Normal Left Ventricular Function Research Articles

Multimodality strategy for cardiac damage assessment in falciparum malaria: A preliminary study

Malaria caused by the Plasmodium falciparum (P.f) parasite can result in life-threatening complications. Traditionally, cardiac involvement has not been included as a frequent cause of morbidity and mortality. Cardiac damage in P.f infection is probably underdiagnosed. To analyze the hypothesis of cardiac damage in apparently uncomplicated P.f infection with a multimodality strategy unavailable in most endemic countries. Cardiac biomarkers, ECG and 24 h ECG recording, transthoracic echocardiography with global strain analysis, and complete CMR analysis, including T2 (Fig. 1) and T1 mapping and extracellular volume quantification (ECV), were performed in patients hospitalized for malaria in a French tertiary center. Ten cases (sex ratio: 1 – mean age: 45 ± 13 years) imported from sub-Saharan Africa were prospectively included. Mean P.f parasitemia was 1.6 ± 1.7%. Hs-c Troponin T and NT pro BNP were mildly increased respectively in 1 and 2 patients. 24-h ECG recording revealed > 500 ventricular premature beats in 2 patients. Imaging revealed normal left and right ventricular systolic function, diastolic function and longitudinal global strain in all but one patient. CMR revealed 2 cases of focal late gadolinium enhancement consistent with the diagnosis of acute myocarditis in 1 case. ECV value was increased in 1 case (dilated cardiomyopathy). All patients were treated with piperaquine + dihydroartemisine and had a favorable outcome. Multimodality strategy reveals some cardiac abnormalities (ventricular ectopy, myocarditis) in patients hospitalized for falciparum malaria. Specificity of such findings remains questionable in this preliminary study. Further investigation is required to conclude about the hypothesis of a significant malaria-induced cardiac.

Novel Approach for Assessing Postinfarct Myocardial Injury and Inflammation Using Hybrid Somatostatin Receptor Positron Emission Tomography/Magnetic Resonance Imaging.

Novel Approach for Assessing Postinfarct Myocardial Injury and Inflammation Using Hybrid Somatostatin Receptor Positron Emission Tomography/Magnetic Resonance Imaging.

Cardiopulmonary capacity is reduced in children with ventricular arrhythmia

Premature ventricular contractions (PVCs) are frequently seen in children and are considered benign. A substantial group of adolescents with PVCs complain about a broad range of clinical symptoms, including low exertion tolerance. The purpose of this study was to evaluate prospectively whether ventricular arrhythmia affects physical performance in adolescents with normal left ventricular function, using a cardiopulmonary exercise test (CPET) and evaluating the electrocardiographic (ECG) characteristics of patients with PVCs with regard to exercise capacity. The study group consisted of 49 children with PVCs and normal left ventricular function. The control group consisted of 36 healthy volunteers. Standard ECG, 24-hour Holter ECG, and CPET were performed. PVCs were analyzed for QRS duration, bundle branch block pattern, QRS axis, and coupling interval (CInt). ForCPET, heart rate (HR), oxygen uptake (VO2max), predicted VO2max, and VO2max expressed as a percentage of the predicted value (%VO2) were measured. In 37 patients (76%), arrhythmia subsided during exercise. Patients achieved lower VO2max (32.9 ± 6.3 mL/min/kg) than controls (40.4 ± 6.7 mL/min/kg; P <.01). %VO2 was 71.0 ± 13.7 in patients and 79.3 ± 12.2 in controls (P <.01). Exercise HR at which PVCs subsided correlated with VO2max (r = 0.3; P = .07). Patients with persisting arrhythmia performed worse than those in whom arrhythmia subsided during exercise (VO2max, P<.01; %VO2,P <.01). No correlation between QRS and CInt parameters and VO2max was observed. Patients with PVCs have lower aerobic capacity than their healthy peers. Further worsening of exercise capacity is present when PVCs are preserved during effort.

The correlation between speckle-tracking echocardiography and coronary angiography in suspected coronary artery disease with normal left ventricular function.

Introduction: Our study objects to determine the diagnostic accuracy of two-dimensional speckle tracking echocardiography (2DSTE) in predicting presence and severity of coronary artery disease (CAD). Methods: Patients with stable angina pectoris with normal left ventricular function (>50%) undergoing coronary angiography were enrolled and subjected to speckle tracking echocardiography. Global longitudinal peak systolic strain was measured and correlated to the results of coronary angiography for each patient. Results: Number of male (P=0.001), diabetes (P=0.01) and smoking (P=0.01) patients were significantly higher in the CAD group compared to non-CAD patients. Global longitudinal peak systolic strain (GLPSS) was significantly (P=0.0001) lower in CAD patients in comparison to non- CAD patients. GLPSS showed significantly lower in patients with Syntax score (SS)≥22 in comparison to SS<22. Cut-off value -19 for GLPSS could be used to predict the presence of significant CAD with 80.6% sensitivity and 76.5% specificity (area under curve (AUC) -0.83, P=0.0001). The mean GLPSS value decreased as the number of diseased coronary vessels increased (P=0.0001). The optimal cut-off value of -16 GLPSS with a sensitivity of 76.7% and specificity of 83.3% [AUC 0.84, P<0.0001] was found significant to predict CAD severity. Multivariate regression of GLPSS and another risk factor for predicting significant CAD, GLPSS showed OR=1.55 (CI-1.36-1.76) P=0.0001 for predicting the presence of CAD. Conclusion: 2DSTE can be used as a non-invasive screening test in predicting presence, extent and severity of significant CAD patients with suspected stable angina pectoris.

228 PD-1-TARGETED T-CELL CHECKPOINT INHIBITORS-RELATED MYOCARDITIS COMPLICATED BY COMPLETE ATRIOVENTRICULAR BLOCK: A CASE SERIES OF SUCCESSFUL MANAGEMENT

Abstract Background Immune checkpoint inhibitors (ICI) have revolutionized the clinical management of a broad spectrum of solid and hematopoietic malignancies over the past decade. ICI are associated with several Immune-related Adverse Events, among which myocarditis and atrioventricular blocks are uncommon but potentially fatal toxicities. Material and Methods We describe two patients undergoing treatment with PD-1 checkpoint inhibitors for metastatic cancers who developed myositis and myocarditis complicated by complete atrioventricular block (CAVB). The first patient had a history of metastatic sarcomatoid urothelial carcinoma treated with Pembrolizumab. After two cycles, he developed eyelid ptosis and was hospitalized for syncopal episodes due to CAVB associated with ICI myocarditis. The second patient had a history of metastatic melanoma and was hospitalized for myocarditis and myositis after the second infusion of Nivolumab. Results In the first case, high-dose corticosteroid therapy was promptly initiated, with subsequent rapid recovery of sinus rhythm and rapid resolution of symptoms. The second patient, despite high-dose corticosteroid therapy, developed CAVB requiring implantation of a definitive PM. After initiation of mycophenolate mofetil and intravenous immunoglobulin therapy, gradual recovery was observed. Both patients had normal left ventricular function with no wall motion abnormalities. However, speckle tracking echocardiography revealed a normal global longitudinal left ventricular strain (GLS) of -19.8% in patient 1 and a depressed GLS of -14.7% in patient 2, consistent with the different evolution of the two myocarditis. Conclusions We recommend a high degree of caution and awareness to all physicians when treating immunotherapy patients. Myocarditis is a relatively rare but potentially fatal event due to its early onset, non-specific clinical presentation and fulminant progression. GLS may be useful in detecting myocardial damage in these patients. Discontinuation of ICI, cardiac pacing, treatment with high-dose corticosteroids and immunosuppressive agents may improve the outcome.

397 HEART FAILURE WITH REDUCE VENTRICULAR EJECTION FRACTION FOLLOWING THERAPY WITH RITUXIMAB IN A PATIENT AFFECTED BY MPO ANCA RELATED MICROSCOPIC POLYANGITIIS

Abstract Introduction Rituximab is a chemotherapeutic drug widely used for the treatment of oncologic and rheumatologic diseases. Its cardiotoxic profile has not yet been defined in detail; only a few isolated case reports delineate cardiovascular adverse reactions following its use. In the cases described in literature, the drug was used to treat neoplastic diseases, often in combination with other chemotherapeutic drugs. We present a clinical case of heart failure with reduced ventricular ejection fraction (HFrEF), developed following therapy with Rituximab and a single administration of Cyclophosphamide, in a patient affected by MPO-ANCA-related Microscopic Polyangiitis. Case Report 54-year-old man arrived at the emergency department for weight loss, fever, asthenia, and lower limbs oedema; laboratory findings where diagnostic for acute kidney injury (AKI). His past history was unremarkable. He was admitted to the nephrology department where he was diagnosed with MPO-ANCA-related microscopic polyangiitis. Echocardiography on admission showed normal left systolic ventricular function. He underwent diuretic therapy, intermittent hemodialysis, plasmapheresis and immunosuppressive therapy with steroids, Rituximab (two administration of 375 mg/m2 i.v. one week apart) and Cyclophosphamide (one administration of 300 mg i.v.). Following the achievement of good clinical and hemodynamic compensation, the patient was discharged. However, 5 days later, the patient came back to the hospital, prior to the follow-up that was scheduled for the continuation of immunosuppressive therapy, with symptoms of worsening dyspnea related to acute pulmonary edema. A transthoracic echo showed severe left ventricular systolic dysfunction for global hypokinesia. Cardiac MRI showed hypokinetic dilated cardiomyopathy with severely depressed systolic function (EF 30%) in the absence of lesions compatible with edema and myocardial fibrosis/necrosis. No coronary artery disease was detected with CT coronary angiogram. Given the absence of signs of ischemic cardiopathy or inflammatory related cardiomyopathy, we considered this new onset of HFrEF likely due to cardiotoxicity from chemotherapy drugs, which, in agreement with nephrology colleagues, were discontinued. The patient was started on heart failure medication with Bisoprolol 2,5 mg once daily and Ramipril 2,5 b.i.d., mineralocorticoid receptor antagonist and glifozines were not administered due to the renal injury. Given the HFrEF and numerous features of non-sustained ventricular tachycardia found on EKG monitoring during hospitalization, the patient was discharged with a wearable ICD. He was discharged after 3 weeks in stable clinical conditions with a follow-up appointment in a month. Conclusion Our clinical case provides further evidence regarding the cardiotoxic effect of Rituximab. In contrast with the other cases in literature, Rituximab was used for the treatment of rheumatologic and non-neoplastic pathology, without being combined with several other chemotherapeutics but only with a low-dose administration of Cyclophosphamide. In light of the above, it is worth mentioning that when chemotherapeutics are used, not only in oncology but also in rheumatology, even when their cardiotoxicity profile has not been defined in detail, as in the case of Rituximab, it is essential to use the utmost caution in assessing cardiac function before and after drug administration, so that early detection of cardiotoxicity will be possible.

630 CARDIAC AMYLOIDOSIS: THE IMPORTANCE OF THE RIGHT DIAGNOSTIC TOOLS

Abstract Introduction Amyloidosis (a.) consists of the build-up of misfolded proteins in the whole body leading to life threatening organ disfunction. The most common form is the AL a., that is the result of kappa or lambda monoclonal light chains deposition as amyloid fibril. Cardiac involvement in AL a. has a high mortality. Once cardiac symptoms reveal, early diagnosis is important in order of the inverse relationship between time after the onset of cardiac symptoms and survival. Case Report A 80-y/o male was admitted in our department. Four months before he had an hospitalization in whom a coronarography was performed, showing no emodinamically signifiant lesions, leading to diagnosis of acute coronary syndrome with non occlusive coronary disease. For two months, he experienced progressive dyspnea, edema of the lower limbs and bilateral pleural effusions. On arrival, he was hemodynamically stable, his laboratory results were significant for a pro-BNP of 26,568 pg/ml and high sensitivity troponin T of 359 ng/L but without movement, the electrocardiogram showed sinus rhythm with heart rate of 72 bpm, right bundle block, non specific alterations of repolarization and low voltages. The chest X-ray showed bilateral pleural effusion. A first echocardiogram was performed and showed normal left ventricular systolic function with an ejection fraction of 60%, without wall motion abnormalities, severe concentric hypertrophy, with a left ventricular posterior wall thickness of 16 mm that is over the cutoff proposed by Marume et al., a LV septal WT of 17 mm, over the cutoff of Arvidsson at al., and a granular appearance of the myocardium, seen as hyperrefractile myocardial echoes. There was a moderate-severe diastolic dysfunction (E/E’ ratio of 22). A small pericardial effusion (8 mm) and a right ventricular dilatation (30mm) were present, too. The last parameter is a poor prognostic marker of right heart failure (in our patient there was also a tricuspid insufficiency) and a median survival of four month, as Patel et al. demonstrate. All these parameters are suspicious for storage disease, in particular amyloid deposition. M spike was not shown at serum and urine electrophoresis, and no paraproteins were found in immunofixation. However, increased kappa and lambda free light chains (248 mg/L and 31 mg/L respectively) with an increased serum and urinary kappa/lambda ratio (8.00 and 105.19) were found. Thus, a fine needle aspiration was performed, showing a bone marrow localization of Multiple myeloma (MM). A bone marrow biopsy was done but the result was still unknown at the time of discharge. A negative scintigraphy was performed. The patient was discharged from our department with a diagnosis of chronic heart failure and ongoing investigation about the link between MM and CA. One month later we have seen the result of the bone marrow biopsy that was negative for Congo red staining. During the same month the patient died, so there was no possibility to practice a cardiac biopsy. Discussion The purpose of this abstract is to emphasize the importance of fast diagnosis and cardiac biopsy in a characteristic case of clinical and echocardiogram suspicious of CA and a negative scintigraphy. Therefore the cardiac biopsy is preferable to extracardiac biopsy, as fat pad or bone marrow ones, because the cardiac one is more specific and sensitive. The heart of the matter is that it is not possible for all the departments to carry out this procedure in short-term, as in our case, and a non rapid diagnosis is linked with arrhythmic sudden cardiac death but also a rapidly worsening heart failure, as in our patient.

NT-pro-BNP as a Predictor for Recurrence of Atrial Fibrillation after Primary Cryoballoon Pulmonary Vein Isolation.

NT-pro-BNP is produced in the cardiac atria and ventricles in response to increased wall stress. It may be a marker of both AF disease progression and co-morbidities that affect success after pulmonary vein isolation (PVI). This single-center retrospective study analyzed the association between pre-procedural NT-pro-BNP serum levels and the long-term outcome after a first-ever PVI in cryo-technique. Patients were followed by searching the hospital information system and conducting structured telephone interviews. Treatment failure was defined as any relapse of atrial fibrillation (AF) occurring 90 days after the index PVI at the earliest. Kaplan-Meier survival curves and Cox proportional hazards models were computed to assess the impact of NT-pro-BNP on AF recurrence. Following 374 patients over a median of 3.8 years (range: 0.25-9.4 years), baseline NT-pro-BNP was associated with the combined endpoint in univariate analysis (HR 1.04 per 100 pg/mL increase, 95% CI: 1.02-1.07, p &lt; 0.001). Results were virtually unchanged in the multivariate model or if the data were log-transformed. Intraprocedural left atrial pressure correlated positively with log NT-pro-BNP. NT-pro-BNP was associated with AF relapse during a long-term follow-up after first-ever cryo-PVI in our cohort of patients with predominantly normal left ventricular function. This lab parameter is easy to obtain and has significant potential to guide treatment decisions.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Risk of Pacing-Induced Cardiomyopathy in Patients with High-Degree Atrioventricular Block-Impact of Right Ventricular Lead Position Confirmed by Computed Tomography.

Prospective studies applying fluoroscopy for assessment of right ventricular (RV) lead position have failed to show clear benefits from RV septal pacing. We investigated the impact of different RV lead positions verified by computed tomography (CT) on the risk of pacing-induced cardiomyopathy (PICM). We retrospectively included 153 patients who underwent routine fluoroscopy-guided pacemaker implantation between March 2012 and May 2020. All patients had normal pre-implant left ventricular ejection fraction (LVEF). Patients attended a follow-up visit including contrast-enhanced cardiac CT and transthoracic echocardiography. Patients were classified as septal or non-septal based on CT analysis. The primary endpoint was PICM (LVEF < 50% with ≥10% decrease after implantation). Based on CT, 48 (31.4%) leads were septal and 105 (68.6%) were non-septal. Over a median follow-up of 3.1 years, 16 patients (33.3%) in the septal group developed PICM compared to 31 (29.5%) in the non-septal group (p = 0.6). Overall, 13.1% deteriorated to LVEF ≤ 40%, 5.9% were upgraded to cardiac resynchronization therapy device, and 14.4% developed new-onset atrial fibrillation, with no significant differences between the groups. This study demonstrated a high risk of PICM despite normal pre-implant left ventricular systolic function with no significant difference between CT-verified RV septal or non-septal lead position.

Quantifying the impact of equity, diversity, and inclusion in electrophysiology: Training the first female electrophysiologists from Jamaica and Saint Lucia.

Delivery of electrophysiology (EP) care in developing nations and underserviced populations faces many hurdles, including the lack of local expertise and knowledge creation. The West Indies has experienced a paucity of local EP expertise. The University of Toronto has undertaken a unique collaborative educational effort with the University of the West Indies. We describe the effects of equity, diversity, and inclusion (EDI) in EP training at Toronto General Hospital in Canada by quantifying the impact of training the first female electrophysiologists to practice in Jamaica and Saint Lucia. Data from the ministries of health in Jamaica and Saint Lucia were reviewed. The number of arrhythmia clinic patients seen, EP studies and ablations performed, pacemaker clinic patients seen, and implantable devices, permanent pacemakers (PPMs), and implantable cardioverter-defibrillators (ICDs) implanted were assessed. One hundred one arrhythmia consults were seen by the new electrophysiologist in Jamaica after her return from training in 2020. She has since performed 19 EP studies/catheter ablations at a newly established ablation laboratory. Three cases of left ventricular (LV) dysfunction due to tachy-cardiomyopathy were treated successfully with catheter ablation with immense improvement in LV ejection fraction. Thirteen PPMs, 1 ICD, and 3 LV leads were implanted, after which no early complications were identified. In Saint Lucia, where there is no dedicated electrophysiology laboratory, 2 patients who required catheter ablation for tachycardia-mediated LV dysfunction were identified by the electrophysiologist since her return to the island in 2018. The patients were appropriately referred, resulting in restoration of normal LV function. Six PPMs also were implanted in Saint Lucia. Knowledge translation has been limited by the lack of accessibility to the required devices, catheters, and specialized equipment and accessories, mainly because of their costs. Training the first female electrophysiologists from Jamaica and Saint Lucia led to a quantifiable impact on EP care in both of these Caribbean countries. EDI strategies in EP training programs provide much needed benefits to developing nations, but more support is needed to allow new electrophysiologists to fully utilize their EP training to care for underserviced populations.

Left Ventricular Functions Assessment by Speckle Tracking in Comparison with The Two-Dimensional (2D) Echocardiography in Patients with Fragmented QRS

Background and Aim: Fragmented QRS (fQRS) are electrocardiographic signals reflecting altered ventricular conduction around regions of a myocardial scar and/or ischemia. However, it could be presented in normal healthy individuals. But, its incidence and its role in prediction of cardiac disease is not yet addressed. This study aiming to assess the left ventricular (LV) functions in patients with apparent normal LV functions with fQRS using two-dimensional (2D) speckle tracking echocardiography. Patients and Methods: This cross-sectional study take place from March to October 2020. Fifty non cardiac patients who undergo preoperative cardiac assessment of non-cardiac surgery at cardiology department were included. All subjects are submitted to full history taking, complete general and local examinations, twelve lead ECG searching for fQRS complex and exclude ischemia and arrhythmia, and transthoracic echocardiography to assess LV functions as described previously. Results: 36% fQRS complex was in anterior lead, 50% were in Inferior lead and only 14 % was in Lateral lead. Mean EF was 58.9 ± 5.8%, ranging from 55 to 65, FS was 26.7±1.9%, with range of 24 to 40%. LVEDD 4.5±0.7cm, LVESD was 3.3±0.4cm, Intraventricular septum was 10.1±0,6 mm and Posterior wall thickness 9.6±07 mm. Left ventricular longitudinal strain in 2 chamber apical view was 16.4±3.3%, 4 chamber apical view was 16.7±3%, apical long axis view was 17.7±3.5% and average LV GLS was 18.1±2.9%. There were 15 cases abnormal LV diastolic function according to E/e` ratio and 9 cases according to LV-GLS. There was statistically significant different between assessment of LV function by 2D echocardiography and speckle tracking. Conclusion: The presence of fQRS on standard electrocardiography in apparently healthy people with preserved EF is associated with some sort of subclinical LV dysfunction and two-dimensional speckle tracking is more accurate and sensitive than two-dimensional echocardiography in detection of those patients.

Right Ventricular Segmental Rotation and Torsion in Normal Subjects on 2D Speckle Tracking Echocardiography

Background/Aims: Little is known about the complex anatomy of right ventricular (RV) torsion in the general population. This study was designed to assess RV’s global and segmental torsional motion in subjects without cardiac pathologies.Methods: We used the Vivid 7 ultrasound system (GE Healthcare, Chicago, IL, USA) to acquire parasternal short-axis views of the RV at the basal and apical levels, and analyzed global and segmental torsion using a 2D speckle tracking algorithm in EchoPAC workstation (GE Healthcare, Wauwatosa, WI, USA).Results: Forty-eight individuals (44 ± 17 years, 54% male) were included, with either normal left ventricular diastolic function (group I, n = 40) or grade I diastolic dysfunction (group II, n = 8). Group I showed global peak systolic torsion of 9.0 ± 6.6 degrees with higher segmental torsion in the mid-interventricular septum (IVS) than in the anterior walls (&lt;i&gt;p&lt;/i&gt; = 0.001). Global RV torsion showed a very strong positive correlation with apical rotation (r = 0.91, &lt;i&gt;p&lt;/i&gt; &lt; 0.001). Group I exhibited higher segmental torsion in the anterior-IVS and mid-IVS walls than group II (9.8 ± 7.1 vs. 3.5 ± 9.6 degrees, &lt;i&gt;p&lt;/i&gt; = 0.036; 10.4 ± 9.1 vs. 2.4 ± 12.3 degrees, &lt;i&gt;p&lt;/i&gt; = 0.038, respectively).Conclusions: Analysis of RV segmental torsion was feasible using a 2D speckle tracking algorithm. Apical rotation can be used as a simplified index of global RV torsion. Further studies are needed to evaluate the clinical impact of RV torsion in various pathologies.

Prevalence, Determinants, and Prognostic Value of Left Atrial Dysfunction in Patients With Chronic Coronary Syndrome and Normal Left Ventricular Ejection Fraction

Patients with chronic coronary syndrome (CCS), even when they have complete revascularization and normal left ventricular (LV) systolic function, experience subsequent cardiovascular disease (CVD), highlighting the importance of surrogate markers to prevent adverse consequences. Speckle-tracking echocardiography-derived left atrial (LA) reservoir strain has emerged as a sensitive marker for CVD in various clinical settings. The present study investigated the prevalence, determinants, and prognostic value of LA dysfunction in CCS. We included 278 consecutive patients with CCS with completed percutaneous coronary intervention and preserved LV ejection fraction who underwent follow-up echocardiography. Speckle-tracking analysis was performed to assess LA reservoir strain, and LA dysfunction was defined as LA reservoir strain ≤24%. The primary outcome comprised new-onset atrial fibrillation, heart failure hospitalization, acute coronary syndrome, stroke, or all-cause death. At baseline, 28 patients (10.1%) had LA dysfunction. Multivariable analysis identified age, hypertension, LV ejection fraction, and multivessel disease as independent determinants of LA reservoir strain (all p <0.05). During a median follow-up of 4.8 years, the primary outcome occurred in 60 patients (21.6%). LA dysfunction carried a significant risk for primary outcome independent of traditional risk factors, LV parameters, and LA size (adjusted hazard ratio 3.10, p=0.003); the risk increase remained significant even after excluding atrial fibrillation from the primary outcome (adjusted hazard ratio 2.27, p=0.043). In conclusion, approximately 10% of patients with CCS with normal LV ejection fraction had LA dysfunction associated with adverse cardiovascular outcomes. Further studies are needed to explore whether therapeutic interventions affecting LA remodeling may help prevent CVD events.

Accidental coronary artery kinking by leadless pacemaker fixation tine.

We present a case of a 59-year-old woman who presented with a coronary syndrome soon after an uneventful leadless pacemaker (MicraVR™, Medtronic) implantation. A routine postoperative electrocardiogram (ECG) revealed alteration of the baseline ECG (Panel A, left) with appearance of a complete right bundle branch block (RBBB) and ST-segment elevation in V3 (Panel A, middle). She reported intermittent moderate chest pain which worsened in left lateral position. An emergency transthoracic echocardiogram showed minimal pericardial effusion (<0.5 mm) with a normal systolic left ventricular function. A coronary computed tomography angiogram suggested that the septal anchor of the pacemaker partially occluded the distal segment of the left anterior descending (LAD) artery (Panel B). This was associated with enhancement defects on septo-apical and apical segments, consistent with ischaemia. The coronary angiography confirmed the partial LAD kinking in relation to the device anchor which was considered extravascular (Panel C). After patient consent, pacemaker retrieval was successfully performed using a 26Fr Gore DrySeal™ introducer sheath, a 12Fr Cook Performer™ guiding sheath holding an EV3 Amplatz gooseneck Snare of 15 mm. Once the pacemaker was trapped and before applying traction, a 0.14 Asahi FielderXT™ coronary wire was inserted through the lesion, to protect the vessel in case of injury. The coronary integrity was confirmed after device removal (Panel D). The RBBB disappeared 48 h later, leaving a Q wave in lead V3 (Panel A, right). Systematic postoperative ECG is warranted after leadless pacemaker implantation.

Risk factors for the development of premature ventricular complex-induced cardiomyopathy: a systematic review and meta-analysis

BackgroundPremature ventricular complexes (PVCs) are a potentially reversible cause of heart failure. However, the characteristics of patients most likely to develop impaired left ventricular function are unclear. Hence, the objective of this study is to systematically assess risk factors for the development of PVC-induced cardiomyopathy.MethodsWe performed a structured database search of the scientific literature for studies investigating risk factors for the development of PVC-induced cardiomyopathy (PVC-CM). We investigated the reporting of PVC-CM risk factors (RF) and assessed the comparative association of the different RF using random-effect meta-analysis.ResultsA total of 26 studies (9 prospective and 17 retrospective studies) involving 16,764,641 patients were analyzed (mean age 55 years, 58% women, mean PVC burden 17%). Eleven RF were suitable for quantitative analysis (≥ 3 occurrences in multivariable model assessing a binary change in left ventricular (LV) function). Among these, age (OR 1.02 per increase in the year of age, 95% CI [1.01, 1.02]), the presence of symptoms (OR 0.18, 95% CI [0.05, 0.64]), non-sustained ventricular tachycardias (VT) (OR 3.01, 95% CI [1.39, 6.50]), LV origin (OR 2.20, 95% CI [1.14, 4.23]), epicardial origin (OR 4.72, 95% CI [1.81, 12.34]), the presence of interpolation (OR 4.93, 95% CI [1.66, 14.69]), PVC duration (OR 1.05 per ms increase in QRS-PVC duration [1.004; 1.096]), and PVC burden (OR 1.06, 95% CI [1.04, 1.08]) were all significantly associated with PVC-CM.ConclusionsIn this meta-analysis, the most consistent risk factors for PVC-CM were age, non-sustained VT, LV, epicardial origin, interpolation, and PVC burden, whereas the presence of symptoms significantly reduced the risk. These findings help tailor stringent follow-up of patients presenting with frequent PVCs and normal LV function.

Abstract 14070: Role of Early Aortic Valve Replacement versus Conventional Management in Asymptomatic Patients With Severe Aortic Stenosis: A Meta-Analysis

Introduction: Aortic-valve replacement (AVR) is an effective therapy for patients with severe symptomatic aortic stenosis (AS) but the appropriate timing of intervention for asymptomatic patients with severe AS remains controversial. Increased mortality associated with the onset of symptoms challenges the conventional “watchful waiting” strategy followed for this subset of patients. An early intervention may be warranted, however the data supporting this hypothesis is small. Our aim was to perform meta-analysis looking at outcomes of early surgical AVR (SAVR) in asymptomatic severe AS patients with preserved LVEF. Methods: Electronic databases were searched for studies comparing early SAVR and conventional treatment in patients with asymptomatic severe AS and normal LV function. The primary outcome of interest was all cause mortality. Secondary outcome was heart failure hospitalization. Random-effects model was used to estimate the pooled risk ratio (RR), and 95% confidence interval (CI) using Revman 5.4.1. Subgroup analysis stratified by study design was performed. Heterogeneity was assessed by Higgins I 2 statistic. Results: We found total of 8 studies (2 RCTs; 6 observational) from which 2669 patients with asymptomatic severe AS were identified. 1354 underwent SAVR and 1315 were managed conservatively. The mean age was 68 years with mean follow up duration of 4.8±2 years. There was statistically significant reduction in all-cause mortality (RR: 0.37; CI: 0.27-0.50; p&lt;0.05; I2 = 68%) and heart failure hospitalization (RR: 0.24; CI: 0.16-0.36; p&lt;0.05; I2 = 0%) among patients who underwent AVR compared with conservative treatment with subgroup analysis by study design showing similar trends. Conclusion: Our meta-analysis shows that compared with conventional treatment strategy, early SAVR in asymptomatic patients with severe AS is associated with improved long-term outcomes notably reduced all cause mortality and heart failure hospitalizations.

Abstract 13211: Dysregulated Myocardial Calcium Handling is a Driver of Early Heart Failure in Type 1 and Type 2 Diabetes

Introduction: Dysregulated myocardial calcium handling may be a precursor for heart failure in type 1 (T1D) and type 2 diabetes (T2D). Manganese-enhanced magnetic resonance imaging (MEMRI) is a novel non-invasive method of assessing in vivo myocardial calcium handling. Hypothesis Myocardial calcium handling is impaired in patients with either T1D or T2D, despite normal left ventricular (LV) systolic function. Methods Prospective, multicentre, study in patients with T1D (n=19), T2D (n=30), and healthy volunteers (n=28), all of whom were free of known cardiovascular disease. Cardiac MRI was performed including MEMRI, during which T1 mapping was performed at baseline and every 2.5 min for 30 min after manganese infusion (Figure 1a). The rate of myocardial manganese uptake, determined by Patlak modelling [1]. Results No difference in LV systolic function was observed between groups, but those with T2D had more concentric LV remodelling compared to T1Ds and healthy volunteers (LV mass:volume 0.90±0.16 vs. 0.75±0.09 vs. 0.74±0.10 g/mL, respectively; p=0.001, Table 1). Mean myocardial manganese uptake was significantly lower in both T1Ds (6.47±0.99 mL/100g/min) and T2Ds (6.43±0.77 mL/100g/min) compared with healthy volunteers (8.33±0.77 mL/100g/min; p&lt;0.001 for both, Figure 1b). Conclusion For the first time, we have demonstrated that myocardial calcium handling is impaired in patients with either T1D or T2D despite apparently normal LV systolic function. This may be a precursor to the development of diabetic cardiomyopathy and has implications for developing novel therapeutic targets for its prevention and treatment. [1] Skjold, A et al. J Magn Reson Imag 2006;24:1047-1055 graphic_{ECFA3EC4-96D0-4ADC-8599-3D854C84F04F}graphic_{F1770AC6-718C-4C39-B107-4A5DD60957A8}

Abstract 11623: Retrograde Facilitated Antegrade Dissection and Re-Entry

History: A 69-year-old man presented with severe medically refractory stable angina and was referred for revascularization of a right coronary artery (RCA) chronic total occlusion (CTO Figure 1.A ). The patient had undergone coronary artery bypass surgery 16 years prior as well as numerous percutaneous coronary intervention. Echocardiography demonstrated normal left ventricular systolic function. Procedure: Antegrade wiring was attempted first with a Fielder XT guidewire (GW) and a Turnpike Spiral microcatheter (MC Figure 1.B ). Due to the ambiguous proximal cap and long occlusion length, retrograde crossing was attempted next. After attempting to cross multiple collaterals a Sion Black crossed a proximal septal collateral ( Figure 1.C ), but several MCs could not follow the GW, despite ballooning the collateral with a 1.5 mm balloon and GuideLiner support. We switched to antegrade dissection and re-entry with a knuckled Gladius Mongo that reached the distal RCA ( Figure 1.D ). With the Stingray balloon and ‘double blind stick and swap’ technique we crossed into the distal true lumen, but the GW position was lost after removal of the balloon. We crossed with the retrograde GW to the antegrade guide catheter (Figure 1.E) , but ‘tip in’ technique as well as passing the retrograde MC was not successful. Using a new Stingray balloon and the retrograde GW as true lumen marker ( Figure 1.F ) we crossed into the distal true lumen. After drug-eluting stent implantation ( Figure 1.G ) the distal bifurcation was recanalized with kissing balloon dilation ( Figure 1.H ) and implantation of another stent with a nice final result ( Figure 1.I ). Conclusion: Persistence is key in CTO PCI in patients with severe medically refractory stable angina and limited revascularization options. Crossing the collaterals with MC can be challenging: possible solutions are smaller MC, predilation in septal collateral, ‘tip in’ or switching to another crossing strategy such as ADR with retrograde facilitation.

Abstract 10735: Brash Syndrome: Frequently Under-Recognized and Often Confused With Simple Hyperkalemia

Introduction: BRASH syndrome is a relatively newly recognized and under-reported clinical entity characterized by bradycardia, renal dysfunction, atrioventricular node blockade (AVNB), shock, and hyperkalemia. We report a case of BRASH syndrome that was refractory to medical therapy alone, requiring transvenous pacing, hemodialysis, and vasopressor support. Case presentation: An 82-year-old female with hypertension, diabetes, and paroxysmal atrial fibrillation (on metoprolol and verapamil) was found unresponsive at a nursing home. She had refractory shock (99/34 mmHg) and symptomatic bradycardia with heart rate (HR) of 33 BPM. EKG showed atrial fibrillation rhythm with ventricular rate of 31 BMP and peaked T-waves. Labs revealed creatinine of 1.98 mg/dL, potassium of 6.8 mmol/L, and TSH of 2.90 ulU/ml. She had no signs of infection and echocardiogram showed normal left ventricular systolic function. She was intubated for airway protection. AVNB agents were immediately held. Potassium-lowering agents and vasoactive drugs were administered. Temporary transvenous pacemaker was placed due to persistent bradycardia with hemodynamic instability even after transcutaneous pacing. Temporary hemodialysis was started for worsening renal failure and refractory hyperkalemia. She was weaned off vasopressor support, mechanical ventilation, hemodialysis and temporary pacing over the next few days. Renal function improved and HR stabilized at 70 BPM. Discussion: In our case, AVNB agent overdose caused bradycardia which in turn led to decreased cardiac output and renal hypoperfusion. Resultant acute kidney injury led to decreased clearance of renally excreted metoprolol and verapamil and worsening hyperkalemia, which locked the patient in a vicious cycle of BRASH syndrome leading to hemodynamic compromise. Therefore, rapid diagnosis and correct management with transvenous pacemaker and renal replacement therapy are crucial to reduce mortality.