Left Ventricular Septum Research Articles

Left ventricular systolic function between left bundle branch pacing and right ventricular septum pacing in patients with pacemaker dependence by three-dimensional speckle tracking imaging.

To compare the left ventricular systolic function between the 1eft bundle branch pacing (LBBP) and right ventricular septum pacing (RVSP) in patients with pacemaker dependence by three-dimensional speckle tracking imaging (3D-STI). A total of 65 patients with atrioventricular block (AVB) (Mobitz type II second-degree AVB, high-degree AVB, or third-degree AVB), who underwent permanent cardiac pacing implantation including 32 patients receiving LBBP (LBBP group) and 33 patients receiving RVSP (RVSP group) from June 2018 to June 2019,were enrolled in this study. These patients met the following inclusion criterion: pre-operative left ventricular ejection fraction (LVEF)>50% and ventricular pacing rate>40% at 6-month programming follow-up; and the patients underwent echocardiography at pre-operation and 6 months after operation. The 3D-STI was used to obtain global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS). All the patients in the LBBP group and the RVSP group had normal LVEF, there was no significant difference between the 2 group (P>0.05). The LVEF was slightly decreased at 6-month follow-up in the RVSP group, but there was no significant change compared with pre-operation (P>0.05). There were no significant difference in LVEF, GLS, GCS, GRS and GAS at pre-operation and 6-month after operation between the LBBP group and the RVSP group (all P>0.05). Compared with pre-operation, the GLS and GCS were significantly decreased in the LBBP group; while the GLS, GCS, GRS and GAS in the RVSP group were also significantly decreased at 6-month follow-up (all P<0.05). For patients with pacemaker dependence and normal LVEF at pre-operation, the cardiac function in the LBBP group is not significantly better than that in the RVSP group in short term follow-up. But in terms of physiologic pacing and long-term cardiac function protection, the 1eft bundle branch pacing is an optimal pacing mode.

Evaluation of the Criteria to Distinguish Left Bundle Branch Pacing From LeftVentricular Septal Pacing.

This study sought to assess the predictive value of the proposed electrocardiogram and intracardiac electrogram characteristics for confirmation of left bundle branch (LBB) capture. Previously proposed criteria to distinguish left bundle branch pacing (LBBP) and left ventricular septum (LVS) pacing (LVSP) have not been fully validated. A His bundle pacing lead, an LBBP lead, and a multielectrode catheter at the LVS were placed. Direct LBB capture was defined as demonstration of retrograde His potential on the His bundle pacing lead and/or anterograde left conduction system potentials on the multielectrode catheter during LBBP. The routinely used parameters-His, LBB potential, time from stimulus to peak ventricular activation (Stim-LVAT), and paced QRS morphology during LVSP and LBBP at various depths and outputs were analyzed. Thirty patients (21 non-left bundle branch block [LBBB], 9 LBBB) who demonstrated direct LBB capture using the defined criteria were included. The proportion of paced right bundle branch block was 100% during LBB capture in all patients compared to 23.4% in non-LBBB and 44.4% in LBBB during LVSP. LBB potential was recorded in all patients during intrinsic rhythm (non-LBBB group) or His corrective pacing in LBBB. Paced QRS duration was longer during selective LBBP compared to nonselective LBBP or LVSP only. All patients with characteristics of selective LBBP or abrupt decrease in Stim-LVAT of≥10ms demonstrated LBB capture. Direct LBB capture can be confirmed by recording retrograde His potential and anterograde left conduction system potentials. Abrupt decrease in Stim-LVAT of≥10ms and demonstration of selective LBBP could be used as simple criteria to confirm LBB capture.

Cardiovascular system status of long-livers in Moscow: the prevalence of cardiovascular diseases and their risk factors

Over the past century, an increase in life expectancy has been observed in Russia and in the world. According to the United Nations, by 2100, the number of centenarians worldwide will reach 25 million. Despite the annual increase in the number of super-centenarians, this age group remains poorly understood.Aim. To estimate the prevalence of cardiovascular diseases (CVD) and the main risk factors among super-centenarians in Moscow.Material and methods. According to the register of long-livers in Moscow, 82 people aged 95 to 105 were included. Participants were examined at home.The history of life and the presence of chronic diseases was collected by participant words. To assess the state of cardiovascular system, an ultrasound of the heart and main arteries was performed.Results. Conventional CVD risk factors were the exception rather than the rule among study participants (smoking — 8 patients (9,8%), alcohol abuse — 4 (4,9%), obesity — 6 (7,3%)). Dyslipidemia was relatively widespread (n=37; 45,1%), however, there were no pronounced abnormalities in the lipid profile: the maximum increase in low-density lipoproteins was 5,6 mmol/L. The most common CVDs among the participants were hypertension (n=64; 78%), coronary artery disease (n=42; 51,2%), and heart failure (n=26; 31,7%); other diseases were much less common. The most common echocardiographic changes were left atrial dilatation (n=38; 74,5%), increased left ventricular mass, thickening of left ventricular posterior wall (n=24; 48%) and interventricular septum (n=51; 100%). Diastolic and systolic heart failure were not widespread among long-livers: 16 (32%) and 2 (3,9%), respectively. Despite a rather large number of atherosclerotic plaques in the common carotid and femoral arteries, the number of hemodynamically significant plaques was low (n=3; 4,6%). An intima-media thickening up to 1,0-1,1 mm was found.Conclusion. Long-livers in Moscow are characterized by a low prevalence of traditional CVD risk factors (with the exception of hypertension) and a fairly high prevalence of atherosclerotic CVDs, which are characterized by a subclinical course.

Predictors of outcome in a Spanish cohort of patients with Fabry disease on enzyme replacement therapy

Fabry disease may be treated by enzyme replacement therapy (ERT), but the impact of chronic kidney disease (CKD) on the response to therapy remains unclear. The aim of the present study was to analyse the incidence and predictors of clinical events in patients on ERT. Study designMulticentre retrospective observational analysis of patients diagnosed and treated with ERT for Fabry disease. The primary outcome was the first renal, neurological or cardiological events or death during a follow-up of 60 months (24–120). ResultsIn 69 patients (42 males, 27 females, mean age 44.6±13.7 years), at the end of follow-up, eGFR and the left ventricular septum thickness remained stable and the urinary albumin: creatinine ratio tended to decrease, but this decrease only approached significance in patients on agalsidase-beta (242–128mg/g (p=0.05). At the end of follow-up, 21 (30%) patients had suffered an incident clinical event: 6 renal, 2 neurological and 13 cardiological (including 3 deaths). Events were more frequent in patients with baseline eGFR≤60ml/min/1.73m2 (log Rank 12.423, p=0.001), and this remained significant even after excluding incident renal events (log Rank 4.086, p=0.043) and in males and in females. Lower baseline eGFR was associated with a 3- to 7-fold increase the risk of clinical events in different Cox models. ConclusionsGFR at the initiation of ERT is the main predictor of clinical events, both in males and in females, suggesting that start of ERT prior to the development of CKD is associated with better outcomes.

Can shear wave imaging distinguish between diffuse interstitial and replacement myocardial fibrosis?

Abstract Funding Acknowledgements Type of funding sources: None. Background Diffuse interstitial or myocardial replacement fibrosis are common features of a large variety of cardiomyopathies. These alterations contribute to functional changes, particularly to an increased myocardial stiffness (MS). Histological examination is the gold standard for myocardial fibrosis quantification, however, it requires endomyocardial biopsy which is invasive and not without risks. Cardiac magnetic resonance (CMR) can characterize the extent of both diffuse and replacement fibrosis and may have prognostic value in various cardiomyopathies. Echocardiographic shear wave (SW) elastography is an emerging approach for measuring MS in vivo. SWs occur after mechanical excitation of the myocardium, e.g. after mitral valve closure (MVC), and their propagation velocity is directly related to MS, thus providing an opportunity to assess stiffness at end-diastole. Purpose The aim was to investigate if velocities of natural SW can distinguish between interstitial and replacement fibrosis. Methods We prospectively enrolled 47 patients (22 patients after heart transplant [54.2 ± 15.8 years, 82.6% male] and 25 patients with established hypertrophic cardiomyopathy [54.0 ± 13.5 years, 80.0% male]) undergoing CMR during their check-up. We performed SW elastography in parasternal long axis views of the LV using a fully programmable experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2-5AC) at 1100 ± 250 frames per second. Tissue acceleration maps were extracted from an anatomical M-mode line along the midline of the LV septum. The SW propagation velocity at MVC was measured as the slope in the M-mode image. All patients underwent T1 mapping as well as late gadolinium enhancement (LGE) cardiac magnetic resonance at 1.5 T to assess the presence of diffuse or replacement fibrosis (Figure A). Therefore, patients were divided in three groups: no fibrosis, diffuse fibrosis and replacement fibrosis. Results Mechanical SW’s were observed in 46 subjects starting immediately after MVC and propagating from the LV base to the apex. SW propagation velocity at MVC correlated well with native myocardial T1 values (r = 0.65, p &amp;lt; 0.0001) and differed significantly among groups (p &amp;lt; 0.0001), with a significant post-test between any pair of groups (Figure B). SW velocities below a cut-off of 6.01 m/s showed the highest accuracy to identify patients without any type of fibrosis (sensitivity 88 %, specificity 89%, area under the curve = 0.93) (Figure C). A cut-off of 8.11 m/s could distinguish replacement fibrosis from diffuse fibrosis with a sensitivity and specificity of 59% and 92 %, respectively (area under the curve = 0.80) (Figure D). Conclusions Shear wave velocities after mitral valve closure can distinguish between normal and pathological myocardium and can detect differences between diffuse and replacement fibrosis. Abstract Figure.

Myocardial deformation assessed among heart failure entities by cardiovascular magnetic resonance imaging.

AimsAlthough heart failure (HF) is a leading cause for hospitalization and mortality, normalized and comparable non‐invasive assessment of haemodynamics and myocardial action remains limited. Moreover, myocardial deformation has not been compared between the guideline‐defined HF entities. The distribution of affected and impaired segments within the contracting left ventricular (LV) myocardium have also not been compared. Therefore, we assessed myocardial function impairment by strain in patients with HF and control subjects by magnetic resonance imaging after clinically phenotyping these patients.Methods and resultsThis prospective study conducted at two centres in Germany between 2017 and 2018 enrolled stable outpatient subjects with HF [n = 56, including HF with reduced ejection fraction (HFrEF), HF with mid‐range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF)] and a control cohort (n = 12). Parameters assessed included measures for external myocardial function, for example, cardiac index and myocardial deformation measurements by cardiovascular magnetic resonance imaging, left ventricular global longitudinal strain (GLS), the global circumferential strain (GCS) and the regional distribution of segment deformation within the LV myocardium, as well as basic phenotypical characteristics.Comparison of the cardiac indices at rest showed no differences neither between the HF groups nor between the control group and HF patients (one‐way ANOVA P = 0.70). The analysis of the strain data revealed differences between all groups in both LV GLS (One‐way ANOVA: P < 0.01. Controls vs. HFpEF: −20.48 ± 1.62 vs. −19.27 ± 1.25. HFpEF vs. HFmrEF: −19.27 ± 1.25 vs. −15.72 ± 2.76. HFmrEF vs. HFrEF: −15.72 ± 2.76 vs. −11.51 ± 3.97.) and LV GCS (One‐way ANOVA: P < 0.01. Controls vs. HFpEF: −19.74 ± 2.18 vs. −17.47 ± 2.10. HFpEF vs. HFmrEF: −17.47 ± 2.10 vs. −12.78 ± 3.47. HFrEF: −11.41 ± 3.27). Comparing the segment deformation distribution patterns highlighted the discriminating effect between the groups was much more prominent between the groups (one‐way ANOVA P < 0.01) when compared by a score combining regional effects and a global view on the LV. Further analyses of the patterns among the segments affected showed that while the LVEF is preserved in HFpEF, the segments impaired in their contractility are located in the ventricular septum. The worse the LVEF is, the more segments are affected, but the septum remains an outstanding location with the most severe contractility impairment throughout the HF entities.ConclusionsWhile cardiac index at rest did not differ significantly between controls and stable HF patients suffering from HFrEF, HFmrEF, or HFpEF, the groups did differ significantly in LV GLS and LV GCS values. Regional strain analysis revealed that the LV septum is the location affected most, with reduced values already visible in HFpEF and further reductions in HFmrEF and HFrEF.

Moxibustion Improves Chronic Heart Failure by Inhibiting Autophagy and Inflammation via Upregulation of mTOR Expression.

How moxibustion improves chronic heart failure is extremely complex and still unclear. This study aimed to explore whether moxibustion inhibits autophagy and reduces inflammation by regulating mTOR expression to induce myocardial protective effects and alleviate symptoms associated with chronic heart failure. Echocardiography was used to detect cardiac function and cardiac structure of rats, including heart rate (HR), left atrium diameter (LA), left ventricular diameter (LV), left ventricular posterior wall (LVPW), interventricular septum (IVS), ejection fraction (EF), and fractional shortening (FS). BNP and NT-pro BNP levels were measured by enzyme-linked immunosorbent assay (ELISA). Autophagy-associated protein (ATG) genes and mTOR were detected by PCR. The expression of mTOR and phosphorylated-mTOR was detected through western blotting of proteins from myocardial tissue samples. The left ventricular inflammatory response was detected by immunohistochemistry and included ICAM-1, VCAM-1, MMP-2, and MMP-9 expression. The relationship between autophagy and inflammation was analyzed by correlation analysis. The results from echocardiography and ELISA showed that moxibustion could significantly improve heart function and structure. Western blot and PCR results showed that moxibustion treatment elevated mTOR expression. Further, moxibustion could inhibit autophagy and regulate the expression of key autophagy-related genes, including Vps34, ATG3, ATG5, ATG7, ATG12, and ATG13. By contrast, rapamycin could partially reduce the effects of moxibustion. Immunohistochemistry results indicated that moxibustion could reduce myocardial inflammation. Moreover, there was a positive correlation between autophagy and inflammation. Moxibustion can protect cardiac function in rats with heart failure, possibly inhibiting excessive autophagy of cardiomyocytes and reducing inflammatory reactions through the elevation of mTOR expression.

Impact of anatomical position of the inflow cannula on stroke in patients with left ventricular assist devices.

Stroke is a substantial complication of left ventricular assist device (LVAD) implantation. The relationship between stroke and the anatomical position of the inflow cannula of patients who underwent LVAD implantation was investigated. We enrolled 15 patients with advanced-stage heart failure who underwent implantation of continuous-flow-LVAD. Data of patients who suffered a stroke within 6 months after LVAD implantation were retrospectively compared to those who remained free of stroke. The distance between the inflow duct and left ventricular (LV) septum (duct-sep distance) and its ratio to LV diastolic diameter (LVDd) were measured from echocardiography at 1 month after LVAD implantation. Receiver operating characteristic curves for the endpoint of stroke using the duct-sep distance to LVDd ratio was created and the cut-off value was calculated. The incidence of stroke during the 6 months after LVAD implantation according to this ratio was estimated using the Kaplan-Meier method. At 1 month after LVAD implantation, there were no significant differences in baseline characteristics and echocardiography parameters between the stroke and stroke-free groups. Receiver operating characteristic curve analysis for the endpoint of stroke using the duct-sep distance to LVDd ratio revealed 0.217 as a cut-off value (sensitivity: 80%, specificity: 80%, area under the curve: 0.72). Stroke was more frequent in patients with a duct-sep distance to LVDd ratio ⩾0.217 at 1 month than in those with a lower ratio. The duct-sep distance to LVDd ratio was associated with the occurrence of stroke, suggesting that inflow cannula position influences the incidence of stroke.

Study of Cardiovascular Changes in Adolescents with Simple Obesity

Obesity is a risk factor for cardiovascular morbidity and mortality that has deleterious effects on cardiovascular function. The aim of this work was to screen early cardiovascular abnormalities in obese asymptomatic adolescents using Conventional Echocardiography and Electrocardiogram. Fifty asymptomatic obese adolescents selected from National Heart Institute were compared to fifty non-obese normal controls with mean age of (12.44 ± 1.91) and (11.99 ± 1.89) years respectively. All studied adolescents were subjected to: careful history taking, complete clinical examination, laboratory investigation: fasting blood glucose, lipid profile, fasting insulin, insulin resistance, echocardiography and ECG. Results: It revealed statistical significant differences between obese and non-obese groups regarding left ventricle septal wall in diastole (LVSd), posterior wall thickness in diastole (LVPWd), relative wall thickness (RWT), LV end diastolic and systolic diameter (LVEDD and LVESD) and LV mass (P-value: 0.000). The left atrial dimensions (LA) were also significantly higher in the obese subjects than in the control group (P-value: 0.000). For the Doppler measurements, the early and late mitral valve velocity and the ratio between them (MVE velocity, MVA velocity and MV E/A) were significantly higher in obese than control subjects (P-value: 0.000). A strong positive correlation was noted between BMI and left atrial size (P-value: 0.003), left ventricular septum in diastole (LVSd) (P-value: 0.000), LVEDD (P-value: 0.005) and LVESD (P-value: 0.000), posterior wall thickness in diastole (LVPWd) (P-value: 0.012), left ventricle septal wall in diastole (LVSd) (P-value: 0.000) and left ventricular mass (P-value: 0.010). Conclusion: This study demonstrated that asymptomatic obese adolescents had significant changes in left ventricular dimensions and early diastolic filling compared to non-obese subjects.

Cardiac Morphology in Neonates with Intrauterine Growth Restriction

Background: Intrauterine growth restriction (IUGR) affects cardiac development. We hypothesized that IUGR impacts early cardiac modelling. Aim: To assess the impact of IUGR on cardiac morphology in premature and term neonates. Study design: Prospective, observational cohort study Subjects: Pregnant women and their neonates with early (week 30+0 -31+6, n=9) and late (week 32+0 -42+0, n=19) IUGR with centralized fetal circulation. A gestational age matched control group (n=41) of non-IUGR neonates with normal prenatal growth and circulation. Outcome measures: Heart size measured by echocardiography. Results: Adjusted for gestational age, birth weight, sex and twin/singleton, IUGR neonates had significantly shorter mean (SEM) left ventricular septum length than non-IUGR neonates (27.8 mm (0.4) vs 29.7 (0.3)), shorter diameter of left atrium (9.4 (0.2) vs 10.8 (0.2)), left ventricle (15.0 (0.3) vs 17.3 (0.2)) and right ventricle (8.3 (0.3) vs 9.9 (0.3)) (p<0.01). In unadjusted estimates, IUGR had more impact on atrial cavities and right ventricle areas and diameters than on longitudinal dimensions, but less impact on atrioventricular valve orifices and left ventricle cavity diameters. This indicated a globular shape of the left ventricle and a symmetrical-to-oblong shape of right ventricle in IUGR. In adjusted estimates, the right ventricle dimensions exhibited an oblong shape whereas left ventricle dimensions were symmetrical. Conclusion: IUGR neonates had smaller hearts compared with non-IUGR neonates. In unadjusted estimates, IUGR hearts portrayed a symmetrical-to-oblong shape of the right ventricle and a globular shape of the left ventricle. In adjusted estimates, right ventricle shape remained oblong, whereas left ventricle shape was symmetrical. Funding Information: The research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sector. Declaration of Interests: None declared. Ethics Approval Statement: The Hospital’s Data Protection Officer and The Regional Ethics Committee of Research, South East, Norway approved the study (2016/923D). The parents gave written informed consent.

Systematic quantification of histologic ventricular fibrosis in isolated mitral valve prolapse and sudden cardiac death

Cardiac fibrosis in mitral valve prolapse (MVP) is implicated in the development of sudden cardiac death (SCD); however, the pattern remains poorly characterized. The purpose of this study was to systematically quantify left and right ventricular fibrosis in individuals with isolated MVP and SCD (iMVP-SCD), whereby other potential causes of death are excluded, compared to a control cohort. Individuals with iMVP-SCD were identified from the Victorian Institute of Forensic Medicine, Australia, and matched for age, sex, and body mass index to control cases with noncardiac death. Cardiac tissue sections were analyzed to determine collagen deposition in the left ventricular free wall (anterior, lateral, and posterior portions), interventricular septum, and right ventricle. Within the iMVP-SCD cases, the endocardial-to-epicardial distribution of fibrosis within the left ventricle was specifically characterized. Seventeen cases with iMVP-SCD were matched 1:1 with 17 controls, yielding 149 samples and 1788 histologic regions. The iMVP-SCD group had increased left ventricular (anterior, lateral, and posterior; all P <.001) and interventricular septum fibrosis (P <.001), but similar amounts of right ventricular fibrosis (P = .62) compared to controls. In iMVP-SCD, left ventricular fibrosis was significantly higher in the lateral and posterior walls compared to the anterior wall and interventricular septum (all P <.001). Within the lateral and posterior walls, iMVP-SCD cases had a significant endocardial-to-epicardial gradient of cardiac fibrosis (P <.01) similar to other known conditions that cause cardiac remodeling. Our study indicates that nonuniform left ventricular remodeling with both localized and generalized left ventricular fibrosis is important in the pathogenesis of SCD in individuals with MVP.

Intracardiac hemodynemics, fibroblast growth factor-2 and oxyproline levels with mitral valve prolapse in combination with type 1 diabetes mellitus

The purpose. The aim of the study was a comparative analysis of basic echocardiographic parameters, fibroblast growth factor-2 and free and peptide-bounding oxyproline indicators in young patients with mitral valve prolapse, type 1 diabetes mellitus and the combination of both indications.Materials and methods. 93 patients between 19 and 33 years old with either mitral valve prolapse, type 1 diabetes and the combination of both indications were examined. There are 24 people with diagnosed mitral valve prolapse, 33 patients with type 1 diabetes mellitus and mitral valve prolapse and 36 patients with the monomorbid type 1 diabetes mellitus. The establishment of the diagnosis of mitral valve prolapse implemented by echocardiographic criteria L. Freed et al. (2002). The concentration of fibroblast growth factor-2 in blood plasma was determined by the enzyme immunoassay using a Quantikine reagent kit (Human FGF basic Immunoassay), manufactured by R&amp;D Systems, Inc. (USA) and expressed in pg/ml. Free and peptide-bounding oxyproline as the markers of connective tissue metabolism were determined by the method of P. N. Sharaev and expressed in µmol/L.Results. In patients with mitral valve prolapse and ype 1 diabetes mellitus, the higher values of l left ventricular posterior wall thickness and intraventricular septum have been revealed in comparison with the groups of patients with monomorbid mitral valve prolapse and ype 1 diabetes mellitus. Fibroblast growth factor-2 was higher in group with combination of both indications, where it was [23.7 ± 0.25] pg/ml compared to the control group [14.20 ± 0.22] pg/ml (p &lt;0.01). There was also a significant difference in the levels of fibroblast growth factor-2 between group with either mitral valve prolapse [15.33 ±0.24] pg/ml and combination of mitral valve prolapse and type 1 diabetes [23.71 ±0.25] pg/ml (p&lt;0.01). The level of peptide-bound oxyproline, just as the level of free oxyproline, significantly increased in patients with comorbid pathology, compared to the control group: [16.06 ±1.54] µmol/l versus [8.7 ±0.81] µmol/l (p&lt;0.01) respectively. Conclusions. The most significant differences in the indices of intracardiac hemodynamics, fibroblast growth factor-2 and free and peptide-bounding oxyproline compared with control were observed in patients with combination of mitral valve prolapse and type 1 diabetes, which may indicate the influence of diabetic metabolic processes on further structural changes in the mitral valve.

The value of left ventricular longitudinal strain in the diagnosis and differential diagnosis of myocardial amyloidosis

Objective: To investigate the characteristics of left ventricular longitudinal strain (LS) in myocardial amyloidosis (CA), hypertrophic cardiomyopathy (HCM) and Fabry disease (FD), as well as the correlation between left ventricular LS and these diseases. Methods: A total of 14 CA patients, 28 HCM patients and 5 FD patients who visited the Department of Cardiology of the First Affiliated Hospital of Suzhou University from June 2017 to November 2019 were retrospectively included. EchoPAC software was used to analyze left ventricular LS, and univariate logistic regression analysis was used to analyze the correlation between echocardiographic LS indexes and various myocardial hypertrophy diseases. The receiver operating characteristic (ROC) curve was used to assess the sensitivity and specificity of echocardiograph LS indexes in the diagnosis of various myocardial hypertrophy diseases. Results: There were significant differences in LS of left ventricular basal segment, inferior wall, posterior wall, lateral wall and posterior septum among the three groups (P<0.05). The absolute value of LS in the left ventricular basal segment decreased in the CA group; the absolute value of LS in left ventricular posterior wall and lateral wall decreased significantly in the FD group (P<0.05); the absolute values of LS in left ventricular basal segment, inferior wall, posterior septum, lateral wall and posterior wall increased significantly in the HCM group (P<0.05). The absolute value of LS < 7.9% in the left ventricular basal segment, or > 13.2% in the inferior wall and > 9.2% in the basal segment, or < 8.3% in the lateral wall and < 7.9% in the posterior wall were the indicators of high sensitivity and specificity in the diagnosis of CA, HCM and FD, respectively. Conclusions: Left ventricular LS was an important index to differentiate myocardial hypertrophy. Combined with their respective clinical characteristics, it could provide certain reference value for clinical practice.

Echocardiographic abnormalities in 124 severely malnourished adult anorexia nervosa patients: frequency and relationship with body composition and biological features

BackgroundAnorexia Nervosa (AN) is a complex psychiatric disorder that can lead to specific somatic complications. Heart abnormalities are frequently reported, while their frequency and associated factors in severely malnourished AN patients remain poorly defined.ObjectivesThis study aimed to characterize echocardiographic abnormalities in severely malnourished AN patients and to assess associated clinical, biological and related body composition features.MethodsBetween January 2013 and January 2015, all severely malnourished adult patients with AN (Mental Disorders, 4th Edn.-DSM IVr) were included in a monocentric study performed in in a highly specialized AN inpatient unit. Electrocardiogram (ECG) and echocardiography were used to assess both heart rhythm and function. All inpatients underwent a Doppler echocardiography procedure after undergoing combined blood volume adjustment, micronutrients deficiencies supplementation and electrolyte disorders correction. Right Ventricular (RV) and Left Ventricular (LV) systolic and diastolic functions were collected and compared to 29 healthy normal subjects in a control group.ResultsOne hundred and 24 patients (119 (96%) women, 5 (4%) men) with a mean age of 30.1 ± 11 years old and an average Body Mass Index (BMI) of 12 kg/m2 were included. Ninety patients (73%) had been diagnosed with AN Restrictive type (AN-R), 34 (27%) an AN Binge eating/Purging type (AN-BP). Eighteen patients (15%) disclosed an abnormal Left Ventricular Ejection Fraction (LVEF) (< 52% for male and < 54% for female). LVEF impairment was associated with AN-BP patients (p < 0.017) and hypertransaminasemia (AST and/or ALT ≥2 N) (p < 0.05). Left Ventricular mass (LV mass) and Left Ventricular End Diastolic Diameter (LVEDD) were significantly reduced in patients (p < 0.001, p < 0.001). Left and right ventricular tissue Doppler Imaging Velocities (TDI) peak were reduced in patients: Septal and Lateral LV Sm velocities peaks respectively 10 ± 2 cm/s (vs 14 ± 2 cm/s in controls, p < 0.001), 12 ± 3 cm/s (vs 16 ± 3 cm/s in controls, p < 0.001), basal RV Sm velocity peaks at 14 ± 3 cm/s (vs 19 ± 3 cm/s in controls, p < 0.001). Additionally, LV and RV diastolic velocity peaks were reduced: LV septal and lateral velocity peaks were respectively 13 ± 3 cm/s (vs 18 ± 2 cm/s p < 0.001), 12 ± 3 cm/s (vs 22 ± 4 cm/s, p < 0.001) and RV diastolic velocity peaks at 14 ± 3 cm/s (vs 21 ± 4 cm/s p < 0.001). LV diastolic velocity TDI peaks were significantly associated with hypertransaminasemia (p < 0.05) and tended to be associated with a low all body Fat-Free Mass Index (FFMI) (using Dual-energy X- ray Absorptiometry (DXA) (HOLOGICQDR 4500) (p = 0.056). Thirty-four patients (27%) had a pericardial effusion and were significantly associated with a decreased all body FFMI (p < 0.036).ConclusionHeart abnormalities are frequent in malnourished patients with AN, particularly in AN-BP type. Both liver enzymes and body composition abnormalities tended to be associated with heart dysfunction (non-significant association). Prospective studies are needed to better characterize and describe the evolution of cardiac abnormalities during the refeeding period and subsequent weight restoration.

Characteristics and Longer-Term Outcomes of Contemporary Patients

We describe characteristics and outcomes of contemporary pediatric hypertrophic cardiomyopathy (PHC) patients. We studied 398 consecutive pediatric HC patients (<18 years, median 14 years, 65% boys) seen at our center between 2002 and 2018. Baseline clinical and pediatric echocardiographic data was collected. Left ventricular outflow tract gradient (LVOTG), LV fractional shortening and Z-score for left ventricular (LV) wall thickness were calculated. Sudden cardiac death (SCD), appropriate internal defibrillator discharge (ICD), myectomy, and orthotopic heart transplant (OHT) were composite primary endpoint. A total of 133 (33%) had symptoms (71 [18%] dyspnea, 77 [19%] angina, and 19 [5%] syncope), 109 (27%) were on beta-blockers; 179 (45%) had family history of HC. A total of 146 (37%) underwent genetic testing (of which 91 (62%) were HC-gene positive). Basal septal LV thickness, septal LV z-score and fractional shortening were 1.2 ± 0.6 cm, 4.8 ± 5.6, and 42% ± 8, whereas 23% had extreme LV hypertrophy (z-score > 6) and 8% had LVOTG >30 mm Hg (range 0 to 139 mm Hg). At a median of 5.9 years (interquartile range 2.4, 9), there were 23 (6%) ICD's placed, and 47 (12%) primary composite events (9 [2%] deaths, 3 [1%] appropriate ICD discharge, 29 [7%] myectomy, and 8 [2%] OHT). There were no in hospital deaths following myectomy/OHT. Presence of symptoms (Hazard ratio or HR 2.45), ventricular tachycardia (HR 1.52), and higher basal septal LV z-score (HR 1.10) were independently associated with primary composite outcomes. LV septal z-score >4 was independently associated with events on spline analysis. Rate of SCD/appropriate ICD discharge was 0.5%/year. In conclusion, contemporary PHC patients seen at an experienced center have excellent outcomes with presence of symptoms and higher LV septal thickness associated with primary composite events.

Differentiation of Bilayer interventricular septum function in children with systemic lupus erythematosus by tissue Doppler and speckle tracking imaging.

The ventricular septum (VS) is considered a single functional wall. However, a line with high echogenicity in the middle of the VS could be detected with the recent echocardiographic modalities which separate the left from the right side of the VS. Our study aimed to evaluate functional differences between both sides of VS by tissue Doppler and Speckle Tracking Imaging (STI) in children with Systemic lupus erythematosus (SLE). This is a case-control study that included 40 children divided into 20 active SLE patients and 20 healthy children matched for age and sex as controls. Tissue Doppler imaging from the VS was performed with the region of interest was positioned in both sides at the mid-part of the septum. Longitudinal strain of both sides of the VS was obtained by (STI). Ejection fraction (EF) of the right and left ventricles were assessed by real-time 3-dimensional echocardiography. There was significant impaired S`, È, Á, compared with controls. STI of the VS showed significant affection of the left side regarding systolic strain (SS) and strain rate late diastole (SRDA). However, strain rate systole (SRS) and strain rate early diastole (SRED) are affected on both sides of VS compared with control. Á and SRDE of the left VS correlated significantly with SLEDAI (P ≤ .05). È of the right VS correlated with the duration of the disease (P ≤ .05). Bilayer analysis of VS could helps in the evaluation of right and left ventricular functions in subclinical myocarditis in SLE patients.

Salvage DC ablation of ventricular tachycardia following failed RF attempts

Abstract Background Ablation of ventricular tachycardia (VT) is a frequent clinical necessity. Modification of ventricular substrate can usually be achieved by radiofrequency ablation (RF). We present 4 cases of failed RF for recurrent VT. Two patients had multiple RF failures, one patient had in-procedure failure, and one patient had multiple RF attempts and a failed alcohol ablation (pt4). Objective To evaluate success of DC ablation after failed RF Methods A 6 Fr 4mm tip steerable ablation catheter, was placed at the site felt to be critical for the circuit following mapping (earliest activation, mid-diastolic, fractionated, site of concealed entrainment, or ventricular breakout). Two connection cables were utilized, one to the recording/mapping system, and one connected to an external biphasic defibrillator (DC). The DF was connected with one pad anterior chest and the other connected by the cable to electrode pins 1 and 2 folded within the second pad. The electrodes were secured by placing a hemostat on the pad. DC energy (360j) was delivered synchronized by electrodes 1–2 Results During follow-up 3 months to 1 year, no recurrent VT was observed. 3 patients received a total of 4 DC pulses, while the pt4 received 16 (RV and LV septum), complicated by prolonged hypotension. No other complications were observed. Figure shows broad RV breakout from the septum in pt4. Conclusion In patients with RF refractory VT, DC ablation may be safely used and in this limited series, provides long-term success. Interestingly, biphasic energy did not induce transient hypotension in 3 of 4 pts. DC ablation should be considered following failed RF, especially when mid-myocardial origin suspected. Funding Acknowledgement Type of funding source: None

Electrical characteristics of deep septal vs. left bundle branch (area) pacing

Abstract Background/Introduction Recent studies have described transvenous left bundle branch (LBB) pacing as a new conduction system pacing strategy. However, information on effect of pacing depth within the septum and the additional effect of LBB capture is unknown. Purpose To investigate the relation of electrocardographic characteristics with transseptal LV lead implantation depth and LBB capture. Methods 20 consecutive patients referred for pacemaker implantation were enrolled. The right atrial (RA) lead was positioned according to routine practice. The LV septal pacing lead (Medtronic 3830) was transvenously positioned against the right side of the interventricular septum and advanced in small steps of 1–2mm towards the left side of the septum. At each depth in the septum 12-lead ECG's were recorded during pacing, from which vectorcardiograms (VCG) were calculated. QRS duration and QRS area were measured, the latter being the integral of the QRSarea in X, Y and Z directions. Successful LBB capture was defined as paced right bundle branch block (RBBB) morphology, stable and short stimulus to LV activation time (LVAT; R in V5) and recorded LBB potential. Differences were compared among pacing conditions using repeated measures ANOVA with Bonferroni multiple comparisons procedure applied to pairwise comparisons. Statistical significance was assumed at p&amp;lt;0.05. Results LV septal lead implantation was successful in all patients. Left bundle branch capture was achieved in 10/20 patients (50%). Post-procedural LV pacing threshold, impedance and sensing was 0.7±0.1 V at 0.5 ms pulse width, 658±5 Ω and 13±10 mV, respectively. Compared to intrinsic rhythm, QRS duration was significantly increased by both RV septum (RVS; 124±5 vs. 161±3 ms) and LV septum pacing (LVS; 142±3 ms). QRS area increased significantly during RVS pacing as compared to intrinsic rhythm but decreased when moving from RVS to LVS to values close to intrinsic rhythm (panel A &amp; B). LVS-pacing derived QRS area was significantly lower in patients with LBB capture (36±6 mV*ms) compared to patients without LBB capture (deep septal pacing; 46±12 mV*ms). The reduction in QRS area between RVS and LVS pacing coincided with normalization of the QRS vector in the transverse plane (panel C), which is characterized electrocardiographically by predominantly negative-to-positive inversion of the QRS complex in the precordial leads (V1-V3). Conclusions Compared to RV septal pacing, LV septal pacing restores ventricular electrical synchrony, as determined by QRS area, and normalizes the activation vector in the transverse plane to a level comparable to intrinsic rhythm. Differences in resynchronization between left bundle branch pacing and deep septal pacing are small. LBBAP restores ventricular synchrony Funding Acknowledgement Type of funding source: None

Shear wave elastography by high frame rate echocardiography can detect diffuse myocardial fibrosis after heart transplantation

Abstract Background Myocardial fibrosis is fundamental in the development of cardiac failure, regardless of ethiology. In both animal models and humans it has been shown that diffuse myocardial fibrosis (DMF) contributes to functional impairment, especially to increased passive myocardial stiffness, which is an important pathophysiological determinant of left ventricular diastolic dysfunction. Histological examination is the gold standard for myocardial fibrosis quantification, however, it requires endomyocardial biopsies which are invasive and not without risk. Echocardiographic shear wave (SW) elastography, based on high frame rate imaging, is an emerging approach for measuring myocardial stiffness in vivo. Natural SWs occur after mechanical excitation of the myocardium, e.g. after mitral valve closure (MVC) and their propagation velocity is directly related to myocardial stiffness, thus providing an opportunity to assess myocardial stiffness at end-diastole. Purpose The aim was to investigate if propagation velocities of natural SWs can be used to detect diffuse myocardial fibrosis in a cohort of heart transplant recipients. Methods We prospectively enrolled 22 patients (10.3±6.3 years after HTx) that underwent CMR during their annual check-up. We performed SW elastography in parasternal long axis views of the left ventricle using a fully programmable experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2–5AC) at 1100±250 frames per second. The SW propagation velocities at MVC were measured in the basal LV septum. Native T1 and extracellular volume (ECV) were measured at the same segment to evaluate DMF. A cut-off value for native T1 of 1040 ms and for ECV of 29% was used to define DMF in our cohort. Results We found good correlations between SW velocities and both myocardial T1 (r=0.80, p&amp;lt;0.0001, Figure A) and ECV (r=0.64, p=0.003, Figure B) measured with CMR. Further, we derived reference thresholds of natural SW velocities to identify DMF in HTx patients. The optimal cut-off value of SW velocity to identify patients with nativT1&amp;gt;1040 ms was 4.84 m/s (AUC 0.81, sensitivity 82%, specificity 82%, Figure C). To identify patients with ECV&amp;gt;0.29 the cut-off value of SW velocity was 4.74 m/s (AUC 0.74, sensitivity 73%, specificity 78%, Figure D). Conclusions End-diastolic shear wave propagation velocities, as measure of myocardial stiffness, showed a good correlation with CMR defined diffuse myocardial injury. Values higher than 4.74 m/s could identify diffuse myocardial injury in HTX patients with a good sensitivity and good specificity. These findings thus suggest that shear wave elastography has the potential to become a valuable non-invasive method for the detection of diffuse myocardial fibrosis. Funding Acknowledgement Type of funding source: None

How to incorporate left atrial strain in the diagnostic algorithm of left ventricular diastolic dysfunction.

The combination of early trans-mitral inflow and mitral annular tissue Doppler velocities (E/e' ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However, when E/e' is between 8 and 14 its accuracy decreases substantially. Left atrial (LA) deformation analysis by speckle tracking echocardiography was recently proposed as an alternative approach to estimate LV filling pressures, but its role when E/e' is between 8 and 14 has been under-investigated. We aimed to assess whether LA strain could help to identify elevated filling pressures in patients with E/e' between 8 and 14. Among consecutive non-selected patients who underwent a comprehensive echocardiographic evaluation, we enrolled those with E/e' ratio > 8 and ≤ 14. Exclusion criteria were: organic mitral valve disease or mitral surgery; presence of mitral regurgitation greater than moderate in severity; diseases associated with pre-capillary pulmonary hypertension; and undetectable systolic pulmonary artery pressure (PAP-S). Peak LA longitudinal (PALS) and contraction strain (PACS) values was obtained by averaging all segments, and by separately averaging segments measured in the 4-chamber and 2-chamber views. Seventy-six patients had E/e' > 8 and ≤ 14 and formed the study cohort. Mean age 69 ± 12years, LV ejection fraction (LVEF) 54.5 ± 11.2%, mean E/e' 11.2 ± 1.9, PAP-S 33 ± 7mmHg, PALS 31.6 ± 11.7%. PALS was significantly associated to PAP-S after adjustment for LVEF, E/e', septal LV longitudinal shortening velocity (s'), LA volume indexed (p = 0.002) and also for ASE/EACVI diastolic dysfunction classification (p = 0.0002). Furthermore, PALS but not ASE/EACVI diastolic dysfunction grading, resulted independently associated to New York Heart Association (NYHA) class (p = 0.0004). PALS is able to predict increased intra-cardiac pressure and NYHA class in patients characterized by E/e' between 8 and 14. Therefore, we propose that PALS might be incorporated in a simplified diagnostic algorithm based on E/e' classes.