Impaired LV Research Articles

Risk Stratifying Low-Flow, Low-Gradient Aortic Stenosis using N-Terminal Pro B-Type Natriuretic Peptide: Results from TOPAS study

In low-flow, low gradient aortic stenosis (LFLG-AS i.e. with low left ventricular [LV] ejection fraction), there is no data on the value of the clinical activation ratios of B-type natriuretic peptide (BNP-ratio) versus aminoterminal-proBNP (NT-proBNP-ratio) as surrogates of LV impairment to risk-stratify the patients. BNP and NT-proBNP-ratios were calculated by dividing the actual serum level by the upper normal reference value for age and sex in 238 prospectively recruited LFLG-AS patients. After adjustment for the severity of AS, initial treatment (aortic valve replacement [AVR] vs. conservative management), age, sex and the euroSCORE (Model#1), BNP-ratio > 7.4 had a trend to predict time to death (HR = 2.14[1.00–4.58], P = 0.05). NT-proBNP ratio significantly predicted one and three-year mortality (area under the curve [AUC] = 0.67 ± 0.04 and 0.66 ± 0.05, both P = 0.001), and independently predicted mortality (HR = 1.39 [1.11–1.74], per unit LogNT-proBNP-ratio, P = 0.004). In a head-to-head comparison, the AUCs for one and three-year mortality were higher with NT-proBNP-ratio versus BNP-ratio ( P < 0.009). NT-proBNP-ratio but not BNP-ratio independently predicted mortality and significantly improved Model#1 (Likelihood ratio test Chi 2 = 15.953, P = 0.0003). The category-free net reclassification index of NT-proBNP-ratio when added to the multivariable model was 0.71 ( P = 0.008) versus 0.38 ( P = 0.15) for BNP-ratio. Furthermore, there was a marked survival benefit associated with AVR in patients with NT-proBNP-ratio > 11 (62% with severe AS), while those < 11 (46% with severe AS) had excellent short-term survival under conservative management ( Fig. 1 ). NT-proBNP-ratio strongly predicts the risk of mortality and is superior to BNP-ratio to risk stratify LFLG-AS patients. The assessment of LV function impairment using NT-proBNP-ratio has important clinical implications and should be complementary to the determination of true AS severity.

Anthracycline induced inconsistent left ventricular segmental systolic function variation in patients with lymphoma detected by three-dimensional speckle tracking imaging.

Chemotherapy contained anthracycline inevitably cause declines of cardiac function. This study evaluated the deterioration of left ventricular segmental systolic function in patients with lymphoma received anthracycline chemotherapy detected by echocardiographic three dimensional speckle tracking imaging (3D-STI). Sixty patients with newly diagnosed diffuse large B-cell lymphoma who received R-CHOP chemotherapy were enrolled. Three dimensional left ventricular global longitudinal strain (3D-GLS), three dimensional left ventricular global circumferential strain (3D-GCS) and three dimensional left ventricular longitudinal strain of different left ventricular segments (3D-LS) were measured by 3D-STI at baseline, after the completion of two cycles and four cycles of the regimen respectively. Compared with baseline, 3D-GLS reduced significantly after four cycles of anthracycline therapy (P < 0.001), while 3D-GCS showed no significant variation during the whole procedure (all P > 0.05). For individual segment, LS of apical anterior and septal walls decreased significantly after two cycles of chemotherapy (all P < 0.05). After four cycles of treatment, 3D-LS of the mid-ventricular level (all P < 0.05), apical level (all P < 0.05) and apex (P < 0.05) worsened. Serum hs-cTnT levels increased after anthracycline exposure (P < 0.05) and Serum hs-cTnT levels were correlated with 3D-GLS at the end of four cycles (r = 0.12, P = 0.03). Mean values of involved segmental 3D-LS of two and four cycles were both correlated with serum hs-cTnT levels at the end of both two and four cycles (r = 0.368, P = 0.041; r = 0.79, p < 0.001). 3D-STI evaluation of the LV provides an understanding of the segmental impairment of LV wall and the possible process of LV impairment in lymphoma patients after anthracycline chemotherapy.

Audit of Management Post-Acute Coronary Syndrome With At Least Moderate Left Ventricular Impairment in Counties Manukau: Room for Improvement

Introduction: Significant impairment of left ventricular ejection fraction (LVEF) (<40%) following an acute coronary syndrome (ACS) event is associated with a number of adverse outcomes, including recurrent ACS, sudden cardiac death, and heart failure. It can be improved by early revascularisation and access to evidence-based pharmacotherapy. Assessment of LVEF after ACS by echocardiogram is a key performance indicator in New Zealand, but the quality of outpatient management is less well understood. Method: A consecutive cohort of patients with ACS and LVEF (<40%) was extracted from the All New Zealand Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) registry, and a retrospective electronic chart review was performed to identify management strategies in the year following discharge. Results: Fifty-seven patients met the inclusion criteria: 35 (61%) had moderate LV impairment and 22 (39%) had severe impairment; 45 (79%) were male; mean age was 64.5 years (range, 31–87). Fifty-two (91%) attended cardiology follow-up. At 1 year, 29 (51%) had an angiotensin-converting enzyme (ACE) I prescribed and 25 (44%) had a beta blocker prescribed, of at least half the trial dose. Forty-six (81%) attended cardiac rehabilitation. Follow-up echocardiograms were organised for 37 (65%) patients: 15 (27%) reported an improved LVEF >40%, 22 (39%) had persisting LV impairment <40%, and 19 (33%) had no further review of LV function organised. Conclusion: Despite reasonable follow-up – including cardiac rehabilitation – important gaps in evidence-based treatment and monitoring remain and should be a focus of quality improvement.

Presystolic Wave is Associated with Subclinical Left Ventricular Dysfunction Assessed by Myocardial Performance Index in Type 2 Diabetes Mellitus.

BackgroundMyocardial performance index (MPI), demonstrates both systolic and diastolic functions of the left ventricle. Presystolic wave (PSW) is frequently detected on Doppler examination of the left ventricular outflow tract and possible mechanism of PSW is impaired LV compliance and left ventricular stiffness.ObjectiveTo investigate the relationship between PSW and MPI in type 2 diabetic patients.MethodA total of 129 type 2 diabetic patients were included in this study. Patients were divided into two groups according to the presence of PSW on Doppler echocardiography. There were 90 patients (38 male, mean age 57.77 ± 10.91 years) in the PSW-positive group and 39 patients (13 male; mean age: 55.31 ± 11.29 years) in the PSW-negative group. The p values of < 0.05 were considered statistically significant.ResultsMPI was higher in PSW- positive group (0.63 ± 0.17vs 0.52 ± 0.13, p < 0.001). In addition, subclinical left ventricle dysfunction (LVD) was higher in the PSW- positive group (p = 0.029). Univariate analysis showed that the presence of PSW associated with abnormal MPI (p = 0.031). Pearson correlation analysis showed that PSW velocity correlated with MPI (r: 0.286, p = 0.006).ConclusionPresence of the PSW on Doppler examination was associated with subclinical LV dysfunction in patients with DM type 2. This easy-to-perform echocardiographic parameter may be related to subclinical LVD among patients with type 2 DM.

Effect of Levosimendan Infusion 24 Hours Before CABG Surgery in Patients with Impaired Left Ventricular Function on the Need for Postoperative IABP

Background: Due to their unfavorable outcome, patients with impaired left ventricular function undergoing CABG surgery (LVEF ≤ 35%) are in a real need for optimization of their preoperative status in order to achieve the best possible results. In this retrospective comparative study we analysis our results in patients with impaired LV function after using Levosimendan as a continuous infusion 24 hours prior to CABG surgery regarding the need for postoperative IABP. Patients and methods: We included in this study 103 patients with LVEF ≤ 35% that underwent coronary artery bypass grafting with or without repair of ischemic mitral regurgitation and received Levosimendan infusion 24 hours before surgery in the period between January 2016 and January 2019 in 2 hospitals (Group A). These data were compared to another matched control group of 98 patients with similar conditions that were operated in the same hospitals over a previous period of 3 years but received no Levosimendan infusion preoperatively (Group B). Results: There was a statistically significant difference in the postoperative results in favor of group A regarding the need for IABP application (P-value = 0.013). However there were no statistically significant differences between both groups in concern of duration of inotropic support (P-value = 0.40), duration of mechanical ventilation (P-value = 0.30), total ICU (P-value = 0.20) and hospital stays (P-value = 0.40), incidence of postoperative atrial fibrillation (P-value = 0.50), incidence of major adverse effects, and in-hospital mortality (P-value = 0.20). There was only one in-hospital mortality in each group. Conclusion: According to our study, infusion of Levosimendan 24 hours prior to CABG surgery in patients with impaired left ventricular contractility is safe and effective in reducing the need of IABP application. However Levosimendan infusion did not affect significantly postoperative coarse, incidence of major adverse effects, and in-hospital mortality.

The Effect of Atrial Fibrillation on Right Heart Function in Patients with Heart Failure with Reduced Ejection Fraction

Background: Left (LV) and right ventricular (RV) function are proposed to be intimately linked. We previously demonstrated that RV dysfunction increases with severity of LV dysfunction. Atrial fibrillation (AF) is an established cause of LV systolic dysfunction, but its effect on RV size and function in this population is not well characterised. We aim to evaluate the effect of AF on RV systolic function in a cohort of non-ischaemic cardiomyopathy patients. Methods: We compared 64 consecutive patients in sinus rhythm (SR) with 32 patients in AF with stable HFrEF in the absence of coronary artery, significant valvular, congenital, or pulmonary disease. Patients in both SR and AF were categorised based on LVEF (mild 40–49%, moderate 30–39%, severe <30%). Standard and novel echocardiographic parameters of right heart were assessed. RV free wall peak systolic strain (RVFWS) was measured (TomTec Image Arena, Germany v4.6). Results: Patients with SR (mean age 56 ± 19 y; 61% male), and AF (mean age 67 ± 11 y; 75% male) groups had similar proportions of patients in the mild, moderate and severe groups (SR: n = 25, 21, 18 vs AF n = 10, 12, 10, respectively). Conditional regression analysis revealed that patients with AF had significantly worse RV impairment compared to patients with SR as defined by RV fractional area change (RVFAC; p < 0.001) and RVFWS (p < 0.001) across all grades of LV impairment. Conclusions: Our results demonstrate that AF is associated with worse RV impairment compared to patients in SR as defined by RVFAC and RVFWS. This highlights the potential benefits of restoration of SR in this cohort of HFrEF patients.

Prognostic value of new imaging parameters in patients with hypertrophic cardiomyopathy: A prospective study

Hypertrophic cardiomyopathy (HCM) is a frequent hereditary cardiac disease and a major cause of sudden cardiac death (SCD). Although very useful, ESC risk score's predictive value has been interrogated since it was retrospective and did not include MRI parameters and new echocardiographic markers. To assess the additional value of new echocardiographic and MRI parameters in predicting SCD and outcome in patients with HCM. Between 2007 and 2017, 307 patients with HCM were prospectively included and followed for 1.63 years. In addition to conventional prognostic factors, all patients underwent cardiac MRI evaluation of late gadolinium enhancement (LGE), and echocardiographic measurements of LV and LA volumes and strains, including left atrial peak longitudinal strain (PALS) and left atrial peak contraction strain (PACS). Primary end-point was SCD or appropriate defibrillator therapy. Secondary end-point was a composite end-point including death, hospitalization for heart failure, new-onset of atrial fibrillation, need for septal ablation, myomectomy, or heart transplantation. Among the 307 patients, 6 patients (2%) died and the secondary end-point occurred in 65 (21%). Factors associated with SCD by univariate analysis were low LVEF [HR 0.91 (0.93–0.99)] impaired PALS [HR 0.86 (0.72–0.97)], and moderate mitral regurgitation (MR). Factors associated with the secondary end-point were impaired LV GLS [HR 1.23 (1.13; 1.35)], impaired LA 4-chamber PALS [HR 0.94 (0.91; 0.97)] and PACS [HR 0.91 (0.86; 95)], LA 2 chamber PALS [HR 0.93 (0.89; 0.96)] and PACS [HR 0.86 (0.83;0. 94)], as well as TTE and MRI MR, and presence of MRI LGE. Impaired LA 4-chamber PALS remained as an independent predictor for the composite end-point [HR 0.92 (0.87; 0.97)] after adjustment. This study suggests an additive prognostic value of an impaired LV and LA TTE strain, the presence of MR, and MRI LGE, to the classical ESC 7 recommended risk factors.

Right coronary artery ligation in mice: a novel method to investigate right ventricular dysfunction and biventricular interaction.

Right ventricular (RV) dysfunction can lead to complications after acute inferior myocardial infarction (MI). However, it is unclear how RV failure after MI contributes to left-sided dysfunction. The aim of the present study was to investigate the consequences of right coronary artery (RCA) ligation in mice. RCA ligation was performed in C57BL/6JRj mice ( n = 38). The cardiac phenotypes were characterized using high-resolution echocardiography performed up to 4 wk post-RCA ligation. Infarct size was measured using 2,3,5-triphenyltetrazolium chloride staining 24 h post-RCA ligation, and the extent of the fibrotic area was determined 4 wk after MI. RV dysfunction was confirmed 24 h post-RCA ligation by a decrease in the tricuspid annular plane systolic excursion ( P < 0.001) and RV longitudinal strain analysis ( P < 0.001). Infarct size measured ex vivo represented 45.1 ± 9.1% of the RV free wall. RCA permanent ligation increased the RV-to-left ventricular (LV) area ratio ( P < 0.01). Septum hypertrophy ( P < 0.01) was associated with diastolic septal flattening. During the 4-wk post-RCA ligation, LV ejection fraction was preserved, yet it was associated with impaired LV diastolic parameters ( E/ E', global strain rate during early diastole). Histological staining after 4 wk confirmed the remodeling process with a thin and fibrotic RV. This study validates that RCA ligation in mice is feasible and induces RV heart failure associated with the development of LV diastolic dysfunction. Our model offers a new opportunity to study mechanisms and treatments of RV/LV dysfunction after MI. NEW & NOTEWORTHY Right ventricular (RV) dysfunction frequently causes complications after acute inferior myocardial infarction. How RV failure contributes to left-sided dysfunction is elusive because of the lack of models to study molecular mechanisms. Here, we created a new model of myocardial infarction by permanently tying the right coronary artery in mice. This model offers a new opportunity to unravel mechanisms underlying RV/left ventricular dysfunction and evaluate drug therapy.

Presystolic wave is associated with carotid intima media thickness.

Carotid intima media thickness (CIMT), a direct marker of atherosclerosis, has emerged as a promising means for cardiovascular risk evaluation. Presystolic wave (PSW) is commonly detected by the Doppler interrogation of the left ventricular outflow tract (LVOT). It is thought to be a result of a stiff left ventricle and impaired LV compliance. Herein, we aimed to investigate a possible association between carotid intima media thickness, an atherosclerotic marker, and PSW. We prospectively enrolled 282 patients divided into two groups based on the presence of PSW: 221 (89F; mean age: 49.3±11.5years) had PSW on Doppler examination while 61 patients (32F; mean age: 46.4±10.3years) did not. Both groups were compared with respect to demographic, clinical properties, and CIMT. Both groups had comparable age, body mass index, and diabetes mellitus, hypertension, dyslipidemia, smoking, and family history for coronary heart disease. PSW-positive group had significantly higher CIMT (PSW-positive: 0.59±0.22mm vs PSW-negative: 0.42±0.11mm; P<0.001) than PSW-negative group. Multivariate analysis showed that the independent predictors of increased CIMT were age (95% CI; 1.044-1.101, P<0.001), dyslipidemia (95% CI; 0.147-0.664, P=0.002), and the presence of PSW (95% CI; 2.168-7.836, P<0.001).Correlation analysis showed that PSW velocity is correlated with increased CIMT in PSW-positive group (r: 0.418, P<0.001). Assessment of PSW on TTE is easy and feasible method. Presence of PSW and increased PSW velocity on TTE might provide information that we should be careful in terms of subclinical atherosclerosis.

Haemodynamic effects of pharmacologic stress with adenosine in patients with left ventricular systolic dysfunction

BackgroundIn patients with heart failure, downregulation of adenosine receptor gene expression and impaired adenosine-related signal transduction may result in a diminished response to adenosine. This may have implications for cardiac stress testing. We evaluated the haemodynamic response to intravenous adenosine in patients with left ventricular systolic dysfunction (LVSD) undergoing stress cardiovascular magnetic resonance imaging (CMR). Methods and resultsWe retrospectively examined 497 consecutive patients referred for clinical stress CMR. Blood pressure and heart rate responses with intravenous adenosine were compared in patients with normal, mild-moderately impaired and severely impaired LV systolic function (ejection fraction [EF] > 55%, 36–55% and < 35%, respectively).Following 2 min of adenosine infusion, there was a significant difference between the groups in the heart rate change from baseline, with a diminished heart rate response in patients with LVSD (p < 0.001). An increase in the dose of adenosine (up to 210 μg/kg/min) was required to achieve a sufficient haemodynamic response in more patients with severe LVSD (41%) than those with mild-moderately impaired and normal LV systolic function (24% and 19%, respectively, p < 0.001). Even with increased doses of adenosine in subjects with severe LVSD, peak haemodynamic response remained blunted. With multivariate analysis age (p < 0.001) and LVEF (p = 0.031) were independent predictors of heart rate response to adenosine. ConclusionPatients with reduced LVEF referred for stress CMR may have a blunted heart rate response to adenosine. Further study is warranted to determine whether this may be associated with reduced diagnostic accuracy and also the potential utility of further dose increases or alternative stressors.

Incidence and impact of prosthesis-patient mismatch following transcatheter aortic valve implantation.

The implications of prosthesis-patient mismatch (PPM) in the context of transcatheter aortic valve implantation (TAVI) are still controversial. The objective of our study was thus to investigate theincidence and prognostic impact of PPM after TAVI. Our analysis included 613 TAVI patients in whom the indexed effective orifice area (iEOA) after TAVI was obtained in vivo using echocardiography. Prosthesis sizing was guided by pre-procedural ECG-gated computed tomography. Based on VARC-2 established criteria for significant PPM (iEOA ≤ 0.85 cm2/m2 in the setting of BMI < 30kg/m2 and iEOA ≤ 0.7 cm2/m2 in the context of BMI ≥ 30kg/m2), patients were attributed to a "No PPM" or a "PPM" group. We observed PPM after TAVI in 192 patients (31.3%) with moderate PPM being present in 150 subjects (24.5%) and severe PPM in 42 patients (6.9%). EuroSCORE, impaired LV function, and male gender were associated with PPM status. The "No PPM" group was characterized by higher rates of self-expandable valves (40.4% vs. 25.5%, p < 0.001). In a multivariate analysis age > 81.2 years, chronic obstructive pulmonary disease, peripheral artery disease, impaired LV function, acute kidney failure stage 3 as well as periprocedural myocardial infarction emerged as independent risk predictors for all-cause mortality after TAVI. After a median follow-up of 12.2 months PPM failed to show a significant association with overall survival (79.2% vs. 79.3%,p = 0.692). The incidence of PPM after TAVI seems to be substantially lower than after SAVR. PPM was less common using self-expandable valves. In our analysis, patients with PPM following TAVI did not have higher rates of all-cause mortality.

Effect of high flow arteriovenous fistula on cardiac function in hemodialysis patients.

BackgroundVascular access for hemodialysis (HD) with an inappropriately high flow may underlie the onset of high output heart failure (HOHF).The aim of this study was to determine the prevalence of high flow access (HFA) in chronic HD patients, and to determine its effects on cardiac functions.MethodsThis cross sectional study was conducted on 100 chronic hemodialysis patients through arteriovenous fistula (AVF). The study cohort was subdivided into 2 groups based on AVF flow: Group A (Non-HFA group with Qa < 2000 ml/min), and Group B (HFA group with Qa ≥ 2000 ml/min). AVF flow (Qa) was assessed using Color Doppler ultrasonography. Transthoracic echocardiography was performed for all patients to assess cardiac dimensions and functions.ResultsPrevalence of HFA among study population was 24%. Mean AVF Qa was 958.63 ± 487.35 and 3430.13 ± 1256.28 ml/min, for group A and B respectively. The HFA group demonstrated a significant dilatation in LV dimensions and volumes and significantly larger LA volume as compared to non-HFA group. A significantly lower LV ejection fraction [EF] was also observed in group B with a mean value of 57.32 ± 6.19% versus 62.90 ± 5.76%. A significant association between HFA group and high Qa/cardiac output (CO) ratio (≥20%) was also observed.ConclusionHFA is a prevalent hemodialysis vascular access problem. HFA was associated with dilated LV dimensions, impaired LV systolic function. High Qa/CO ratio (≥20%) was an independent predictor of high output heart failure (HOHF) in our study population.

Abstract 17086: External Support of the Cardiac Base in the Treatment of Functional Mitral Regurgitation &amp; Heart Failure

Introduction: Ventricular dysfunction in the presence of normal mitral leaflets is characteristic of functional mitral regurgitation (MR). Surgical treatment with mitral valve repair or replacement, address mitral valve annulus and leaflets, not the ventricular muscle. We describe early and mid-term clinical experience with extra-cardiac treatment of FMR with a novel device that is implanted on a beating heart. Hypothesis: External and adjustable support of the cardiac base can effectively reduce functional MR &amp; HF. Methods: The BACE (Basal Annuloplasty of the Cardia Externally) device is a broad belt/band of silicone that is implanted at the base of the heart, by means of slim polyester belt loops sutured on atrial and ventricular sides of the Atrio-Ventricular groove. Forty one patients (mean age 60.24 years) with functional and ischemic MR were evaluated at 10 multi-national centers between December, 2008 and June, 2018. All patients had moderately severe or severe MR (Mean MR grade 3.3) on trans-thoracic and/or trans-esophageal echocardiography, and impaired LV function (Mean EF 38.5%). Risk assessment by Logistic Euroscore showed a mean of 16.5%. Implantation of the BACE device, was performed, according to sizing performed along the base of the heart, overlapping atrial and ventricular surfaces of the atrio-ventricular groove circumferentially. Mean number of coronary grafts was 2.5. Five patients had stand-alone procedures without CABG. Procedures were performed on a beating heart with the majority of them performed off-pump. Intra-operative trans-esophageal echocardiography allowed customized inflation of specific chambers to selectively deform the annulus and sub-annular myocardium. Results: Three patients required peri-operative adjustment of the BACE device. There were no deaths related to the BACE device or device failures. The degree of MR improved from a mean of 3.4 to 0.88. This &gt;2 class improvement in MR was sustained over the 12 month follow up period in all patients. LVEDD decreased from 5.9±0.6 to 5.5±0.6 cm. Conclusions: Ischemic and functional mitral valve regurgitation can be treated by epicardial implantation and dynamic adjustment of the BACE device. Ventricular stabilization may impact HF progression.

GW29-e0931 Pulse pressure and differential DNA methylation in association with prevalence of left ventricular diastolic dysfunction in the Northern Shanghai Study

Left ventricular diastolic dysfunction (LVDD), usually referred to as heart failure (HF) with a preserved LV ejection fraction (HFpEF), is often thought to be the abnormality in cardiac filling ability which is the result of impaired LV capacity. LVDD plays an important role in the progression of

Association of Left Ventricular Global Longitudinal Strain With Asymptomatic Severe Aortic Stenosis

The optimal timing to operate in patients with asymptomatic severe aortic stenosis (AS) remains controversial. Left ventricular global longitudinal strain (LV GLS) may help to identify patients who might benefit from undergoing earlier aortic valve replacement. To investigate the prevalence of impaired LV GLS, the natural course of LV GLS, and its prognostic implications in patients with asymptomatic severe AS with preserved left ventricular ejection fraction (LVEF). This registry-based study included the institutional registries of 3 large tertiary referral centers and 220 patients with asymptomatic severe AS and preserved LVEF (>50%) who were matched for age and sex with 220 controls without structural heart disease. The echocardiograms of patients and controls were performed between 1998 and 2017. Both clinical and echocardiographic data were assessed retrospectively. Severe AS was defined by an indexed aortic valve area less than 0.6 cm2/m2. Left ventricular global longitudinal strain was evaluated on transthoracic echocardiography using speckle tracking imaging. The prevalence of impaired LV GLS, the natural course of LV GLS, and the association of impaired LV GLS with symptom onset and the need for aortic valve intervention. Two hundred twenty patients (mean [SD] age, 68 [13] years; 126 men [57%]) were included. Despite comparable LVEF, LV GLS was significantly impaired in patients with asymptomatic severe AS compared with age- and sex-matched controls without AS (mean [SD] LV GLS, -17.9% [2.5%] vs -19.6% [2.1%]; P < .001). After a median follow-up of 12 (interquartile range, 7-23) months, mean (SD) LV GLS significantly deteriorated (-18.0% [2.6%] to -16.3% [2.8%]; P < .001) while LVEF remained unchanged. Patients with impaired LV GLS at baseline (>-18.2%) showed a higher risk for developing symptoms (P = .02) and needing aortic valve intervention (P = .03) at follow-up compared with patients with more preserved LV GLS (≤-18.2%). Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with asymptomatic severe AS with preserved LVEF. Left ventricular global longitudinal strain further deteriorates over time and impaired LV GLS at baseline is associated with an increased risk for progression to the symptomatic stage and the need for aortic valve intervention.

Triple Versus Double Antianginal Combinations in the Treatment of Patients with Stable Angina with Impaired LV Function: A Single Center Registry

Triple Versus Double Antianginal Combinations in the Treatment of Patients with Stable Angina with Impaired LV Function: A Single Center Registry

Prevalence and determinants or right ventricular dysfunction in severe aortic stenosis

Systolic pulmonary artery pressure (sPAP) is a well-known predictor of outcome in patients with valvular heart disease. In spite of this fact, limited data are available regarding the assessment of RV function in patients with aortic stenosis (AS). Aim of this study is therefore to evaluate the prevalence and the determinants of RV dysfunction in severe AS patients 301 patients (mean age: 79.7 ± 8.7, male sex 55.5%) with severe AS underwent 2D echocardiography and speckle tracking echocardiography (STE) for the evaluation of left ventricular and RV function, aortic valve gradients and sPAP. A tricuspid annular plane systolic excursion (TAPSE) ≤ 17 mm was used to define reduced RV ventricular function. RV function was impaired in 24% of patients (patients with reduced TAPSE had an impaired LV ejection fraction (LVEF) (49.2 ± 15.4 vs. 57.9 ± 10.9%, P < 0.0001), significantly altered STE parameters (GLS: −10.3 ± 3.9 vs. −13.2 ± 3.5%, GCS: −7.0 ± 3.0 vs. −10.4 ± 4.9%, GRS: 18.7 ± 11.6 vs. 28.4 ± 15.6, all P < 0.001) and a higher sPAP (48.4 ± 15.8 vs. 40.9 ± 12.7 mmHg, P = 0.002) with respec to patients with a normal RV function. Correlates of a reduced TAPSE were: LVEF ( β = 0.35, P < 0.0001), LV global longitudinal, circumferential and radial strain ( β = −0.40, β = −0.40, β = 0.37 respectively, all P < 0.0001), LV indexed stroke volume ( β = 0.44, s < 0.0001), lnNT-proBNP ( β = −0.51, P < 0.0001) and sPAP ( β = −0.27, P < 0.0001). At Kaplan-Meier survival curve, a TAPSE ≤ 17 mm was associated with a reduced survival in patients with AS (Log-Rank test, P = 0.034). In patients with severe AS, RV function impairment is frequent and is associated with a poor prognosis. The correlations of TAPSE highlight the RV-LV interdependence in AS patients. Further studies will clarify the real and independent prognostic value of RV function in severe AS patients and test for the RV reverse remodelling after treatment of the AS.

Chemotherapy and echocardiographic indices in patients with non-Hodgkin lymphoma: the ONCO-ECHO study

The cardiotoxicity of chemotherapy (CTx) for non-Hodgkin’s lymphomas is not well recognized. In order to facilitate individual risk counseling for patients, we analyzed the effect of CTx on echocardiographic indices in regard to clinical data in patients treated for non-Hodgkin’s lymphoma (NHL). A prospective multicenter ONCO-ECHO trial included 67 patients with NHL (45 patients with DLBCL (diffuse large B cell lymphoma) and 22 with non-DLBCL). Patients received standard CTx, primarily R-CHOP, CHOP, R-COP and COP regimens. Clinical data and echocardiographic indices were obtained at baseline, 3-, 6- and 12-month follow-up. The primary end point representing CTx cardiotoxicity was defined as a ≥ 10% decrease in the left ventricular ejection fraction (LVEF) during 12-month observation. In a 12-month follow-up five (7.5%) deaths occurred, while no clinical manifestations of heart failure were reported. There was an increase in left ventricular end-systolic diameter (p = 0.002) and E/e′ index (p = 0.036) in 12-month observation. Preexisting coronary artery disease was associated with significant decrease in the ΔLVEF (p = 0.008), increase in ΔLVEDV (p = 0.03) and ΔLVESV (p = 0.02) and increase in the Δ left atrium diameter (p = 0.02); while history of arterial hypertension was related to significant decrease in the ΔLVEF (p = 0.039), diabetes mellitus was related to significant increase in the ΔE/e′ index (p = 0.002). The primary end point was reported in ten (14.9%) patients. There were no independent risk factors for cardiotoxicity in the study population. Chemotherapy administered to NHL patients may induce dilatation and impaired LV diastolic function. Standard cardiovascular risk factors may predispose patients to negative LV remodeling.

Abstract 21053: Single Centre Experience of Portico TM Transcatheter Aortic Valve Implantation

Background: The Portico TM nitinol based self-expanding transcatheter aortic valve implantation (TAVI) system has the capability of being fully repositioned and retrieved in situ. This study investigates the feasibility and performance of Portico TM valve in subjects with severe symptomatic aortic stenosis up to 6 months post procedure. Hypothesis: The Portico TM system is safe and feasible in the treatment of patients with severe aortic stenosis. Methods: TAVI with the Portico TM system was performed in 83 subjects with severe AS using transfemoral (n=78), subclavian (n=4) and transaortic (n=1) access. Valve sizes included 23mm (n=5), 25mm (n=12), 27mm (n=31) and 29mm (n=35). Transthoracic echocardiography (TTE) was conducted pre and post-procedure and at 1mth and 6months in outpatient clinical follow-ups to evaluate aortic valve (AV) gradients and paravalvular regurgitation. Major stroke, vascular complications and mortality were also assessed in this cohort. Results: The mean age was 82±9yrs, with mean STS score of 5.0% and mean Euroscore II of 5.7%. The mean AV gradient improved significantly from baseline 47±17mmHg to 11±6 mmHg at 1mth and this decrease was sustained at 6 months post procedure; p&lt;0.0001. There were no cases of severe paravalvular regurgitation by TTE at 6 months. The 30-day mortality was 1.2% (n=1) and 6 months mortality was 6.0% (n=5). Two patients (2.4%) had post procedure stroke and both were treated with intravenous thrombolysis with improvement in their symptoms, one patient (1.2%) had major vascular complications requiring vascular intervention and 10 patients (12%) required permanent pacemaker implantation. With regards to patients with impaired LV function, 12 patients (14.4%) had an EF &lt; 55% prior to the TAVI procedure. In this group, there was a 15% improvement in EF at 6 months. Furthermore, 89% of all subjects improved at least one NYHA class at 30 days post procedure and 84% of the subjects improved at least one NYHA class at 6 months follow up. Conclusion: From our single center experience, the repositionable transcatheter Portico TM valve is feasible, safe and promising in the management of severe symptomatic aortic stenosis.

Clinical and Laboratory Profile of Patients Presenting With Warfarin Coagulation Abnormality Following Heart Valve Replacement- A Descriptive Study

Despite revolutionary changes in the field of medicine and eradication or prevention of many diseases worldwide in the past few decades, rheumatic heart disease (RHD) still remains as one of the largest preventable disease burdens in the world and is seen to be more prevalent in the developing countries1 . Majority of RHD patients develop valvular heart disease with mitral valve incompetence as the most common valvular lesion seen in these patients2 . In symptomatic patients or those in whom evidence of impaired LV function at rest is seen, surgical intervention is the definitive treatment 3 . Patients who undergo surgical intervention may have either a bio prosthetic valve replacement or a mechanical valve replacement. Those in the latter group requires to be initiated on vitamin K receptor antagonist drugs like warfarin in order to prevent thrombus formation of the mechanical valves.