Mean RVEF Research Articles

ASSESSMENT OF RIGHT VENTRICULAR FUNCTION FOLLOWING PERMANENT PACEMAKER IMPLANTATION BY ECHOCARDIOGRAPHY (INCLUDING 3D ECHOCARDIOGRAPHY)

Objective: Several studies have shown that unfavorable ventricular remodelling & mechanical dyssynchrony caused by Right ventricular (RV) pacing leading to development of Left Ventricular dysfunction. Nevertheless, impact of RV pacing on Right Ventricle function has not been thoroughly assessed. Hence, prospective study was done to assess RV dimensions & function by 2D and three-dimensional (3D) echocardiography at 3 months & 6 months after pacemaker implantation Design and method: This study was a prospective single-centre study. All patients who underwent pacemaker implantation were assessed for RV function by 2D and 3D Echocardiography at baseline (pre-procedure), 3 months & 6 months after pacemaker implantation. The change in follow-up period was evaluated by using single factor analysis of variance ANOVA with repeated measures in normally distributed data & Bonferroni post-hoc test. A p value of <0.05 is considered to be statistically significant Results: From January 2022 to December 2022, a total of 66 patients with permanent pacemaker were enrolled in the study. There was statistically non-significant changes in mean LVEF (%) during follow up (62.13±3.92(Baseline) vs. 62.21±4.15(3-month) vs 62.03+3.83 (6-months), p value>0.05).However, there was statistically significant changes in mean PASP (mm Hg) during follow up (18.45±3.45 (Baseline) vs. 22.18±3.76 (3-month) vs 26.45+3.97, p value <0.05). Also, there was statistically significant changes in mean RIMP during follow up (0.48±0.04(Baseline) vs. 0.50±0.04(3-month) vs 0.50+0.03(6-month),p value<0.05).Likewise, there was statistically significant changes in mean RV E/E’ during follow up (4.47±0.57(Baseline) vs. 4.70±0.74(3-month) vs 4.95+0.82(6-month),p value <0.05).In addition, there was statistically significant changes in mean TR Jet Area (cm2) during follow up (1.68±0.26(Baseline) vs. 2.22±0.43(3-month) vs 2.56+0.53(6-month), p value <0.05). But, there was statistically non-significant changes in mean RVEF % (3D Echo) during follow up (53.51± 2.75(Baseline) vs. 53.02±2.64 (3-month) vs 53.48+2.34 (6-month), p value >0.05).Other echocardiographic parameters of RV function did not show any change in 3-months & 6-months follow-up. Conclusions: There is change in Right Ventricular function after Pacemaker implantation which can be documented as early as 6 months post implantation. Permanent pacemaker was associated with changes in RIMP, RV E/E’, PASP, TR JET AREA during 6 months after Right ventricular pacing

Cardiovascular magnetic resonance derived biventricular strain in healthy adolescents: reference values and comparison between myocardial tagging and feature-tracking

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III (ISCIII) European Regional Development Fun/European Social Fund (A way to make Europe/Investing in your future). Background Strain measurements have demonstrated to be earlier and more sensitive markers of contractile dysfunction than ejection fraction (EF) alone. Myocardial tagging (MT) is considered the reference standard for CMR strain measurements, but its clinical application is limited because acquisition and analysis are laborious and time consuming. Feature-tracking (FT) CMR allows strain quantification using steady-state in free-precession (SSFP) sequence, which is obtained in routine CMR protocols, being easily applicable in clinical practice. Literature regarding reference strain values in pediatric populations is scarce and, to the best of our knowledge, there are no studies comparing FT and MT in healthy adolescents. Purpose To provide CMR strain reference values in healthy adolescents and compare FT to MT results. Methods A CMR study was performed in healthy adolescents enrolled in the "Early ImaginG Markers of unhealthy lifestyles in Adolescents" (EnIGMA) project using a 3-Tesla CMR scanner between March and October 2021. The imaging protocol included a cine SSFP to provide images for chamber size and function, including FT; and MT acquisitions using spatial modulation of magnetization (SPAMM) technique. Cine acquisitions included the entire left ventricular (LV) short axis and long-axis 4 chamber (4c)- and 2 chamber (2c)-views, while MT acquisitions included three short axis slices (basal, mid and apical) and long-axis 4c-view. Endo- and epicardial borders were manually contoured in the end-diastolic (ED) phase. A non-rigid, elastic algorithm was used for segmentation and registration for strain quantification. If tracking was suboptimal, the software only allowed adaptations of the contours on the ED image. Longitudinal (LS) and circumferential (CS) strains were obtained for the LV and right ventricle (RV). Results CMR scans were performed in 123 adolescents (64 girls, 52.0%) with a mean age of 16.0 years (standard deviation [SD]=0.4), a mean LVEF of 62.5% (SD=4.1) and a mean RVEF of 56.2% (SD=4.6). Reference percentiles (P) 3, 10, 25, 50, 90 and 97 for strain values by sex are provided in Figure 1. FT-measured LVLS and LVCS were higher in girls than in boys (-19.8 vs -17.8%, p<0.01; and -22.2 vs -21.0%, p<0.01; respectively), and these differences were confirmed with MT analysis. There were no consistent between-sex differences for RVLS and RVCS. Bland-Altman analyses showed reasonable agreement between FT and MT for LVLS, LVCS, RVLS and RVCS (Figure 2 A, B, C and D). Conclusions This study provided CMR derived reference values for left and right ventricle strain in adolescents aged 15 to 18 years. This work suggests that FT is a reasonably valid technique to measure LV and RV strain in this population. This information may be useful for diagnostic and prognostic implications in adolescent patients.

Abstract 13516: Natural History, Penotypes and Clinical Outcomes in Desmin Related Arrhythmogenic Cardiomyopathy

Background: Mutations in DES gene, encoding the intermediate filament desmin, have been related to arrhythmogenic cardiomyopathy (AC). Our aim is to describe the clinical phenotype, natural history and outcomes in a multicentric international cohort of desmin-related AC patients. Methods: Probands and relatives (85 individuals from 11 families (45% men; mean age 35 [IQR] 23.5-53.5 years old)) carrying a DES mutation from 8 European centers were included. Clinical, electrocardiographical and advanced cardiac imaging data were retrospectively collected and analysed. DES mutations were transfected into cell lines and analyzed by confocal microscopy. Results: Disease penetrance in individuals ≥30 years was 80.8% and 71.4% in individuals <30 years; A left dominant or biventricular form of AC was the main clinical phenotype (69 cases, 81 %). More than half of the patients presented low voltage on the ECG, the mean LVEF was 48.9±16% and the mean RVEF was 53.8±10%. A high prevalence of patients with magnetic resonance imaging (n=30) presented fibrosis (65,2%), with a particular circunferencial (“ring-like”) pattern in 46.4% (Figure A). After a median follow-up of 6 years, 24.7% died (mean age 62[33-76]) (Figure B) and 8.2% suffered appropriate shocks (age 47[31-69.5]) or SD (age 33 [24.5-49]). Finally, there were 6 heart transplants (age 54 [33-68]). A LVEF<50% and male sex were associated with major cardiovascular events. In three DES mutations (E401D, L115E and R415Q) desmin aggreggates were observed (Figure C) Conclusions AC due to DES mutations have a high clinical penetrance as a left dominant or biventricular form of the disease, with an early onset and a high burden of cardiovascular events. A LV “ring-like” LGE pattern was particularly common. Male sex or mildly depressed LVEF were predictors for SD. DES mutation may be pathogenic by causing desmin aggregates. A) Annular pattern of fibrosis B) Carriers free-of-events survival curve. C) Desmin aggregates

Non-contrast cardiac magnetic resonance imaging after SARS-CoV2 infection or vaccination in asymptomatic adolescents: insights from the EnIGMA study

Abstract Background Myocarditis after SARS-CoV2 infection or vaccination is rare, but seems to be relatively more frequent in young population. Cardiac magnetic resonance (CMR) T2 weighted sequences have the potential to detect subclinical myocarditis. However, there is paucity of data on the potential myocardial involvement after SARS-CoV2 infection or vaccination in asymptomatic adolescents. Purpose To evaluate the presence of subclinical myocardial damage in adolescents who were infected with SARS-CoV2 or vaccinated against SARS-CoV2 using non-contrast CMR imaging. Methods Asymptomatic adolescents enrolled in the “Early ImaginG Markers of unhealthy lifestyles in Adolescents” (EnIGMA) project were scanned using a 3-Tesla CMR scanner between March 2021 and October 2021. CMR scans included CINE imaging and myocardial T2-mapping sequences. SARS-CoV2 IgG antibody testing was performed in capillary blood samples, and date of confirmed SARS-CoV2 infection and/or vaccination if any was collected. Participants were assigned to three different groups according to SARS-CoV2 status: Group 1 (non-infected and non-vaccinated), Group 2 (infected and non-vaccinated), and Group 3 (vaccinated, independently of past infection status). CMR images were analyzed by experienced observers blinded to adolescent's SARS-CoV2 status. ANOVA and multiple regression analysis, together with correlation coefficients, were used to study between-group differences and associations among variables of interest. Results A total of 115 adolescents with a mean age of 16.0 years (standard deviation (SD)=0.4), 54% girls, completed the CMR study and SARS-CoV2 data successfully, and were assigned to Group 1 (n=72), Group 2 (n=22), and Group 3 (n=21). Left and right ventricular ejection fraction (LVEF/RVEF) did not significantly differ among groups: mean LVEF was 62.8% (SD=4.1), 63.0% (SD=3.7) and 60.9% (SD=3.9) [p=0.12] and mean RVEF was 56.5% (SD=4.2), 56.5% (SD=5.5) and 54.5% (SD=5.1) [p=0.23] in Groups 1, 2 and 3, respectively. Similarly, there were no between-group significant differences in myocardial T2 relaxation values: mean T2 values were 44.1 ms (SD=2.2), 44.1 ms (SD=1.8) and 44.4 ms (SD=1.9) in Groups 1, 2, and 3, respectively (p=0.63) (Figure 1). No differences were found either after adjusting for age and gender. Median time (interquartile range) from date of infection or vaccination to CMR acquisition was 133 (121) days and 28 (38) days in Group 2 and Group 3, respectively. No correlation between time from infection/vaccination to CMR acquisition and T2 values was detected (Figure 2). Conclusions This observational study did not find evidence of subclinical myocardial involvement after SARS-CoV2 infection or vaccination in asymptomatic adolescents, as assessed with T2-mapping magnetic resonance imaging. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Instituto de Salud Carlos III (ISCIII)-Fondo de Investigaciόn Sanitaria.European Regional Development Fund/European Social Fund (“A way to make Europe”/“Investing in your future”.

No deterioration in function or volumetric parameters in elite athletes after SARS-CoV-2 infections compared to non-infected athletes: results from the ELITE cohort

Abstract Background/Introduction SARS-CoV-2 (subclinical) myocarditis has been demonstrated in up to 5% in athletes, and is currently a topic being intensively investigated. However, more subtle changes in function and volumetric parameters have been less well documented, especially in elite athletes, who perform at the highest levels of sports, with potentially the most outspoken adaptation. Purpose To determine differences in cardiac function and volumetric parameters using cardiac magnetic resonance imaging (CMR) in elite athletes recovered from a SARS-CoV-2 infection as compared to non-infected elite athletes (controls). Methods We included elite athletes from the ELITE (Evaluation of Lifetime Intensive Top-level sports and Exercise) cohort, who voluntary undergo cardiovascular pre-participation screenings, which includes cardiac magnetic resonance imaging (CMR). SARS-CoV-2 infection was diagnosed with a positive-PCR or antibody test (if unvaccinated). The primary outcome was the incidence of structural cardiac changes on CMR, defined as LV/RV BSA indexed-EDV (EDVi), LV/RV BSA indexed-ESV (ESVi), LV/RV EF, presence of pathological late gadolinium enhancement (LGE) (excluding hinge point fibrosis), and T1 times. Results We included 234 elite athletes, mean age 27 (±7), 39% female, with main athletic disciplines (≥10 hours/week) of cycling (24%), field hockey (13%), and water polo (12%). In total 69 elite athletes had documented SARS-CoV-2 infection, and 165 were documented as not exposed to SARS-CoV-2. The majority reported mild symptoms 61/69 (88%), 1/69 (1%) severe symptoms, and 7/69 (11%) no symptoms. Mean time between infection and CMR was 2.8 (±2) months. CMR showed no significant difference between elite athletes with SARS-CoV-2 and without (Table) in mean LVEDVi (117±19 vs 120±19 ml/m2, p=0.29), LVESVi (50.6±11 vs 53.2±11 ml/m2, p=0.12), LVEF (56.9% ±5 vs 55.8% ±5, p=0.14), RVEDVi (120±20 vs 122±19 ml/m2, p=0.56), RVESVi (54.5±11 vs 56.2±11 ml/m2, p=0.29), and RVEF (54.6% ±4 vs 53.9% ±5, p=0.23). In 4/69 (4.7%) vs 1/165 (1.3%) pathological non-ischemic pattern of myocardial LGE was present (≤20% of total LV mass), of which one athlete (1.2%) showed increased T1 time, all with no deterioration in right and left ventricle function and volumetric parameters (Figure) after SARS-CoV-2 infection. All athletes made a full recovery and returned to elite competitive sports. Conclusion(s) This cross-sectional study of elite athletes demonstrates that infection with SARS-CoV-2 is not associated with deterioration in cardiac function and volumetric parameters on CMR compared with non-infected athletes, also in the small subset of athletes with pathological LGE patterns after SARS-CoV-2 infection. Prospective studies with long-term follow-up are needed to establish whether intensive sports is associated with long-term cardiac deleterious effects in elite athletes exposed to SARS-CoV-2. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Dutch Heart FoundationDutch National Olympic Committee & National Sports Federation (NOC*NSF)

287 Acute and late echocardiographic and cardiac MRI findings in multisystem inflammatory syndrome in children

AimsMultisystem Inflammatory Syndrome in Children (MIS-C) is a severe condition affecting children previously exposed to SARS-CoV-2. The aim of our study was to describe the acute and late cardiac abnormalities in patients with MIS-C, evaluated by speckle-tracking echocardiography (STE) and cardiac MRI (CMR).Methods and resultsTwenty-three (13 M, 10 F) patients with confirmed MIS-C diagnosis were recruited. All children underwent standard TTE, STE with analysis of LV global longitudinal strain (GLS). Seventeen (75%) were evaluated with CMR. All children received standard therapy. During follow-up echocardiography and CMR were repeated. Mean age was 8.1 ± 4 years. The majority (78.2%) was Caucasian. Cardiovascular symptoms were present in 10 (43.5%). Nine children (39.1%) shared Kawasaki Disease-like symptoms. Four patients (17.4%) needed ICU admission and three required inotropic support. Short-term survival was 100%. All patients showed a hyperinflammatory state. Tn-I was abnormal (>34 ng/l) in 15 patients (65.2%), BNP was elevated in 20 (86.9%). Median time to STE evaluation was 8 days and to CMR 18 days since fever onset. Mean LVEF and RVEF were, respectively, 59 ± 10% and 45 ± 7%. Coronary dilation was observed in six (26.1%) patients. STE showed reduced mean LVGLS (−17 ± 4.3%). LVEF on CMR was 60 ± 13%, LGE with non-ischaemic pattern was evident in 6/17 patients (35.2%). Median time to follow-up was 49 days for echocardiography and 200 days for CMR since disease onset. STE showed improvement of LVGLS (−18.8 ± 2.2%), while CMR displayed persistence of LGE in two patients and reduction or absence in two of the six patients previously diagnosed.ConclusionsThe elevation of myocardial necrosis markers, the myocardial injury testified by reduced LVGLS and the presence of LGE on CMR in about a quarter of the patients support the hypothesis of a post-viral immune-mediated myocarditis-like pathogenesis of MIS-C. Early follow-up shows improvement of STE and CMR findings corroborating the evidence of excellent short-term survival.

Cardiac MRI findings to differentiate athlete's heart from hypertrophic (HCM), arrhythmogenic right ventricular (ARVC) and dilated (DCM) cardiomyopathy

To provide clinically relevant criteria for differentiation between the athlete’s heart and similar appearing hypertrophic (HCM), dilated (DCM), and arrhythmogenic right-ventricular cardiomyopathy (ARVC) in MRI. 40 top-level athletes were prospectively examined with cardiac MR (CMR) in two university centres and compared to retrospectively recruited patients diagnosed with HCM (n = 14), ARVC (n = 18), and DCM (n = 48). Analysed MR imaging parameters in the whole study cohort included morphology, functional parameters and late gadolinium enhancement (LGE). Mean left-ventricular enddiastolic volume index (LVEDVI) was high in athletes (105 ml/m2) but significantly lower compared to DCM (132 ml/m2; p = 0.001). Mean LV ejection fraction (EF) was 61% in athletes, below normal in 7 (18%) athletes vs. EF 29% in DCM, below normal in 46 (96%) patients (p < 0.0001). Mean RV-EF was 54% in athletes vs. 60% in HCM, 46% in ARVC, and 41% in DCM (p < 0.0001). Mean interventricular myocardial thickness was 10 mm in athletes vs. 12 mm in HCM (p = 0.0005), 9 mm in ARVC, and 9 mm in DCM. LGE was present in 1 (5%) athlete, 8 (57%) HCM, 10 (56%) ARVC, and 21 (44%) DCM patients (p < 0.0001). Healthy athletes’ hearts are characterized by both hypertrophy and dilation, low EF of both ventricles at rest, and increased interventricular septal thickness with a low prevalence of LGE. Differentiation of athlete’s heart from other non-ischemic cardiomyopathies in MRI can be challenging due to a significant overlap of characteristics also seen in HCM, ARVC, and DCM.

Clinical Validation of a 3-Dimensional Ultrafast Cardiac Magnetic Resonance Protocol Including Single Breath-Hold 3-Dimensional Sequences

ObjectivesThis study sought to clinically validate a novel 3-dimensional (3D) ultrafast cardiac magnetic resonance (CMR) protocol including cine (anatomy and function) and late gadolinium enhancement (LGE), each in a single breath-hold. BackgroundCMR is the reference tool for cardiac imaging but is time-consuming. MethodsA protocol comprising isotropic 3D cine (Enhanced sensitivity encoding [SENSE] by Static Outer volume Subtraction [ESSOS]) and isotropic 3D LGE sequences was compared with a standard cine+LGE protocol in a prospective study of 107 patients (age 58 ± 11 years; 24% female). Left ventricular (LV) mass, volumes, and LV and right ventricular (RV) ejection fraction (LVEF, RVEF) were assessed by 3D ESSOS and 2D cine CMR. LGE (% LV) was assessed using 3D and 2D sequences. ResultsThree-dimensional and LGE acquisitions lasted 24 and 22 s, respectively. Three-dimensional and LGE images were of good quality and allowed quantification in all cases. Mean LVEF by 3D and 2D CMR were 51 ± 12% and 52 ± 12%, respectively, with excellent intermethod agreement (intraclass correlation coefficient [ICC]: 0.96; 95% confidence interval [CI]: 0.94 to 0.97) and insignificant bias. Mean RVEF 3D and 2D CMR were 60.4 ± 5.4% and 59.7 ± 5.2%, respectively, with acceptable intermethod agreement (ICC: 0.73; 95% CI: 0.63 to 0.81) and insignificant bias. Both 2D and 3D LGE showed excellent agreement, and intraobserver and interobserver agreement were excellent for 3D LGE. ConclusionsESSOS single breath-hold 3D CMR allows accurate assessment of heart anatomy and function. Combining ESSOS with 3D LGE allows complete cardiac examination in <1 min of acquisition time. This protocol expands the indication for CMR, reduces costs, and increases patient comfort.

Characteristics and prognostic value of right ventricular (dys)function in patients with non‐ischaemic dilated cardiomyopathy assessed with cardiac magnetic resonance imaging

AimsIn non‐ischaemic dilated cardiomyopathy (DCM), concomitant right ventricular (RV) dysfunction is frequently observed. This study sought to determine the correlation of RV dysfunction with several cardiac magnetic resonance (CMR) imaging characteristics in patients with DCM, and the prognostic value of RV dysfunction on all‐cause mortality and ventricular arrhythmias (VA) was evaluated.Methods and resultsConsecutive patients with DCM and left ventricular (LV) dysfunction (ejection fraction < 50%) on CMR were included retrospectively. Left atrial (LA), LV, and RV volumes and function were quantified. RV systolic dysfunction was defined as RVEF<45%. The presence and pattern of late gadolinium enhancement (LGE) on CMR were assessed visually. Septal midwall LGE was defined as midmyocardial stripe‐like or patchy hyperenhancement in the septal segments, and the extent was quantified using the full width at half maximum method. Primary endpoint was a composite of all‐cause mortality and VA, including resuscitated cardiac arrest, sustained VA, and appropriate implantable cardioverter defibrillator therapy. Secondary endpoints were time to all‐cause mortality alone and time to VA alone. A total of 216 DCM patients were included (42% female, age 58 ± 14 years). Mean RVEF was 46 ± 12%, and RV dysfunction was present in 38%. RVEF was moderately correlated with LA dilation (LA minimal volume ρ = −0.38, P < 0.001) and strongly correlated with LA and LV dysfunction (LA emptying fraction r = 0.58, P < 0.001 and LVEF ρ = 0.52, P < 0.001). Septal midwall LGE was more often observed in patients with RV dysfunction compared with patients with preserved RV function (respectively 40% vs. 26%, P = 0.04). No correlation was found between RVEF and the extent of septal midwall LGE (ρ = −0.12, P = 0.34). During a median follow‐up of 2.2 years [IQR 1.6–2.8], 30 patients experienced the primary endpoint. RV dysfunction was significantly associated with shorter time to the composite primary endpoint (HR 3.19 [95% CI 1.49–6.84], P < 0.01) and to the secondary endpoint of VA alone (HR 6.48 [95% CI 1.83–22.98], P < 0.01). There was a trend towards increased mortality when RV dysfunction was present (HR 2.54 [95% CI 0.99–6.57], P = 0.05).ConclusionsRight ventricular dysfunction was predominantly observed in patients with DCM with advanced heart failure and pronounced myocardial remodelling, defined as increased LV and LA dilation and dysfunction and the presence of septal midwall LGE on CMR. During follow‐up, RV dysfunction was associated with shorter time to all‐cause mortality and ventricular arrhythmic events.

Compressed sensing real-time cine imaging for assessment of ventricular function, volumes and mass in clinical practice.

This study was conducted in order to evaluate the accuracy of a compressed sensing (CS) real-time single-breath-hold cine sequence for the assessment of left and right ventricular functional parameters in daily practice. Cardiac magnetic resonance (CMR) cine images were acquired from 100 consecutive patients using both the reference segmented multi-breath-hold steady-state free precession (SSFP) acquisition and a prototype single-breath-hold real-time CS sequence, providing the same slice number, position, and thickness. For both sequences, the left (LV) and right ventricular (RV) ejection fractions (EF) and end-diastolic volumes (EDV) were assessed as well as LV mass (LVM). The visualization of wall-motion disorders (WMD) and signal void related to mitral or tricuspid regurgitation was also analyzed. The CS sequence mean scan time was 23 ± 6 versus 510 ± 109s for the multi-breath-hold SSFP sequence (p < 0.001). There was an excellent correlation between the two sequences regarding mean LVEF (r = 0.995), LVEDV (r = 0.997), LVM (r = 0.981), RVEF (r = 0.979), and RVEDV (r = 0.983). Moreover, inter- and intraobserver agreements were very strong with intraclass correlations of 0.96 and 0.99, respectively. On CS images, mitral or tricuspid regurgitation visualization was good (AUC = 0.85 and 0.81, respectively; ROC curve analysis) and wall-motion disorder visualization was excellent (AUC ≥ 0.97). CS real-time single-breath-hold cine imaging reduces CMR scan duration by almost 20 times in daily practice while providing reliable measurements of both left and right ventricles. There was no clinically relevant information loss regarding valve regurgitation and wall-motion disorder depiction. • Compressed sensing single-breath-hold real-time cine imaging is a reliable sequence in daily practice. • Fast CS real-time imaging reduces CMR scan time and improves patient workflow. • There is no clinically relevant information loss with CS regarding heart valve regurgitation or wall-motion disorders.

Assessment of right ventricular function by echocardiography in patients with ischemic cardiomyopathy and non-ischemic cardiomyopathy

Left ventricle (LV), right ventricular (RV) structural and functional changes occurs in advanced heart failure (HF). Assessment of RV function is important as it has prognostic significance in prognosis. RV functions, depending on the underlying cause of ischemic cardiomyopathy (ICMP) or nonischemic cardiomyopathy(NICMP) are affected by different levels. Patients with clinical sign of HF and echocardiographic parameters as LVEF ≤ % 35 and LV end diastolic diameter (LVEDD) ≥ 55 mm, sinus rhythm (SR), clear image quality, absence or mild valve insufficiency were included in the study. The study consisted of 20 ICMP and 24 NICMP patients with LVEF < %35 and increased LV end-diastolic diameter (LVEDD > 5.5 cm), non severe valve disease and SR. RV and LV volume, diameter and function are assessed by echocardiography. Patients have similar basic characteristics. LV functions were evaluated by two-dimensional(2D) echocardiography, transmitral flow Doppler and tissue Doppler echocardiography and the analysis revealed similar results in both groups. RV longitudinal diameter in ICMP was significantly lower when compared to the NICMP(6.80 ± 0.83 cm, 7.4 ± 1.03 cm; p=0.03). Mean RVEF was comparable between groups and %59 in NICMP while 62% in ICMP. There were no significant differences between groups regarding RV transtricuspid flow Doppler parameters. In tissue Doppler parameters, lateral annulus Sm velocity which reflects RV systolic function was lower in ICMP than NICMP (0.09 ± 0.02 cm/sn vs 0.11 ± 0.018 cm/sn; p = 0.004). TAPSE assessed by M-mode echocardiography was significantly lower in ICMP group than NİCMP(1.98 ± 0.39, 2.28 ± 0.33; p = 0.009). The present study show that RV function was significantly decreased in ICMP when compared to NICMP.

Right Ventricular Systolic Dysfunction Assessed by Cardiac Magnetic Resonance Is a Strong Predictor of Cardiovascular Death After Coronary Bypass Grafting

Limited data are available regarding the prognostic value of right ventricular (RV) systolic dysfunction (RVSD) in patients with coronary artery disease. Our objective was to evaluate the effect of RVSD assessed by cardiac magnetic resonance on survival of patients with low left ventricular (LV) ejection fraction (EF) undergoing coronary bypass grafting (CABG). We prospectively assessed overall and cardiovascular death of 107 consecutive patients (94 men; age, 66 ± 10 years) undergoing CABG who had a LVEF of 0.35 or less by cardiac magnetic resonance before CABG. Mean LVEF was 0.25 ± 0.07, and mean RVEF was 0.46 ± 0.16. RVSD, defined by RVEF of 0.35 or less, was present in 32 patients (30%). In-hospital mortality rate (n= 8) was significantly higher in patients with RVSD (18.7% vs 2.7%, p= 0.004). Over a median follow-up of 4.7 years, 44 patients died, 33 of a cardiovascular cause. The primary end point of cardiovascular death was reached by 15 of 32 patients with RVSD and 18 of 75 patients without RVSD (47% vs 24%, p= 0.019). Univariate survival analysis showed that age, New York Heart Association Functional Classification, diabetes, estimated glomerular filtration rate, LVEF, LV indexed end-diastolic volume, RVEF, RV indexed end-diastolic volume, RV systolic function, and The Society of Thoracic Surgeons risk score were independent predictors of the primary end point of cardiovascular death. By multivariable analysis, the Society of Thoracic Surgeons risk score (hazard ratio, 1.32; 95% confidence interval, 1.13 to 1.55; p= 0.001) and RVSD (hazard ratio, 2.14; 95% confidence interval, 1.06 to 4.31; p= 0.034) remained significant independent predictors of cardiovascular death. RVSD strongly and independently predicts cardiovascular death in patients with coronary artery disease and low EF undergoing CABG. Evaluation of RV function should thus be part of preoperative evaluation of such patients.

0469: Feasibility and usefulness of cardiac magnetic resonance as a complement to echocardiography in the evaluation of heart failure with preserved left ventricular ejection fraction in elderly patients

To evaluate the feasibility and usefulness of cardiovascular magnetic resonance (CMR) in the evaluation of heart failure with preserved left ventricular ejection fraction (HFpEF) in elderly patients. Patients aged 65 and older hospitalized for symptomatic heart failure with a left ventricular ejection fraction (LVEF) >40% underwent both CMR and 2D echocardiographic assessment of cardiac volumes, mass and function. Among 14 patients (mean age 80.2±8.7 Y [66-91]), a good correlation was found between echocardiography and CMR for LVEF (56.7±8.1% vs 54.3±9.2%, r=0.8). Echocardiography mildly underestimated LV end diastolic volume (EDV) (55.6±25.8 vs 67±24.1mL/m 2 , r=0.84) and end systolic volume (ESV) (24.9±15.8 vs 31.3±13.9mL/m 2 r=0.66). Echocardiography overestimated the LV mass (87.4±23.5 vs 64±22.3g/m 2 , r=0.5). Left atrial volume (assessed by CMR) was increased (52.8±24.9mL/m 2 ), 8 patients had atrial fibrillation with larger left atrial volume (71.5±26.9 vs 38.8±10.9mL/m 2 for sinus rhythm, p 0.008). Right ventricular (RV) EDV and ESV assessed by CMR were normal. Mean RVEF was 43.7±8.7% and RVEF was <45% in 8 (57%) patients who also had lower LVEF (p=0.005) and higher pulmonary artery systolic pressure (p=0.01). Late gadolinium enhancement (LGE) was found in 8 cases, 4 with mid-wall LGE, 2 with subendocardial or transmural LGE and 2 with sub epicardial LGE. CMR was feasible, safe and was a useful complement to echo-cardiography in elderly patients hospitalized for HFpEF. In this population, LVEF assessed by CMR and echocardiography were comparable. Echocardiography underestimated LV volumes and overestimated LV mass. Risk factors for adverse outcome such as RV dysfunction and the presence of LGE were found in more than half of the cases.

Right Ventricular Ejection Fraction in Ischemic Versus Nonischemic Cardiomyopathy

The relation between the etiology of cardiomyopathy and the function of the right ventricle (RV) has not been well described in the current era of 3-dimensional cardiac imaging. New advances in cardiac imaging with computed tomography (CT) have allowed accurate measurements of ejection fraction (EF), often a challenging task considering the unique RV shape. We evaluated 130 patients at the Loma Linda Veterans Affairs Healthcare System with cardiomyopathy and a left ventricular (LV) EF ≤ 40%. Etiology of cardiomyopathy was determined by CT angiography as ischemic (n = 56) or nonischemic (n = 74). RV volumes and RVEF were calculated based on 3-dimensional data set from CT images. Baseline LVEF was similar with a mean LVEF of 28% (± 6%) in the ischemic group and 28% (± 9%) in the nonischemic group (p = 0.46). RV function and volumes were moderately decreased in both cohorts, without significant difference between the groups (mean RVEF 34 ± 11% in ischemic group and 32 ± 10% in nonischemic group, p = 0.26). In conclusion, most patients with LV dysfunction also have RV dysfunction. The degree of RV dysfunction is not dependent on the etiology of cardiomyopathy.

Prognostic implication of right ventricular involvement in peripartum cardiomyopathy: a cardiovascular magnetic resonance study.

AimsPeripartum cardiomyopathy (PPCM) is a major cause of acute heart failure in the peripartum period and considered potentially life threatening. While many aspects of its clinical profiles have been frequently reported, functional analysis, in particular of the right ventricle, and tissue characterization by cardiovascular magnetic resonance (CMR) imaging have been only sporadically described. The aim of the present study was to analyse pathological alterations and their prognostic relevance found in CMR imaging of patients newly diagnosed with PPCM.Methods and resultsIn this multicenter study 34 patients with confirmed PPCM underwent CMR imaging at the time of diagnosis and at 5 ± 1 months follow‐up. Cine imaging of PPCM patients showed moderate to severe reduction of systolic left ventricular (LV) function (mean LVEF: 29.7 ± 12.8%). In 35% of the patients right ventricular (RV) systolic function was also reduced with a mean RVEF of 42.9 ± 13.9%. Dilatation of the LV was observed in 91% (mean LV‐EDV/BSA 128.5 ± 32.1 mL/m2), and dilatation of the RV was present in 24% (mean RV‐EDV/BSA 87.4 ± 18.5 mL/m2) of the patients. Focal non‐ischemic late gadolinium enhancement (LGE) was visible in 71%, and regional wall motion abnormalities were evident in 88% of the patients. LGE and wall motion abnormalities were predominantly located in the anteroseptal and basal to midventricular segments. RV dysfunction at baseline was associated with reduced probability of full cardiac recovery at 5 ± 1 months follow‐up.ConclusionsBesides LV systolic dysfunction, RV dysfunction and dilatation are observed in about one third of PPCM patients at the time of diagnosis. RV dysfunction is associated with unfavourable outcome. A distinct pattern of LV wall motion abnormalities and myocardial scar is evident in most PPCM patients. The present study may help to establish a set of CMR criteria suitable for diagnosis in patients with suspected PPCM and may add further knowledge to the pathology of the disease.

0181: Long term effects of cardiac resynchronization therapy in corrected tetralogy of Fallot

Patients with corrected tetralogy of Fallot (TF) often suffer from symptomatic right ventricular failure always associated with right bundle branch block (RBBB) on resting ECG. Our objective was to evaluate the mid-term safety and efficacy of cardiac resynchronization (CRT) in this population. We collected retrospectively every adverse events due to biventricular pacing of patients with corrected tetralogy of Fallot implanted with CRT system in our department. We also compared clinical datas (NYHA score), stress tests, ECG, echocardiographic results before implantation, at 6 months of follow-up and at the last evaluation. From August 2005 to Septembre 2009, 9 patients were implanted with CRT system, 6 (66,7%) with transvenous leads and 3 (33,4%) with epicardic leads, mostly composed of men (6, 66,7%) with a mean age of 34,2±14,5 years, 4 (44,5%) had an Implantable Cardioverter Defibrillator (ICD) function. During a median follow-up of 65 months [50-80], no main adverse event was reported, we had 1 atrial lead dislogement, 3 (33%) lead disfunctions causing only 1 (11%) resynchronisation failure and 1 (11%) intermittent phrenic nerve stimulation. CRT were associated with lower NHYA score (1,4±0,52 then 1,3±0,8 vs 2±0,4, p<0,05) and an improved exercise tolerance (100±21,6W then 112,9±12,9W, vs. 71,3±26,2W, p<0,05) at 6 months and at the end of follow-up. Mean RVEF was increased (54,3±8,2 vs. 38,5±7,5; p=0,035 and so was LVEF (53,8±8,3% vs. 48,8±8,8%, p=0,04). CRT in corrected tetralogy of Fallot anad right ventricule failure is safe and seems to be associated with an improvement of patient’s functional status. This first study on CRT in this population should be confirmed by a large prospective randomised multicentric clinical trial.

Right Ventricular Function and Prognosis in Stable Heart Failure Patients

BackgroundRight ventricular ejection fraction (RVEF) is a mortality predictor in heart failure (HF) patients. There are controversial results regarding the influence of RVEF on other important prognostic variables. The purpose of this study was to investigate the effect of RVEF on exercise parameters obtained during cardiopulmonary exercise testing (CPET), creatinine and B-type natriuretic peptide (BNP) levels, and a composite outcome of death, heart transplantation, or ventricular assist device implantation in ambulatory HF patients. Methods and ResultsThis retrospective cohort study included 246 ambulatory HF patients with CPET and RVEF evaluated with the use of first-pass radionuclide angiography. We analyzed the impact of RVEF on other prognostic factors with the use of multivariable linear regression. The mean age was 49 ± 12 years. The mean peak VO2 was 16.4 ± 5.7 mL kg−1 min−1, mean peak VE/VCO2 34.1 ± 9.1, mean creatinine 1.17 ± 0.40 mg/dL, and median BNP 158 pg/mL (interquartile range 374 pg/mL). The mean left ventricular ejection fraction was 35 ± 12% and the mean RVEF 38 ± 10%. For every 10% decrease in RVEF, peak VO2 decreased 0.97 mL kg−1 min−1 (P < .05), creatinine increased 0.12 mg/dL (P < .01), and log BNP increased 0.26 (P < .05). ConclusionsWe found an independent association between RVEF and prognostic markers in HF patients. Worsening RV function may exert its negative effect on prognosis through increasing congestion (elevated BNP), affecting renal blood flow (increased creatinine) and limiting left ventricular preload, thereby reducing exercise tolerance.

Abstract 299: Poor Right Ventricular Function Predicts Poor Prognosis in Patients with Nonischemic Cardiomyopathy

Background: Diagnosis of heart failure carries poor prognosis, especially in left ventricular (LV) systolic dysfunction. The prognostic implications of right ventricular (RV) function in the setting of cardiomyopathy (CM) is unclear. Methods: All patients at VA Loma Linda Healthcare System who underwent cardiac computed tomography angiography between 2005 and 2011 with LV ejection fraction (EF) of ≤40% were included. LV and RV volumes were calculated from gated 3 dimensional datasets. Coronary analysis was performed using standard multiplanar reformatted image sets. Outcomes data was obtained by chart review and phone. Kaplan-Meier statistics and survival curves were generated. Results: 130 patients met inclusion criteria. All the patients were men, age 62±9 years, LVEF of 28±8%, and mean RVEF of 33±11%. Ischemic etiology of CM was found in 56 patients (43%) and nonischemic in 74 (57%). Average follow-up was 871 days. Overall mortality was 43% in the ischemic group, compared to 20% in the nonischemic group, even with higher LVEF in ischemic group (28.4 vs 27.4%, p=0.03). Survival in the whole cohort was associated with age, coronary disease (HR 2.0), chronic pulmonary disease (HR 2.1), and left anterior descending artery disease (HR 2.5). Decreased RVEF predicted worse prognosis in patients with nonischemic but not ischemic CM. Conclusions: Decreased RV function is associated with worse prognosis in nonischemic CM. Ischemic etiology of CM carries poor prognosis regardless of RV function.

Right ventricular function in dilated cardiomyopathy: relation to location of focal myocardial fibrosis

Background Severe right ventricular dysfunction (RVD) is an important prognostic parameter in dilated cardiomyopathy (DCM). The relationship between myocardial fibrosis of the left ventricle (LV) and particularly the septum and right ventricular (RV) function remains poorly understood. We sought to investigate this relationship in a large cohort of DCM patients using cardiovascular magnetic resonance (CMR). Methods We studied 257 patients (52±15ys,193men) with known DCM using a clinical 1.5 T CMR scanner (Philips Achieva). Short axis slices covering entirely both ventricles were acquired using standard SSFP-sequences for measurement of LV and RV volumes and ejection fraction (EF). Focal myocardial fibrosis was assessed in late gadolinium enhancement (LGE) CMR images acquired 10 minutes after i.v. injection of 0.2mmol/kg Gd-DTPA (Magnevist). SSFP and LGE CMR images were assessed by different observers who were blinded to measurement results and clinical data. Severe RVD was defined as RVEF<35%. In a subgroup of patients (n=96) invasive measurement of pulmonary artery pressure was performed. Results Mean LVEF was 35±14% while mean RVEF was 42 ±13%. Focal myocardial fibrosis was present in 92 (36%) patients and was located a) intra-murally within the inter-ventricular septum in 29 patients (LGE -septum) or b) sub-epicardially/diffuse in 63 patients (any-LGE). None of the patients had sub-endocardial LGE. LGEseptum patients exhibited a significantly higher RVEF (49±12%; vs. 40±14%;p=0.006), a higher RV EDV index (115±43 ml/m2; vs. 99±23 ml/m2 ;p=0.05) and a higher RV ESV index (73±45 ml/m2; vs. 52±22 ml/m2 ;p=0.01)

Echocardiogram Versus Cardiac Magnetic Resonance Imaging for Assessing Systolic Function of Subaortic Right Ventricle in Adults With Complete Transposition of Great Arteries and Previous Atrial Switch Operation

In adults with congenital heart disease and a systemic right ventricle, subaortic ventricular systolic dysfunction is common. Echocardiographic assessment of systolic right ventricular (RV) function in these patients is important but challenging. The aim of the present study was to assess the reliability of conventional echocardiographic RV functional parameters to quantify the systolic performance of a subaortic right ventricle. We compared 56 contemporary echocardiograms and cardiac magnetic resonance studies in 37 adults, aged 26.9 ± 7.4 years, with complete transposition and a subaortic right ventricle. The fractional area change (FAC), lateral tricuspid annular plane systolic excursion, lateral RV systolic motion velocities by tissue Doppler, RV myocardial performance index, and the rate of systolic RV pressure increase (dp/dt) measured across the tricuspid regurgitant jet were assessed by echocardiography and correlated with the cardiac magnetic resonance-derived RV ejection fraction (EF). The mean RVEF was 48.0 ± 7.8%. FAC (r(2)= 0.206, p= 0.001) and dp/dt (r(2)= 0.173, p= 0.009) significantly correlated with RVEF, and the other nongeometric echocardiographic parameters failed to show a significant correlation with RVEF by linear regression analysis. FAC <33% and dp/dt <1,000 mm Hg/s identified a RVEF of <50% with a sensitivity of 77% and 69% and a specificity of 58% and 87%, respectively. In conclusion, in patients with a systemic right ventricle, routine nongeometric echocardiographic parameters of RV function correlated weakly with cardiac magnetic resonance-derived EF. RV FAC and the measurement of the rate of systolic RV pressure increase (dp/dt) should be preferentially used to assess systemic systolic function in adult patients with a subaortic right ventricle.