 42 aKD patients were enrolled in the present study. The peak systolic epimyocardial (GLSEpi), middle layer (GLSMid) and endomyocardial (GLSEndo) longitudinal strain, global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW) and myocardial work efficiency (GWE) were measured by two-dimensional speckle-tracking echocardiography in apical three-chamber, four-chamber, and two-chamber views. The absolute values of GLSEpi, GLSMid, and GLSEndo in aKD patients were significantly lower than those in normal controls (p < .01). The values of GCW and GWE were significantly lower than those of normal controls (p < .05). There were no significant differences among the AUCs of layer-specific LV GLS and global MW (p > .05). The correlation test showed that layer-specific LV GLS showed a good correlation with GCW. Multivariable analysis showed that Hb and LVEF were independent factors for GCW. In this research, we found that subclinical LV systolic dysfunction was detected by layer-specific GLS and MW in aKD patients. GCW has the same diagnostic value as layer-specific LV GLS. Hb and LVEF are independent factors of LV myocardial function.

49 GLOBAL LONGITUDINAL STRAIN TO EVALUATE THE SUCCESSFUL OF MEDICAL TREATMENT IN SECONDARY CARDIAC LYMPHOMA: A CASE REPORT

Abstract Background Cardiac lymphoma is often lately diagnosed and associated with a poor outcome because of delayed treatment. We report the case of a patient with diffuse large B-cell lymphoma (DLBCL) massively infiltrating the heart, who showed significant improvement in echocardiographic features after high-dose chemotherapy. Case summary A 39-year-old female was admitted to our hospital after a vasovagal syncope secondary to excisional biopsy of an inguinal lymph node. Symptoms and signs were consistent with heart failure. Brain natriuretic peptide was markedly elevated (472 pg/ml). Transthoracic echocardiography (TTE) revealed moderate hypertrophy of both ventricles, with preserved left ventricular ejection fraction, reduced function of the right ventricle and a monophasic diastolic pattern. Left Ventricular Global longitudinal strain (LV GLS) was significantly reduced (up to -5%). These findings led us to the strong suspicion of biventricular infiltrative heart disease. Positron emission tomography-computed tomography (PET-CT) scan showed metastases to the kidneys, mesenteric and skeletal systems. The results of histological analysis and immunohistochemical staining confirmed the diagnosis of stage IV-B DLBCL. Prompt and aggressive treatment was initiated, performing a multiparametric cardiac monitoring based on biomarkers and TTE prior to and after each cycle of chemotherapy. We early observed a significant reduction of myocardial infiltration with an impressive recovery of LV GLS up to -10% after the 1st cycle of chemotherapy. The echocardiographic abnormalities of the right chambers resulted totally restored. Complete regression of the cardiac lymphoma was obtained, with a recovery of LV GLS up to -11.2% at the end of protocol and -16.8% at the 1st month follow-up. The PET-CT scan confirmed the recovery of the heart. Discussion In this case, functional heart improvement due to total regression of cardiac lymphoma has been early detected by strain imaging. GLS could be an early indicator of therapy responsiveness and may be implemented in routinely evaluation of these patients with infiltrative cardiac diseases.

224 RIGHT VENTRICULAR MECHANICS AND THE CLINICAL IMPLICATION OF 2D SPECKLE TRACKING ASSESSMENT IN SEVERE AORTIC STENOSIS

Abstract Introduction The prognostic role of RV function assessment in severe AS has been demonstrated in previous studies. However, the role of 2D speckle tracking RV evaluation in the context of severe AS has not been completely clarified. Methods We retrospectively evaluated consecutive patients with severe AS referred to TAVI at our institution. Exclusion criteria were severe aortic regurgitation, severe mitral stenosis and poor acoustic window for a correct 2D speckle tracking right chamber evaluation. The echocardiographic exams were analyzed off-line with a semi-automatic software (Tomtec Arena, Autostrain ®) to assess RVFW strain and LV GLS. Additionally, a conventional echocardiographic evaluation was made in both right and left chambers (LVEF, FAC, LVEF). Prevalence of conventional RV disfunction was defined as a TAPSE&amp;lt;17 mm or FAC&amp;lt;35%. RVFW impairment cuf-off was defined below 20%. Multivariate regression models were elaborate to assess the major determinants of RV function. Moreover, logistic regression analysis has been made to analyze if RV function could predict high-risk clinical features in the context of severe AS. Results Our cohort was composed of 110 consecutive patients. Mean RVFW was 21±7%, TAPSE 21±4 mm, FAC 44±11% and mean RV area 10±4 cmq/mq. The prevalence of RV disfunction defined by standard echocardiography was 26% (29 patients), instead, RVFW was impaired (below 20%) in 53 patients (40%). At multivariate regression analysis, the main RVFW determinants were MR, AS severity, LVMI, GLS and E/e’ (R2 0.68, p&amp;lt;0.001 including AVA; R2 0.53, p&amp;lt;0.001 including mean gradient). At logistic regression analysis RVFW strain was associated with previous HF hospitalization admission independently from TAPSE (CI 95% 1.03–1.22, p=0.008). Furthermore in a second model, RVFW strain was a significant predictor of advanced NYHA class independently from FAC (CI 95%, 1.01–1.18, p=0.0036). Conclusion The major determinants of RV function in patients with severe AS were MR and LV function. A pressure overload driven by the MR-LV dysfunction combination on right sided heart could impact profoundly negatively on RV function. RVFW strain in this study resulted a more sensitive parameter that conventional RV assessment in highlighting more symptomatic severe-AS patients.

507 LONG-TERM SUBCLINICAL HEART INVOLVEMENT IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES

Abstract Introduction Global longitudinal strain (GLS) is a validated and reproducible technique for the measurement of LV longitudinal deformation. There is strong evidence of the prognostic value of GLS in patients with HF and is associated with cardiac mortality independent of clinical and cardiac status. In the present study, we aimed to assess whether GLS can reliably predict prognosis in patients diagnosed with idiopathic inflammatory myopathies. Methods We conducted a prospective observational study enrolling all consecutive patients referred to our clinic between June 2016 and January 2022 with a confirmed diagnosis of IIM and no overt cardiac disease. For each patient, echocardiogram and GLS calculations were done at baseline and at each follow-up. All patients enrolled have been revalued from two to four times during the median 2.5-year follow-up period. Results Forty patients (67% female, mean age 56±12 years) were consecutively enrolled. We detected a significant deterioration of the GLS of the LV (from -19.3±3.6%to -16.8±4.6%; p = 0.006) during the follow-up, while the GLS of the RV was unchanged. We also noticed an increase in the filling pressures as estimated through E/E’, which resulted to be statistically significant (6.5±3.9 to 9.0 ±3.5; p = 0.002), underlying a subclinical diastolic dysfunction of the LV. Traditional markers of systolic dysfunction, such as EF and TAPSE, did not show a significant worsening during the follow-up period. Patients developing a reduction in LV GLS &amp;gt;5% during follow-up experienced an increased incidence of cardiovascular-related death (19% vs 6%; p=0.03). Discussion Cardiovascular manifestations constitute a major cause of death in myositis. Although these complications rarely occur clinically, subclinical manifestations such as conduction disturbances, ventricular dysfunction, myocardial infarction and arrhythmias are often observed. This risk appears to increase especially in the first years after diagnosis. There is therefore a problem of the early recognition of patients who may develop heart disease. Several studies propose to use magnetic resonance imaging as a gold standard to select patients at risk, but its high cost and limited availability make it difficult to use as a screening test. The GLS, consistently with the estimated filling pressures, has demonstrated a high predictive power of cardiovascular-related death in our study, without a modification of the traditional systolic function values. Conclusion The GLS has a high power predictive, it is low cost and highly repeatable, therefore in our opinion, it could play an important role as a screening test in identifying patients with a diagnosis of IIM at higher risk of developing cardiovascular-related death.

Environmental Tobacco Smoke Exposure Estimated Using the SHSES Scale, and Feature Tracking Computed Tomography-Derived Left Ventricular Global Longitudinal Strain in Hypertensive Patients

Aim of the study was to assess the relationship between environmental tobacco smoke (ETS) and computed tomography-derived left ventricular global longitudinal strain (LV GLS) in patients with arterial hypertension. 103 non-smokers with AH were included in the study (age 67.73 ± 8.84 years). ETS exposure was assessed with the Second-Hand Smoke Exposure Scale (SHSES). LV GLS was measured on computed tomography using feature tracking technology. In accordance with SHSES scale patients were divided into subgroups: subgroup A—no ETS exposure, subgroup B—low ETS exposure, subgroup C—medium ETS exposure, and subgroup D—high ETS exposure. Peak of LV GLS was statistically significantly lower in subgroup D than in subgroup A. There was a negative correlation between the exposure to ETS expressed by the SHSES scale and peak of LV GLS (r = − 0.35, p < 0.05). Regression analysis showed that higher SHSES score, higher age, left ventricular hypertrophy, left ventricular diastolic dysfunction, and higher CAD-RADS are independent risk factors for lower peak of LV GLS values. On the contrary, the effective blood pressure control appeared to be independent protecting factor against lower peak of LV GLS values. In summary, there is an unfavorable weak relationship between ETS exposure estimated using the SHSES scale and LV GLS in hypertensive patients.

Role of global longitudinal strain in the assessment of left ventricular systolic function in patients with systemic lupus erythematosus: a systemic review and meta-analysis

Abstract Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized with high cardiovascular morbidity and mortality. However, cardiac involvement, especially at an early stages of the disease is largely underdiagnosed due to non-specific nature of the symptoms and low sensitivity of current diagnostic tools such as 2D conventional echocardiography derived left ventricular ejection fraction (LVEF), on the other hand, speckle tracking echocardiography (STE) derived left ventricular global longitudinal strain (LV GLS) has shown to be a reliable and sensitive tool for the diagnosis of subtle myocardial changes in various entities. Purpose The present study aimed to perform an extensive systemic review and meta-analysis of the current case-control studies based on the assessment of the left ventricular systolic function with standard and advanced echocardiographic methods. Methods The objectives, literature search strategies, inclusion and exclusion criteria, outcome measurements, and methods of statistical analysis were analyzed according to an established protocol of the cochrane collaboration steps and meta-analysis of observational studies in epidemiology recommendations (MOOSE). Results A total of 825 papers were collected according to our searching criteria, of those 20 studies including 1121 SLE patients and 1010 controls with evaluated LVEF and 8 studies including 387 patients and 283 controls with evaluated LV GLS were selected. We found, that overall patients with SLE exhibited lower levels of LVEF [weighted mean difference -WMD (95%CI) 0.336 (−0.423 to −0.248); p&amp;lt;0.001] (Fig. 1), although separately some included studies showed that the difference in terms of LVEF between SLE and the control group is not always significant. LV GLS was significantly lower in SLE patients as compared to controls [WMD (95%CI) −1.341 (−1.517 to −1.166); p&amp;lt;0.001] (Fig. 1), LV GLS was unequivocally lower in SLE patients (Fig. 2) in every reported study, moreover some studies showed significant association between deteriorated LV GLS and cardiovascular events. Conclusions LV systolic function as measured by LVEF and LV GLS is significantly affected in SLE patients. Data from meta-analysis suggest that STE derived LV GLS assessment potentially represents a new tool to improve precise and early assessment of LV function and may improve risk-stratification in patients with SLE. Funding Acknowledgement Type of funding sources: None.

Correlation between central aortic stiffness indices and cardiac mechanics in hypertensive patients: new insights from speckle tracking echocardiography imaging

Abstract Background Left ventricular (LV) and left atrial (LA) mechanics are altered in hypertensive patients. Recent evidence suggests that central aortic pressure, rather than brachial pressure is strongly related to future cardiovascular events. Currently, oscillometric non-invasive devices are considered a reliable method for estimation of central aortic pressure and stiffness indices. Purpose To evaluate the relation between central aortic pressure measured using oscillometric non-invasive device and cardiac mechanics assessed by speckle tracking echocardiography (STE). Methods Fifty hypertensive patients with apparently structural normal heart were consecutively enrolled. A new oscillometric device was programmed to measure blood pressure over a period of 30 minutes (total of 15 sequential readings) and then data was transferred to a computer-based software where the central aortic pressure and stiffness indices (Augmentation index {AIx} and Pulse wave velocity {PWV}) were automatically calculated. All patients underwent conventional transthoracic echocardiography and STE. STE analysis of LV and LA functions was done using a specific software. LV systolic (global longitudinal strain {GLS}) as well as diastolic (measured at peak mitral filling {E} and at isovolumetric relaxation time {IVRT}) strain/strain rate were measured. LA strain was measured during reservoir (LASr), conduit (LAScd) and contraction (LASct) phases. Results The mean age was 45.9±10.6 years and 38% of patients were males. Most of the population was overweight with mean BMI 28±1.9 kg/m2. About 2/3 of population has uncontrolled hypertension (mean brachial systolic and diastolic blood pressure was 139.8±17.5 and 88.4±11.3 mmHg, respectively). The mean central systolic (cSBP) and diastolic blood pressures (cDBP) were elevated (122.2±13.3 and 84.6±10.8 mmHg, respectively). cSBP and cDBP showed significant weak negative correlation with LV diastolic strain rate (Dsr) at peak E (cSBP: r=−0.33, p=0.02; cDBP: r=−0.28, p=0.04). There was no significant correlation between LV GLS and central stiffness indices (p&amp;gt;0.05). cDBP was significantly negatively correlated with LASct (r=−0.3, p=0.03), with no other significant correlation between central stiffness indices and other LA functions (LASr and LAScd) (p&amp;gt;0.05). Conclusions Changes in LV diastolic strain/strain rate parameters assessed by STE are related to central aortic pressure particularly cSBP and cDBP in patients with hypertension. This relation was also observed with LA strain parameters namely LASct. Funding Acknowledgement Type of funding sources: None.

Added value of left atrial strain in outcome prediction after myocardial infarction. SWEDEHEART-registry based echocardiographic study

Abstract Background Left ventricular function parameters, such as ejection fraction and global longitudinal strain are widely accepted prognostic parameters after myocardial infarction. Left atrial strain has been suggested as a novel risk parameter in this population. Objective To investigate whether left atrial (LA) deformation parameters (LA reservoir strain, LARS) can improve prognostic value of traditional echo parameters in prediction of heart failure and dead in patients after myocardial infarction. Moreover, to study relationship between LARS and established LV function parameters, and test its reproducibility between the readers. Method A total of 380 patients with myocardial infarction, hospitalized at our university hospital between 2008–2014, underwent echocardiography during hospital stay. The collected images was reanalyzed with respect to left atrial strain. Patients were followed up within the Swedish myocardial infarction registry (SWEDEHEART). Results To the final analysis a total of 253 patients (64 years of age, 81% men) were included, and followed up over median of 4.9 years. Among the parameters tested in the univariate analysis, LARS was able to predict long-term risk of heart failure admissions and death in patients with myocardial infarction (HR 0.95, 95% CI 0.91–0.99 for combined end-point). LARS below 27.2% identifies patients with higher risk of combined endpoint with AUC 0.68 (p=0.001). After adjustment for background characteristics and established LV function measures, LARS has lost significance, meaning that it provides no additional information in this population. LARS correlates moderately with LV GLS (r=−0.52, p&amp;lt;0.001) and weakly with LVEF (r=0.31, p&amp;lt;0.001), to a moderate extent and to a small extent with LAVI and LVEF, respectively. LARS shows moderate to perfect agreement between reviewers. Conclusions LARS is a good prognosticator of death and heart failure hospitalizations after myocardial infarction, but not independent of the established LV function parameters. We showed a good correlation between LARS and LV strain parameters and its near perfect inter-reader reproducibility. Funding Acknowledgement Type of funding sources: None.

Global longitudinal strain as a potential marker for earlier treatment referral for severe aortic stenosis

Abstract Background Aortic stenosis (AS) is the most prevalent valvular disease in the developed countries. The disease progression is long and It is of greatest importance to choose the optimal intervention timing and to secure best long term prognosis. Purpose To establish left ventricular strain as independent predictor for left ventricular function improvement after AVR which could be used for treatment decision making. Methods In this prospective, crossectional study 76 patients were included that fulfilled the criteria for severe aortic stenosis according to the guidelines from professional associations. In all patients before the AVR detailed clinical, functional, angiographic examination was performed as well as transthoracic echocardiography using Philips Epique 7. With 2D TTE the left ventricular systolic and diastolic function was assessed and with speckle tracking echocardiography global longitudinal strain (GLS %) was evaluated. Same TTE evaluation was performed 4 months after AVR. Measurements were analyzed using QLAB 7.1. Statistical analysis was performed using SPSS 25.0. Results Surgical treatment of the aortic valve significantly reduced aortic stenosis severity in all patients. Age didn't have any impact on change of left ventricular function after AVR. In both genders there was significant reduction in disease severity as well as improvement in systolic and diastolic function of the left ventricle (Figure 1) with greater improvement of GLS values in the female gender. Analysis of GLS changes after AVR in patients divided by EF showed significant improvement of GLS in patients no matter the value of preoperative EF (Figure 2). For EF improvement after AVR independent predictors were: left ventricular systolic dimension and GLS. Analysis of our cohort before AVR showed significant correlation of impaired GLS with male gender, obesity, more severe AS, larger LVD dimension and wall thickness, as well as LV systolic and diastolic volumes, higher LVMI, lower EF and lower stroke index, reduced MAPSE and s'TDI, higher wall motion score index, higher Zva and lower left atrial EF. After AVR there was significant improvement of GLS in all patient, however patients with reduced preoperative EF had significantly worse GLS after AVR. In the patients with preserved EF ≥50%, GLS before AVR was independent predictor for postoperative improvement of EF and number of segment with LS less than 13% was independent predictor for positive remodeling only in patients with low flow. Conclusions Impairment of LV GLS is of particular significance in the wide variety of patients with preserved EF that vary in ratio between flow and gradient were worse values of GLS imply worse prognosis. The results from our study support promotion of LV GLS as a marker for decision on AVR timing in respect of its prognostic implications. It is our expectation that GLS evaluation would find its place in future guidelines for diagnosis and treatment of patients with AS. Funding Acknowledgement Type of funding sources: None.