Left Ventricular Systolic Dysfunction Research Articles

Direct vs. staged TAVI in the acute management of decompensated severe aortic stenosis

Abstract Funding Acknowledgements None. Background Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe aortic stenosis across a spectrum of surgical risks, potentially diminishing the role of balloon aortic valvuloplasty (BAV) as a transient solution or a bridge to definitive intervention. With advancements in TAVI technology and expertise, patients even in unstable conditions are increasingly receiving direct, definitive TAVI, avoiding the risks associated with staged, multiple procedures. Aims The study set out to assess whether immediate TAVI is safer and more effective than BAV followed by elective aortic valve replacement (AVR) in acute severe aortic stenosis. Methods Conducted as a retrospective analysis at a single center, this study encompassed a cohort of consecutive patients who received either urgent or emergency BAV, as bridge to AVR, or TAVI to manage decompensated severe aortic stenosis from May 2012 to May 2023. The primary outcomes were mortality rates at both 30 days and one year following the procedures. Results In this cohort, 258 cases of urgent or emergent percutaneous aortic valvuloplasty were evaluated. BAV was performed in 47 patients, whereas 211 received direct TAVI. A significantly higher proportion of the BAV group (36%) was treated due to cardiogenic shock as the primary indication, compared with just 11% in the TAVI group (p< 0.001). Demographic parameters and comorbid condition profiles were equivalently balanced across both groups. The median age was 81 years (interquartile range: 74-85, p= 0.40), and males constituted 56% of the patient population (p= 0.72). Most patients (65%) presented with left ventricular systolic dysfunction, and nearly half (49%) were diagnosed with obstructive coronary artery disease. The reduction in peak aortic valve gradient was significantly more pronounced in the TAVI group (-56±25 mmHg) compared to the BAV group (-27±19 mmHg, p< 0.001). TAVI recipients also had a higher incidence of VARC-2 minor and major bleeding events (26% versus. 6% for BAV, p<0.001), and a greater occurrence of advanced atrioventricular block necessitating temporary pacing (19% vs. 9% for BAV, p= 0.02). Thirty-day survival rates favored the TAVI group (93%) over BAV (86%). This trend persisted at the one-year mark, with survival rates of 84% for TAVI and 70% for BAV. Furthermore, the one-year hazard ratio for mortality among patients undergoing BAV was 2.01 (95% confidence interval: 1.34–3.01, p< 0.001). Conclusion The data from this retrospective analysis indicate that for patients with decompensated severe aortic stenosis, immediate TAVI may confer a mortality benefit over BAV followed by elective procedures. Despite a higher rate of procedural complications, the direct TAVI approach was associated with better survival rates at both 30 days and one year. These outcomes suggest a potential reevaluation of treatment strategies in acute settings may be warranted.

Left ventricular systolic function in patients with acute coronary syndrome-risk profile

Abstract Funding Acknowledgements None. Introductions and objectives Left ventricular (LV) systolic dysfunction is one of the most important determinants of long-term outcome in acute coronary syndrome (ACS). Aim To determine the impact of the patient’s risk profile on the LV systolic function. Methods A single-center cross-sectional cohort study that included 3093 patients with ACS without pre-existing LV dysfunction. The comparison was performed between patients who did or did not develop a reduction in LV systolic function during the index event (<50%/≥50%), analyzing patients’ demographic, clinical, biochemical data, LV functional data, and anatomical distribution of the coronary artery disease (CAD). Result 1369 patients out of 3093 developed LV systolic dysfunction (44.3%). They were predominantly males 75.1% (1028), p=0.002; older (63.39±11.04 vs 61.21±11.12, p<0.00000); had higher level of cardiac troponin (p=0.00002), higher stress glycemia (9.2±5.3; p=0.0000001), HbA1c (6.9±1.8, p=0.000003), WBC (11.7±4.1, p=0.00001), blood urea nitrogen (BUN) (6.8±3.7, p=0.000003), and creatinine (93.2±45.1 p=0.000167), and had anemia (OR 0.35 (CI 0.29–41, p=0.000012). They had more severe CAD (SINTAX score 16.8±8.4 p=0.000012). Patients with preserved LV systolic function were predominantly females (29.7%, OR 1.1 95% CI 1.0-1.2), p = 0.002), younger (p<0.00000), and severely metabolically burdened (hypothyreosis (2.7%, OR 1.28 95% CI 0.93-1.76, p=0.052), higher levels of triglycerides (2.2±1.7 vs 1.9±1.5, p = 0.001), cholesterol (5.3±1.4 vs 5.2±1.4, p = 0.002), non-HDL-C (4.1±1.5 vs 3.9±1.3, p=0.006), however less likely to have pre-existing DM (OR 0.8 (CI 0.78–0.92), p=0.000094). They were more often NSTEMI [851 (49.4%), p = 0.000012]. Independent variables associated with a reduction in LV function were: advanced age, male gender, previous DM and anemia, stress glycemia, WBC, creatinine, and BUN. Conclusion Patients who developed reduced LV function had a very specific risk profile with bigger neuro-hormonal activation and inflammation, higher degree of myocardial damage, and worse renal function, whereas those with preserved LV systolic function after ACS were younger, predominantly females, more severely metabolically burdened, more often with NSTEMI and without LAD involvement.

ASSESSMENT OF LEFT VENTRICULAR FUNCTION AFTER CORONARY ARTERY BYPASS GRAFTING

Coronary artery bypass grafting (CABG) is a commonly performed surgical intervention for coronary artery disease (CAD), aiming to restore blood flow to the myocardium and improve cardiac function. Left ventricular (LV) systolic function is a crucial determinant of postoperative outcomes in CABG patients, yet the predictors of adverse outcomes remain incompletely understood. Objective: This study aimed to evaluate left ventricular function outcomes following CABG and identify predictors of mortality among CABG patients. Methods: A prospective cohort study was conducted at, Ch. Pervaiz Elahi Institute Of Cardiology (CPEIC), Multan, Pakistan, from December 2022 to December 2023. The study included 96 patients undergoing CABG surgery. Preoperative data collection encompassed demographic information, medical history, and baseline clinical characteristics. Left ventricular function was assessed using echocardiography preoperatively and postoperatively. Statistical analysis involved descriptive statistics, univariate analysis, and univariate regression. Results: The study cohort comprised 96 participants, with a mean age of 56.1 years (±12.2) and a male predominance (67.7%). Prevalent comorbidities included diabetes mellitus (78.1%) and hypertension (79.2%). LV systolic dysfunction (30.2%) and old ischemic heart disease (72.9%) were common preexisting conditions. Intraoperative variables included perioperative inotropes (5.2%) and emergent surgeries (3.1%). Postoperative complications included reoperation for bleeding (5.2%) and deterioration of LV ejection fraction (34.4%). The mortality rate was 5.2%. Postoperatively, the mean LVEF increased significantly from 32.00% (±5.219) to 37.00% (±9.801) in isolated CABG patients. Conclusion: This study confirms the significant improvement in LV systolic function following CABG and underscores the high benefit of CABG in patients with reduced EF. However, diabetes mellitus, advanced diastolic dysfunction, and the insertion of IABP were identified as significant predictors of adverse outcomes. Identifying patients with these risk predictors could provide complementary prognostic information and help optimise care, monitoring, and follow-up to improve their expected poor outcomes.

Echocardiographic image monitoring during Impella use: our experience

Abstract Funding Acknowledgements None. Introduction Impella CP is a type of percutaneous left ventricular (LV) mechanical circulatory support located inside LV and placed through the aortic valve. There is little information about the incidence of valvular complications related to its use or other complications assessable by echocardiography. Purpose To determine the existence of complications assessable by echocardiography in patients treated with Impella CP in our centre. Methods Retrospective analysis of patients treated with Impella CP in 2020 and 2021 in our centre. Baseline clinical characteristics were studied and pre- and post-procedure echocardiograms of these patients were reviewed. Results A total of 32 echocardiograms were analysed in 16 patients with a mean age of 70 years. Clinical and echocardiographic features are described in table 1. After device removal, the presence or degree of aortic regurgitation did not change in the patients, including 2 patients who had moderate aortic regurgitation pre-implantation. However, on echocardiograms after device removal, intraventricular thrombus was detected in 2 patients, who also had severe LV systolic dysfunction and who had the longest duration in days of implantation (6 and 7 days). The mean number of days of implantation was 1.68 days. Conclusion Echocardiography is a useful tool for the management and detection of complications during the time of support with Impella CP, such as valve dysfunction and the presence of intraventricular thrombus. In our centre, the use of Impella is not related to the onset or worsening of aortic valve pathology.

Impairment of Left Ventricular Function in the Depressed Chinese Miniature Swine Model by Cardiovascular Magnetic Resonance Feature-Tracking: A Preliminary Study.

Individuals with depression have an increased risk of cardiovascular disease, and more often have a poor prognosis with cardiovascular disease. This study aimed to investigate the impact of depression on Left Ventricular (LV) alterations using Cardiovascular Magnetic Resonance Featuretracking (CMR-FT). Seven anesthetized, healthy Chinese miniature swine were included in the study. Basic data, including CMR scans at baseline and after 14 days of depression modeling, were collected. Behavioral tests, including the Open-field Test (OFT), Sucrose Preference Test (SPT), and measurements of the time taken to consume a specific amount of food and sugar, were conducted to assess the success of the depression models. CMR cine images were acquired and CVI software was employed to analyze Global Longitudinal Strain (GLS), Global Circumferential Strain (GCS), and Global Radial Strain (GRS). Late Gadolinium Enhancement (LGE) imaging was used to detect myocardial infarction and/or scar. The outcomes demonstrated successful depression modeling, indicated by reduced scores in the OFT and SPT, as well as an extended time to intake food and sugar compared to baseline. However, no significant differences were observed in LV End-diastolic Volume (LVEDV), LV Endsystolic Volume (LVESV), LV Ejection Fraction (LVEF), LV End-diastolic Myocardial Mass (LVMASSED), and Cardiac Output (CO) before and after modeling. Regarding LV global strain parameters, there was a downward trend in GRS (25.35% ± 6.9% vs. 22.86% ± 6.4%, P=0.021), GCS (-16.71% ± 4.2% vs. -14.78% ± 2.3%, P=0.043), and GLS (-17.66% ± 2.9% vs. -14.53% ± 2.5%, P=0.056), respectively, after modeling. GRS and GCS were significantly reduced after modeling compared to baseline. The study suggests that depression may contribute to early LV systolic dysfunction, particularly affecting LV GCS and GRS.

Mild renal dysfunction causes aggravated cardiac damage in type 2 diabetic patients: a comprehensive echocardiography study.

We sought to detect left ventricular (LV) adverse alterations in structure and function in type 2 diabetes mellitus (T2DM) patients with or without mild renal dysfunction (MRD) using comprehensive echocardiography techniques and to explore the independent risk factors for LV remodeling (LVR) and dysfunction in these patients. The study included 82 T2DM patients with normal LV ejection fraction (presence (n = 42)/absence (n = 40) of MRD). Age- and gender-matched controls (n = 40) were also recruited. LV structure and function were evaluated using conventional echocardiography and three-dimensional speckle tracking echocardiography (3DSTE). Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were all measured using 3DSTE. Compared with the controls with absolute advantage of LV normal geometry, LVR was more frequently present in the two T2DM groups, with the largest proportion in those with T2DM and MRD (P < 0.001). Fasting plasma glucose (FPG) and MRD were both significant risk factors for LVR in T2DM patients. The detection rates of LV diastolic dysfunction and subclinical systolic dysfunction were significantly higher in the T2DM groups than in the controls (P = 0.000). Moreover, the two case groups also showed significantly lower strain values in multiple directions than the controls (all P < 0.05). FPG was significantly associated with LV diastolic dysfunction, whereas FPG and MRD were both significantly associated with subclinical LV systolic dysfunction in T2DM patients. The combined use of conventional echocardiography and 3DSTE allowed the timely detection of early cardiac damage in T2DM patients with or without MRD.

Empagliflozin to prevent progressive adverse remodelling after myocardial infarction (EMPRESS-MI): rationale and design.

Patients with a reduced left ventricular ejection fraction (LVEF) following an acute myocardial infarction (MI) are at risk of progressive adverse cardiac remodelling that can lead to the development of heart failure and death. The early addition of a sodium-glucose cotransporter 2 (SGLT2) inhibitor to standard treatment may delay or prevent progressive adverse remodelling in these patients. EMpagliflozin to PREvent worSening of left ventricular volumes and Systolic function after Myocardial Infarction (EMPRESS-MI) is a randomized, double-blind, placebo-controlled, multi-centre trial designed to assess the effect of empagliflozin on cardiac remodelling evaluated using cardiovascular magnetic resonance (CMR) in 100 patients with left ventricular systolic dysfunction following MI. Eligible patients were those ≥12h and ≤14days following acute MI, with an LVEF <45% by CMR. Patients were randomized to empagliflozin 10mg once a day or matching placebo. The primary outcome will be change in left ventricular end-systolic volume indexed to body surface area over 24weeks from randomization. Secondary endpoints include measures of left ventricular and atrial volumes, left ventricular mass, LVEF, and circulating cardiac biomarkers. EMPRESS-MI will assess the effect of the SGLT2 inhibitor empagliflozin on cardiac remodelling in patients with left ventricular systolic dysfunction after an acute MI.

Comparative Analysis of Response to Cardiac Resynchronisation Therapy Upgrades in Patients with Implantable Cardioverter-Defibrillators and Pacemakers

Introduction: The efficacy of de novo cardiac resynchronisation therapy (CRT) in patients with heart failure (HF), left ventricular systolic dysfunction (LVSD), and a broad QRS morphology is well established. However, the optimal stage for upgrading patients with existing pacemakers (PPMs) or implantable cardioverter-defibrillators (ICDs) and HF with high-burden right ventricular (RV) pacing remains uncertain. Thus, this multicentre retrospective analysis compared patients with pre-existing PPMs or ICDs who underwent CRT upgrades to investigate the appropriate stage for CRT implantation in these patients and to assess the validity of treating both PPM and ICD recipients under the same recommendation level in the current guidelines. Materials and Methods: A total of 151 participants underwent analysis in this study, comprising 93 upgrades to cardiac resynchronisation therapy with pacemaker (CRT-P) and 58 upgrades to cardiac resynchronisation therapy with defibrillator (CRT-D) across three centres in the UK. The aim of the study was to investigate the safety and efficacy of upgrading to CRT from an existing conventional pacemaker or an ICD in the context of high-burden RV pacing. The analysis was conducted separately for each group, assessing changes in echocardiographic parameters, functional New York Heart Association (NYHA) class, and procedure-related complications. Results: The PPM group had a higher percentage RVP burden compared to the ICD group. Post-upgrade, NYHA functional class and EF and LV volumes improved in both groups; however, the response to an upgrade from a pacemaker was greater compared to an upgrade from an ICD. Post-procedural complication risks were similar across the two subgroups but significantly higher compared to de novo implantation. Conclusions: Within the CRT-P subgroup, participants exhibited better responses than their CRT-D counterparts, evident both in echocardiographic improvements and clinical outcomes. Furthermore, patients with non-ischemic cardiomyopathy (NICM) were better responders than those with ischaemic cardiomyopathy. These findings suggest that international guidelines should consider approaching each subgroup separately in the future.

Association between the triglyceride-glucose index and subclinical left ventricular systolic dysfunction in obese patients

BackgroundThe association between the triglyceride–glucose (TyG) index and subclinical left ventricular (LV) systolic dysfunction in obese patients remains unclear. This study aimed to investigate the relationship between the TyG index and LV global longitudinal strain (GLS) in obese patients.MethodsA total of 1028 obese patients from January 2019 to January 2024 were included in the present study. Clinical parameters and biochemical and echocardiographic data were obtained from the participants. LV GLS was obtained from the GE EchoPAC workstation for evaluating subclinical LV function. The TyG index was calculated as Ln (fasting TG [mg/dL] × fasting glucose [mg/dL]/2). LV GLS was compared between obese patients with a high TyG index and those with a low TyG index.ResultsObese patients with a high TyG index had greater incidences of hypertension, diabetes mellitus and hyperlipidaemia. The LV GLS was significantly lower in the high TyG index group than in the low TyG index group (P = 0.01). After adjusting for sex, age, body mass index, heart rate, hypertension, diabetes mellitus, dyslipidaemia, blood urea nitrogen, serum creatinine, LV mass and LV hypertrophy, the TyG index remained an independent risk indicator related to an LV GLS < 20% (OR: 1.520, 95% CI: 1.040 to 2.221; P = 0.031).ConclusionsWe concluded that an increase in the TyG index is independently associated with subclinical LV systolic dysfunction in obese patients.

Echocardiographic assessment of right ventricular performance in COVID-19 related acute respiratory distress syndrome: the importance of systo-diastolic interaction.

The cardiac manifestations of COVID-19 have been described in patients with acute respiratory distress syndrome (ARDS) admitted to intensive care unit (ICU). The presence and impact of right ventricular (RV) diastolic function and performance has not been studied in this population yet. We describe the prevalence of RV diastolic dysfunction, assessed by the pulmonary valve pre-ejection A wave (PV A wave), and the RV systo-diastolic interaction, using the RV total isovolumic time (t-IVT), in COVID-19 ARDS. Prospective observational study enrolling patients with moderate to severe COVID-19 ARDS admitted to ICU who underwent a transthoracic echocardiogram within 24h of ICU admission and at least a second one during the ICU stay. Respiratory, hemodynamic and biochemistry parameters were collected. 163 patients (age 61.0 ± 9.3years, 72% males) were enrolled. 36 patients (22.1%) had RV dysfunction, 45 (27.1%) LV systolic dysfunction. 73 patients (44.7%) had PV A wave. The RV t-IVT correlated with TAPSE at ICU admission (p < 0.002; r -0.61), presence of PV A wave (p < 0.001; r 0.78), peak inspiratory pressure (PIP) (p < 0.001; r 0.42), PEEP (p < 0.001; r 0.68), dynamic driving pressure (DDP) (p < 0.001; r 0.58), and PaO2/FiO2 ratio (p < 0.01; r -0.35). The presence of PV A wave was associated with higher PIP (p < 0.001; r 0.45), higher PEEP (p < 0.001; r 0.56), higher DDP (p < 0.01, r 0.51), and lower PaO2/FiO2 ratio (p < 0.001; r -0.49). RV t-IVT and the presence of PV A wave are non-invasive means to describe a significant RV diastolic dysfunction and may be consider descriptive signs of RV performance in COVID-19 ARDS.

Left ventricular systolic dysfunction predicts clinical prognosis in patients with acute ischemic stroke after intravenous thrombolysis.

Although intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis is the most effective early treatment for acute ischemic stroke (AIS), outcomes vary greatly among patients. Left ventricular systolic dysfunction (LVSD) is prone to distant organ ischemia and may be a predictor for poor prognosis in AIS patients undergoing intravenous thrombolysis (IVT). Our aim was to investigate the predictivity of LVSD diagnosis (as measured by left ventricular ejection fraction (LVEF)) on 90-day clinical outcomes in AIS patients undergoing thrombolysis. The current prospective cohort study continuously enrolled 273 AIS patients from the National Stroke Prevention and Treatment Engineering Management Special Database who underwent IVT and completed echocardiography within 24 h of admission between 2021 and 2023. LVSD was examined by evaluation of the echocardiographic LVEF values using Simpson's biplane method of discs in line with international guidelines, and defined as a LVEF value < 50%. Multivariable ordinal logistic regression model was performed to analyze the association between LVEF and functional outcome at 3 months. Restricted cubic spline (RCS) was used to examine the shape of the dose-response association between reduced LVEF and poor functional outcomes. Subgroup analysis was also employed to further verify the reliability and practicability of the results. Baseline data analysis showed LVSD patients had more comorbidities including on multivariate analyses, LVSD (OR 2.78, 95% CI 1.23 to 6.24, P=0.014), pre-existing diabetes mellitus (OR 2.08, 95% CI 1.11 to 3.90, P=0.023) and NIHSS on arrival (OR 1.31, 95% CI 1.21 to 1.49, P<0.001) were independent predictors of poor functional outcomes (mRS ≥ 3) at 3 months. Multivariable-adjusted spline regression indicated a linear dose-response association between LVEF after IVT and poor functional outcomes (p for linearity < 0.001), with the optimal cutoff values of LVEF being 0.48. Our finding indicated that AIS patients with LVSD after IVT had poorer outcomes, suggesting the need to monitor and optimize LVEF in stroke management.

Transcatheter transfemoral aortic valve replacement in a patient with acromegaly and severe left ventricular myocardial hypertrophy. Case report

Main causes of secondary hypertrophic cardiomyopathy include acromegalic cardiomyopathy. Heart damage in patients with the acromegaly is mediated both by the direct action of growth hormone and insulin-like growth factor-1, and increased deposition of collagen and lymphomononuclear cells in the myocardium, which leads to architectural changes, disturbances in fluid and electrolyte balance, severe left ventricular myocardial hypertrophy, diastolic and systolic left ventricular dysfunction and chronic heart failure. This article presents the world's first described observation demonstrating the possibility of successful transfemoral aortic valve repair to a comorbid patient with severe aortic stenosis according to the potential risks caused by the active form of the acromegaly.

Stasis imaging predicts the risk of cardioembolic events related to acute myocardial infarction

In the setting of ST-segment elevation myocardial infarction (STEMI), imaging-based biomarkers could be useful for guiding oral anticoagulation to prevent cardioembolism. Our objective was to test the efficacy of intraventricular blood stasis imaging in predicting a composite primary endpoint of cardioembolic risk during the first 6 months after STEMI. We designed a prospective clinical study, Imaging Silent Brain Infarct in Acute Myocardial Infarction (ISBITAMI, NCT02917213), including patients with a first STEMI, an ejection fraction ≤ 45% and without atrial fibrillation to assess the performance of stasis metrics to predict cardioembolism. Patients underwent ultrasound-based stasis imaging at enrollment followed by heart and brain magnetic resonance at 1-week and 6-month visits. From the stasis maps, we calculated the average residence time, RT, of blood inside the left ventricle and assessed its ability to predict the primary endpoint. The longitudinal strain of the 4 apical segments was quantified by speckle tracking. A total of 66 patients were assigned to the primary endpoint. Of them, 17 patients had 1 or more events: 3 strokes, 5 silent brain infarctions, and 13 mural thromboses. No systemic embolisms were observed. RT (OR, 3.73; 95%CI, 1.75-7.9; P < .001) and apical strain (OR, 1.47; 95%CI, 1.13-1.92; P = .004) showed complementary prognostic value. The bivariate model showed a c-index = 0.86 (95%CI, 0.73-0.95), a negative predictive value of 1.00 (95%CI, 0.94-1.00), and positive predictive value of 0.45 (95%CI, 0.37-0.77). The results were confirmed in a multiple imputation sensitivity analysis. Conventional ultrasound-based metrics were of limited predictive value. In patients with STEMI and left ventricular systolic dysfunction in sinus rhythm, the risk of cardioembolism may be assessed by echocardiography by combining stasis and strain imaging.

Predictors of Polymorphic Ventricular Tachycardia and Ventricular Fibrillation in Patients with Takotsubo Syndrome

Polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) are life-threatening complications of Takotsubo syndrome (TTS). Data regarding risk factors for PVT/VF based on the TTS variant are lacking. This study aims to identify demographic and clinical factors associated with PVT and VF in patients with TTS. Patients meeting the InterTak criteria for TTS between 2010-2022 were retrospectively identified. The occurrence of PVT/VF with each risk factor was analyzed using logistic regression. Sensitivity analysis was performed to assess the interaction between risk factors. PVT/VF occurred in 27 of the 296 patients with TTS (9.1%). Patients with PVT/VF were younger (52 vs. 62 years, P=0.019) and more frequently used stimulants in the 4 weeks before admission (22.2% vs. 8.2%, OR 3.20, p =0.023). All PVT/VF occurred within 24 hours of hospitalization. An initial QTc threshold of 490 ms had the highest sensitivity and specificity for the occurrence of PVT/VF (AUC=0.687). Patients with PVT/VF were more likely to have a QTc >490 ms on admission (55.6% vs. 18.7%, OR=5.45, P< 0.01), apical variant TTS (78% vs. 56%, OR=2.69, p=0.038), and an admission EF < 30% (63% vs. 41.5%, OR=2.39, p=0.032); each factor was independently associated with PVT/VF irrespective of QTc duration on sensitivity analysis. In conclusion, nearly 1 in 10 of patients with TTS had PVT/VF. A QTc > 490 ms, recent stimulant use, apical variant TTS, and severe left ventricular systolic dysfunction on admission are associated with higher PVT/VF risk, with the first 24 hours being a high-risk period.

Evaluation of left ventricular function in normotensive type-2 dm patients by echocardiography

The prevalence of diabetes mellitus (DM) is increasing globally. Indians are also believed to have a greater degree of insulin resistance and a stronger genetic predisposition to diabetes. Type II DM is a risk factor for cardiovascular disease and cardiovascular complications and these are a major cause of mortality and morbidity in diabetic patients. Left ventricular dysfunction, increased left ventricular wall thickness, increased left ventricular mass, and specific diabetic cardiomyopathy are some of the cardiovascular complications associated with diabetes. So the present study was performed to assess normotensive diabetic patients by echocardiography to evaluate their left ventricular function. A case control cross sectional study was conducted on 40 normotensive type 2 diabetes mellitus patients. 40 patients who were non-diabetic, non-hypertensive were taken as a control. A standard 2D echocardiography with M mode and Doppler was performed on case and control. In our study among 40 cases, 55% were male and 45% were female with mean age of case population being 47.5±7.24 year and among 40 controls, 50% were male and 50% were female with mean age 48.03±7.14 year. Mean BMI in case group was 29.49±2.37 kg/m2 and in control group 29.36±2.46 kg/m2. In our study we found that LVDD was present in 57.5% cases, 47.5% of cases had grade 1 LVDD whereas 10% had grade 2 LVDD. In comparison, only 10% of controls had LVDD with all of them having grade 1 LVDD. Also LV Systolic dysfunction, LVM and LVMI were higher in cases as compared to controls. Thus we concluded that the prevalence of left ventricular diastolic dysfunction in asymptomatic, normotensive patients with type 2 DM without significant coronary artery disease is much higher than previously suspected as evidenced by the results of this study and also of similar other studies and it increases with the duration of Diabetes. Left ventricular systolic dysfunction, LVM and LVMH prevalence were also higher in cases as compared to controls and they also correlate with duration of Diabetes.

Operative Morbidity and Mortality of Aortic Stenosis with Left Ventricular Dysfunction

Objectives: Study of the operative morbidity and mortality of aortic stenosis with left ventricular systolic dysfunction (LVEF &lt; or = 35%). Method: 73 patients with a mean age of 55+/-8 years, 59 of whom were men, underwent surgery between January 2014 and december 2019; 14% (10/73) of these patients had a pre-operative low trans-valvular aortic gradient (&lt;30mmHg). We determined the factors predictive of operative mortality using univariate and multivariate analyses, analysed changes in functional status and left ventricular ejection fraction, and compared operative mortality and late survival in these 73 patients with those in a control group with no left ventricular dysfunction. Results: The mean NYHA stage, before and after aortic valve replacement, fell from 3.8 to 1.7, and the mean improvement in LVEF was 28+/-13. In univariate analysis, the parameters significantly associated with operative mortality were arterial hypertension (p=0.039), congestive heart failure (p=0.030), a smaller indexed left ventricular mass (p=0.039), a mean gradient of less than 30mmHg (at the limit of significance (p=0.053)), a low cardiac index (p=0.0045), and mono-truncular coronary involvement (p=0.042). In multivariate analysis, no variable was identified as an independent predictor of operative mortality. Conclusion: Operative mortality was significantly higher 11.7%vs 2.9% (p=0.048) in the group with left ventricular dysfunction, although late survival rates were similar in the 2 groups (86.8% vs 93%). Given the spontaneous prognosis and the increased operative risk, these patients should be operated on.

Echocardiographic Assessment of Left Ventricular Function in Three Oncologic Therapeutic Modalities in Women with Breast Cancer: The ONCO-ECHO Multicenter Study.

Background: Oncological treatment of breast cancer may be associated with adverse effects on myocardial function. Objectives: The objective of this study was to compare the influence of three oncological treatment methods of intervention on the echocardiographic (ECHO) parameters of left ventricular function. Materials and Methods: One hundred and fifty-five women with breast cancer were divided into three groups depending on the type of therapy used: group I (AC)-anthracyclines; group II (AC + TZ)-anthracyclines + trastuzumab; and group III (RTls+)-anthracyclines with or without trastuzumab + left-sided radiotherapy. Prospective ECHO examinations were performed at baseline and every 3 months, up to 12 months from the start of the therapy. Patients with a history of chemotherapy or who were diagnosed with heart disease were not included in the study. Results: Out of 155 patients, 3 died due to cancer as the primary cause, and 12 withdrew their consent for further observation. Baseline systolic and diastolic ECHO parameters did not differ between the analyzed groups. Cardiotoxicity, according to the LVEF criteria, occurred during follow-up in 20 patients (14.3%), irrespective of the treatment method used. Diastolic echocardiographic parameters did not change significantly after 12 months in each group, except for the left atrial volume index (LAVi), which was significantly higher in the AC + TZ compared to the values in the RTls+ group. Conclusions: All three oncologic therapeutic modalities in women with breast cancer showed no significant differences in relation to the incidence of echocardiographic cardiotoxicity criterion; however, transient systolic decrease in LVEF was most frequently observed in the AC + TZ therapeutic regimen. Left-sided radiotherapy was not associated with excess left ventricular systolic and diastolic dysfunction during a 12-month follow-up period. The predictors of negative changes in diastolic parameters included age and combined anthracycline and trastuzumab therapy.

Simple models vs. deep learning in detecting low ejection fraction from the electrocardiogram

Abstract Aims Deep learning methods have recently gained success in detecting left ventricular systolic dysfunction (LVSD) from electrocardiogram (ECG) waveforms. Despite their high level of accuracy, they are difficult to interpret and deploy broadly in the clinical setting. In this study, we set out to determine whether simpler models based on standard ECG measurements could detect LVSD with similar accuracy to that of deep learning models. Methods and results Using an observational data set of 40 994 matched 12-lead ECGs and transthoracic echocardiograms, we trained a range of models with increasing complexity to detect LVSD based on ECG waveforms and derived measurements. The training data were acquired from the Stanford University Medical Center. External validation data were acquired from the Columbia Medical Center and the UK Biobank. The Stanford data set consisted of 40 994 matched ECGs and echocardiograms, of which 9.72% had LVSD. A random forest model using 555 discrete, automated measurements achieved an area under the receiver operator characteristic curve (AUC) of 0.92 (0.91–0.93), similar to a deep learning waveform model with an AUC of 0.94 (0.93–0.94). A logistic regression model based on five measurements achieved high performance [AUC of 0.86 (0.85–0.87)], close to a deep learning model and better than N-terminal prohormone brain natriuretic peptide (NT-proBNP). Finally, we found that simpler models were more portable across sites, with experiments at two independent, external sites. Conclusion Our study demonstrates the value of simple electrocardiographic models that perform nearly as well as deep learning models, while being much easier to implement and interpret.

Trastuzumab-Induced Cardiotoxicity: When and How Much Should We Worry?

This review critically analyzes the incidence of trastuzumab-induced left ventricular systolic dysfunction and congestive heart failure (CHF), distinguishing between cases with and without prior anthracycline exposure. It highlights the fact that the elevated risk of trastuzumab-induced cardiotoxicity is closely associated with prior anthracycline exposure. In the absence of prior anthracycline exposure, the incidence rates of trastuzumab-induced cardiotoxicity, particularly CHF (ranging from 0% to 0.5%), are largely comparable with those reported in the general population, especially when reversibility is taken into account. Current cardiac surveillance recommendations during trastuzumab treatment have not yet adapted to the increasing adoption of nonanthracycline treatment strategies and the associated low risk of cardiotoxicity. We propose a refined monitoring protocol to reduce the frequency of cardiac evaluations for low-risk to moderate-risk patients, especially those receiving nonanthracycline treatments. By focusing on patients at high risk or those with prior anthracycline exposure, this strategy seeks to optimize the cost-effectiveness of cardiac care in oncology.

Natural history of cardiac involvement in myotonic dystrophy type 1 – Emphasis on the need for lifelong follow-up

BackgroundCardiac involvement represents a major cause of morbidity and mortality in patients with myotonic dystrophy type 1 (DM1) and prevention of sudden cardiac death (SCD) is a central part of patient care. We investigated the natural history of cardiac involvement in patients with DM1 to provide an evidence-based foundation for adjustment of follow-up protocols. MethodsPatients with genetically confirmed DM1 were identified. Data on patient characteristics, performed investigations (12 lead ECG, Holter monitoring and echocardiography), and clinical outcomes were retrospectively collected from electronic health records. ResultsWe included 195 patients (52% men) with a mean age at baseline evaluation of 41 years (range 14–79). The overall prevalence of cardiac involvement increased from 42% to 66% after a median follow-up of 10.5 years. There was a male predominance for cardiac involvement at end of follow-up (74 vs. 44%, p < 0.001). The most common types of cardiac involvement were conduction abnormalities (48%), arrhythmias (35%), and left ventricular systolic dysfunction (21%). Only 17% of patients reported cardiac symptoms. The standard 12‑lead ECG was the most sensitive diagnostic modality and documented cardiac involvement in 24% at baseline and in 49% at latest follow-up. However, addition of Holter monitoring and echocardiography significantly increased the diagnostic yield with 18 and 13% points at baseline and latest follow-up, respectively. Despite surveillance 35 patients (18%) died during follow-up; seven due to SCD. ConclusionsIn patients with DM1 cardiac involvement was highly prevalent and developed during follow-up. These findings justify lifelong follow-up with ECG, Holter, and echocardiography. Clinical perspectiveWhat is new?•After 10 years of follow-up cardiac involvement increased from 42% to 66%.•Conduction abnormalities, arrhythmias, and left ventricular dysfunction are common despite most patients not reporting any symptoms.•Addition of Holter monitoring and echocardiography to the standard 12‑lead ECG increases the diagnostic yield for detecting cardiac involvement.What are the clinical implications?•Systematic screening for cardiac involvement with 12‑lead ECG, Holter monitoring, and echocardiography is justified in patients with myotonic dystrophy type 1.•All-cause mortality remains high despite cardiac screening which underlines the need improved risk stratification and multidisciplinary care.