Normal Left Ventricular Systolic Function Research Articles

Abstract 4136274: A Case of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) Complicated by a Ventricular Septal Defect (VSD)

Case: A 69-year-old woman with a history of hypertension and tobacco use disorder presented with acute chest pain. The patient was found to have classic anterior ST elevation myocardial infarction (STEMI) pattern on electrocardiogram (ECG) with high-sensitivity troponin of 12,772 ng/L and was taken emergently to the catheterization laboratory. Coronary angiography showed tortuous coronary vessels though without evidence of obstructive coronary artery disease, plaque rupture, ulceration, dissection, or vasospasm. Transthoracic echocardiogram showed an apical ventricular septal defect (VSD) with normal left ventricular systolic function of 60%. Cardiac computed tomography (CT), confirmed a discrete apical VSD that was 7.93 mm in diameter and multiple small VSDs distally in the septum. Right heart catheterization revealed severe left-to-right shunting with a ratio of pulmonary blood flow to systemic blood flow (Qp:Qs) of 2.8. Early surgical repair of the apical VSD was pursued despite known high operative risk given the hemodynamic significance of the shunt. The patient developed ongoing hemodynamic instability from cardiogenic shock with inability to ween from intra-aortic balloon pump (IABP). Unfortunately, because of the location of the residual VSDs and elevated panel-reactive antibody testing of 98%, the patient was deemed to not be a candidate for percutaneous closure or heart transplantation, respectively. Discussion: An acquired ventricular septal defect (VSD) is a rare and catastrophic complication of myocardial infarction, typically with a culprit obstructive coronary artery lesion identified on coronary angiography. Acquired VSDs in myocardial infarction with nonobstructive coronary arteries (MINOCA) is an even more rare phenomenon. Possible causes include low flow, inflammation, intimal disruption, or vasospasm of coronary arteries. Our case highlights that MINOCA can present with life-threatening complications similar to obstructive STEMI. The timing of intervention and treatment approach of acquired VSDs remains an area of debate. The life-threatening effects of VSDs make it critical to manage in a multidisciplinary manner involving advanced imagers, interventional cardiologists, cardiothoracic surgeons, and heart failure specialists. This case emphasizes the importance of maintaining a high index of suspicion for abnormal coronary anatomy, even in patients with MINOCA, and prompt interdisciplinary decision making to reduce mortality.

Predictive value of total atrial conduction time for developing cerebrovascular stroke in patients with sinus rhythm and normal left ventricular systolic function, a case-control study

Abstract Background Stroke is the second leading cause of death worldwide. Recently, atrial cardiopathy has become recognized as a substantial risk factor for cerebrovascular stroke. Greater LA size is linked to stroke in AF patients, but few data linking LA size to stroke in population with sinus rhythm. Purpose To investigate the value of total atrial conduction time (TACT) measured non-invasively by assessing PA-TDI duration as a predictor of stroke in patients who initially presented with sinus rhythm and have normal LV systolic function. Methods In our case-control study, we included 156 patients with acute ischemic stroke and 50 control subjects all presented in sinus rhythm and normal LV systolic function. All participants underwent echocardiography. The bi-plane modified Simpson's approach was used to determine the LV-EF. The left atrial (LA) diameter was measured also left atrial volume index (LAVI) was assessed. The PA-TDI interval was used to estimate the TACT. In the apical four-chamber view, the pulsed-wave tissue Doppler sample was positioned on the lateral and septal walls of the LA above the mitral annulus. The time between the onset of the P wave (lead II) and the peak of the A' wave was called the PA-TDI interval. Also, speckle tracking indices of LA strain were measured. Results LA volume index was larger in the stroke group (39.24±4 versus 33.6±2.8, p: 0.01), PA-TDI duration showed statistical highly significant difference between both groups (165.94±21.695 versus 99.4±22.960, p: <0.001). There were significantly impaired LAS parameters in the stroke group (LA reservoir, contraction & conduit strain, 22.7%, -6.6% & -16.1% versus 40%, -12%, and − 27% in the control group with P < 0.000). ROC curve showed the best cutoff point for LA volume index is >42.2 ml/m2 for prediction of stroke with area under the curve (AUC): 0.7, p value is 0.005. ROC curve showed the best cutoff point for PA-TDI is >155.5 ms. with AUC: 0.9, 90% sensitivity, 91% specificity, p value: <0.001. ROC curve showed that LA reservoir strain and LA stiffness can independently predict stroke at cut-off values of 30% & 24.5% respectively, P < 0.001. Multivariate logistic regression analysis showed that hypertension, LA volume index, LA stiffness and PA-TDI duration are independent predictors of stroke (p: < 0.05, < 0.05, < 0.01 and < 0.001 respectively). Conclusions The assessment of electromechanical asynchrony by measuring the PA-TDI duration may help to predict patients at risk for stroke. It is easy to measure without the need for special software like speckle tracking indices. We also advise patients who exceed the cutoff points of LA volume index and PA-TDI duration to receive antithrombotic therapy for better stroke prevention. Also we recommend adding PA-TDI to CHA2DS2-VASC-HSF score to assess stroke risk in patients with sinus rhythm and paroxysmal AF during their sinus rhythm intervals.

What characterizes normotensive individuals with obesity and normal systolic heart function? A descriptive study from the SCAPIS cohort

Abstract Background Heart failure and cardiovascular disease are strongly related to obesity, and the incidence of these conditions shows a linear relationship with increasing body mass index (BMI). Despite these known facts, some individuals with obesity show no clinical signs of heart disease or arterial hypertension (AH). Purpose We aimed to investigate the characteristics of individuals with obesity without impaired left ventricular function and left ventricular hypertrophy (termed systolic heart function, SHF) and AH, compared to individuals with obesity with signs of impaired SHF or AH, and individuals without obesity with and without signs of impaired SHF or AH. Method A cross-sectional analysis was performed of the 4,692 individuals who had undergone a transthoracic echocardiography within the Swedish CArdioPulmonary bioImage Study (SCAPIS). Participants were divided into four groups: 1) individuals with obesity (BMI³30 kg/m2) without impaired SHF (normal left ventricular systolic function and left ventricular mass) and no AH (based upon the absence of antihypertensive treatment) (ObSHF/AH-, n=623; 13%), 2) individuals with obesity with impaired SHF or AH (ObSHF/AH+, n=252; 5%), 3) individuals without obesity and without impaired SHF and no AH (NObSHF/AH-, n=3179; 68%) and 4) individuals without obesity with impaired left ventricular systolic function, left ventricular hypertrophy or AH (NObSHF/AH+, n=638; 14%). Individuals in group 1 (ObSHF/AH-;) were compared to those in groups 2-4 through descriptive analyses. Results Compared to ObSHF/AH+ individuals, ObSHF/AH- subjects showed significantly lower HbA1c (p<0.001), fasting plasma glucose (p<0.001), triglyceride (p<0.001), NT-proBNP (p=0.035) and troponin I (p<0.001) levels. Furthermore, no significant differences between the two obese groups could be seen regarding BMI (p=0.074), whereas waist-to-hip ratio was lower in ObSHF/AH- subjects (p<0.001). ObSHF/AH- individuals had higher glucose and lipid levels as well as higher blood pressure than individuals without obesity. Interestingly, no differences were seen between ObSHF/AH- and NObSHF/AF- subjects regarding NT-proBNP (p=0.864) and troponin I levels (p=0.110). Furthermore, left ventricular mass index (LVMI) was significantly higher in ObSHF/AH- subjects compared to NObSHF/AH- individuals (73.8 vs. 72.1 g/m2, p=0.015) and the ejection fraction was significantly lower (57.4 vs. 59.6 %, p<0.001). Conclusion When ObSHF/AH- and NObSHF/AH- subjects were compared, markers of cardiac damage/remodeling did not differ significantly, indicating that heart function might be preserved despite a worsened metabolic profile and an obese phenotype, through putative protective mechanisms yet to be explored. However, parameters of SHF were unfavorable for ObSHF/AH- when compared to NObSHF/AH-, further implicating preclinical cardiac impairment in individuals with obesity.

Post-Exercise Syncope in a Previously Healthy 67-Year-Old Man: The Bezold–Jarisch Reflex and the Role of Autonomic Nervous System Dysfunction

A 67-year-old man started treatment due to frequent asymptomatic premature ventricular complexes (PVCs) accidentally being registered during a preventive examination by a specialist, because of which he was referred to cardiologist. During the initial 24-hour (h) ECG monitoring, 4.5% PVCs and one episode of asymptomatic non-sustained ventricular tachycardia (NSVT) with three PVCs in row, at a frequency of 150 beats per minute (bpm), were detected. After the introduction of beta blockers into therapy, a lower number of PVCs, without NSVT, were recorded in the control 24 h Holter ECG, while transthoracic echocardiography (TTE) showed normal left ventricular (LV) systolic function without cardiomyopathy. So, an exercise test was indicated, and it was interrupted in the third minute at 120 beats per minute (bpm) due to fatigue and pain in the hips, without malignant arrhythmias, angina or dyspneic complaints. During the rest period, a significant inferolateral depression of the ST junction was observed, which recovered in the ninth minute. Immediately after the ECG monitoring stopped, the patient lost consciousness; his pulse was not palpable, but breathing was audible, so cardiac massage was started. After he had regained consciousness, the ECG showed alternating sinus and junctional rhythm with the lowest frequency of 33 bpm, which was accompanied by marked hypotension (80/50 mmHg). The patient was immediately hospitalized; coronary angiography and repeated TTE were completely normal, while continuous ECG monitoring did not confirm malignant rhythm disorders or asystole. It was concluded that it was vasovagal syncope (VVS), most likely caused by the Bezold–Jarisch reflex (BJR).

Assessment of Biventricular Systolic and Diastolic Function Using Conventional and Strain Echocardiography in Children with Sickle Cell Disease Surviving 1-year After Hematopoietic Stem Cell Transplant.

Hematopoietic stem cell transplant (HSCT) is a potentially curative therapy for children with sickle cell disease (SCD). The effects of HSCT on ventricular function are not well characterized in children with SCD. Echocardiograms from children with SCD who underwent HSCT between 2007 and 2017 were retrospectively analyzed before and 1-year after HSCT. Left ventricular (LV) volumes, mass, and ejection fraction were calculated by the 5/6 area*length method. LV end-diastolic and systolic dimensions, septal, and posterior wall thickness, and fractional shortening were measured by M-mode. Mitral and tricuspid inflow Dopplers (E and A waves) as well as mitral, tricuspid, and septal tissue Dopplers (E', A') were assessed. E/A, E'/A' and E/E' ratios were calculated. Biventricular strain imaging was performed using speckle-tracking echocardiography. Peak global systolic longitudinal and circumferential LV strain, and global longitudinal right ventricular strain, as well as early and late diastolic strain rate, were measured on LV apical 4-chamber, LV short-axis mid-papillary, and RV apical views, respectively. Forty-seven children (9.7 ± 5.5years, 60% male) met inclusion criteria. Pre-HSCT, subjects had mild LV dilation with normal LV systolic function by conventional measure of ejection fraction and fractional shortening. There was a significant reduction in LV volume, mass, and ejection fraction after HSCT, but measurements remained within normal range. LV longitudinal and circumferential strain were normal pre-HSCT and showed no significant change post-HSCT. RV strain decreased after HSCT, but the absolute change was small, and mean values were normal both pre- and post-HSCT. Conventional measures of diastolic function were all normal pre-HSCT. Post-HSCT there was a reduction in select parameters, but all parameters remained within normal range. Early and late diastolic strain rate parameters showed no significant change from pre- to post-HSCT. At one-year after HSCT in children with SCD conventional measures of systolic and diastolic function are within normal limits. Except for a small decrease in RV systolic strain with values remaining within normal limits, systolic strain and diastolic strain rate values did not significantly change 1-year after HSCT.

Prognostic Value of Echocardiographic-derived Stroke Volume in Severe Primary Mitral Regurgitation.

Studies have demonstrated the importance of forward flow, and specifically of stroke volume (SV) and SV index (SVI), as prognostic markers in different cardiovascular diseases. Here we aimed to evaluate the association between SV and SVI thresholds and prognosis in patients with severe primary mitral regurgitation (MR). The association between either SV (<55, 55-70 and >70ml) or SVI (<30, 30-35 and >35mL/m²) thresholds and all-cause mortality and heart failure (HF) hospitalizations was examined in a retrospective analysis of 283 patients (60% male, median age 70 years, IQR 58-82) with severe primary MR, normal left ventricular size and systolic function and no other significant left-sided valvular abnormalities. Compared with normal values, SV<55ml was found to be associated with worse outcomes (HR 1.8, IQR 1.1-2.8, P=0.016), whereas SV between 55-70ml was not. A non-significant trend for worse outcomes was noted for SVI<35ml/m² compared with normal SVI. In patients with severe primary MR, SV<55ml was found to be associated with increased rates of HF hospitalization and all-cause mortality. This easily obtainable parameter may allow for better risk stratification of patients with primary MR.

Aortic valve replacement vs. conservative treatment in asymptomatic severe aortic stenosis: long-term follow-up of the AVATAR trial.

The question of when and how to treat truly asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function is still subject to debate and ongoing research. Here, the results of extended follow-up of the AVATAR trial are reported (NCT02436655, ClinicalTrials.gov). The AVATAR trial randomly assigned patients with severe, asymptomatic AS and LV ejection fraction ≥ 50% to undergo either early surgical aortic valve replacement (AVR) or conservative treatment with watchful waiting strategy. All patients had negative exercise stress testing. The primary hypothesis was that early AVR will reduce a primary composite endpoint comprising all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure (HF), as compared with conservative treatment strategy. A total of 157 low-risk patients (mean age 67 years, 57% men, mean Society of Thoracic Surgeons score 1.7%) were randomly allocated to either the early AVR group (n = 78) or the conservative treatment group (n = 79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18/78 patients (23.1%) in the early surgery group and in 37/79 patients (46.8%) in the conservative treatment group [hazard ratio (HR) early surgery vs. conservative treatment 0.42; 95% confidence interval (CI) 0.24-0.73, P = .002]. The Kaplan-Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early surgery compared with the conservative group (HR 0.44; 95% CI 0.23-0.85, P = .012, for all-cause death and HR 0.21; 95% CI 0.06-0.73, P = .007, for HF hospitalizations). The extended follow-up of the AVATAR trial demonstrates better clinical outcomes with early surgical AVR in truly asymptomatic patients with severe AS and normal LV ejection fraction compared with patients treated with conservative management on watchful waiting.

Resting Global Longitudinal Strain as a Noninvasive Diagnostic Tool in Predicting Significant Coronary Artery Disease in Patients with Non-ST-Elevation MI and Normal Left Ventricular Systolic Function on Echocardiography

Objectives: This study aimed to assess the relationship between resting global longitudinal strain (GLS) and significant coronary artery disease (CAD) in patients with Non-ST Elevation Myocardial Infarction (NSTEMI) and normal ejection fraction (EF). Methodology: We enrolled 108 patients with NSTEMI and normal EF in this observational cross-sectional study. Resting GLS was measured, and coronary angiography was performed to assess CAD. The relationship between significant CAD and GLS was analyzed using the chi-square test. The specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of GLS in predicting CAD were calculated. Results: The mean age of the patients was 49.05 ± 7.28 years. The study had a male predominance. Diabetes was present in 30 patients (27.8%), hypertension in 31 patients (28.7%), dyslipidemia in 19 patients (17.6%), and 65 patients (60.2%) were smokers. Normal strain was observed in 36 patients (33.3%), while 72 patients (66.7%) had reduced strain. Significant CAD was present in 72 patients (66.7%). The p-value for the association between significant CAD and reduced GLS was &lt;0.01. The sensitivity, specificity, and accuracy of GLS in predicting CAD were 91.7%, 83.3%, and 88.9%, respectively. Conclusion: GLS can effectively predict the presence of significant CAD in patients with NSTEMI and normal left ventricular systolic function on echocardiography.

Aortic Valve Stenosis Causes Accumulation of Extracellular Hemoglobin and Systemic Endothelial Dysfunction.

Whether aortic valve stenosis (AS) can adversely affect systemic endothelial function independently of standard modifiable cardiovascular risk factors is unknown. We therefore investigated endothelial and cardiac function in an experimental model of AS mice devoid of standard modifiable cardiovascular risk factors and human cohorts with AS scheduled for transcatheter aortic valve replacement. Endothelial function was determined by flow-mediated dilation using ultrasound. Extracellular hemoglobin (eHb) concentrations and nitric oxide (NO) consumption were determined in blood plasma of mice and humans by ELISA and chemiluminescence. This was complemented by measurements of aortic blood flow using 4-dimensional flow acquisition by magnetic resonance imaging and computational fluid dynamics simulations. The effects of plasma and red blood cell (RBC) suspensions on vascular function were determined in transfer experiments in a murine vasorelaxation bioassay system. In mice, the induction of AS caused systemic endothelial dysfunction. In the presence of normal systolic left ventricular function and mild hypertrophy, the increase in the transvalvular gradient was associated with elevated eryptosis, increased eHb, and increased plasma NO consumption; eHb sequestration by haptoglobin restored endothelial function. Because the aortic valve orifice area in patients with AS decreased, postvalvular mechanical stress in the central ascending aorta increased. This was associated with elevated eHb, circulating RBC-derived microvesicles, eryptotic cells, lower haptoglobin levels without clinically relevant anemia, and consecutive endothelial dysfunction. Transfer experiments demonstrated that reduction of eHb by treatment with haptoglobin or elimination of fluid dynamic stress by transcatheter aortic valve replacement restored endothelial function. In patients with AS and subclinical RBC fragmentation, the remaining circulating RBCs before and after transcatheter aortic valve replacement exhibited intact membrane function, deformability, and resistance to osmotic and hypoxic stress. AS increases postvalvular swirling blood flow in the central ascending aorta, triggering RBC fragmentation with the accumulation of hemoglobin in the plasma. This increases NO consumption in blood, thereby limiting vascular NO bioavailability. Thus, AS itself promotes systemic endothelial dysfunction independent of other established risk factors. Transcatheter aortic valve replacement is capable of limiting NO scavenging and rescuing endothelial function by realigning postvalvular blood flow to near physiological patterns. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT05603520 and NCT01805739.

Comparing Left Bundle Branch Area vs Right-Ventricular Septal Pacing in High-Degree Conduction Disease After Transcatheter Aortic Valve Replacement: Randomized Trial Study Protocol

Left bundle branch area pacing (LBBAP) is a novel method of conduction-system pacing in the muscular interventricular septum. Although LBBAP has been shown to produce physiologic electrical and mechanical intraventricular synchrony, superiority of LBBAP, compared to right ventricular septal pacing (RVSP) at preserving normal left-ventricular (LV) systolic function after transcatheter aortic valve replacement (TAVR) has not been demonstrated. Left Bundle BRAVE is an investigator-initiated, multicentre, prospective, double-blinded, randomized, crossover study investigating the superiority of LBBAP, compared to RVSP, with respect to preservation of systolic function in patients with high-degree conduction disease after TAVR. Adults with severe aortic stenosis and normal systolic function who sustain high-grade atrioventricular block within 4 weeks of TAVR are eligible. All subjects receive a biventricular pacemaker generator with RVSP, and LBBAP leads. Participants are randomly assigned to 9 months of each pacing mode, in series. The primary endpoint is change in global longitudinal strain, tested in series with change in LV ejection fraction, comparing RVSP to LBBAP. Secondary endpoints include the following: echocardiographic markers of interventricular synchrony and right ventricular performance; heart failure functional status and symptom classification; 6-minute walk test results; pacemaker and lead performance; and brain natriuretic peptide concentration. The Left Bundle BRAVE study is designed to identify an upstream and clinically relevant marker of superiority in LBBAP, compared to RVSP, at preventing deterioration of LV function in patients with a high ventricular pacing burden after TAVR. ClinicalTrials.gov identifierNCT05541679

MYOCARDIAL INFARCTION DUE TO LEFT CIRCUMFLEX ARTERY OCCLUSION: A SUBTLE TROJAN HORSE

Abstract A 47–year–old man presented to the emergency department complaining of recurrent chest pain (CP) since the previous day. His medical history included active smoking and dyslipidemia. The ECG revealed sinus bradycardia (56 bpm) with widespread ST elevation, consistent with benign early repolarization, and hyperacute and broad–based T waves in V2–V3 (Fig. A). The echocardiography showed normal left and right ventricular systolic function and no valvular abnormalities. A low but abnormal initial high–sensitivity cardiac troponin I value (40 pg/mL, normal range: 1.7– 34,2 pg/mL) and a slightly and early increase after two hours (52 pg/ml) were seen. Therefore, the patient was admitted to our intensive cardiac care unit (ICCU) with a working diagnosis of non–ST–segment elevation myocardial infarction (NSTEMI). No sign or symptoms of heart failure on physical examination were recorded. GraceScore 2.0 was calculated as 68 points and coronary angiography was organized within 24h. Two hours after admission to the ICCU, the patient experienced a new episode of CP. Consequently, ECG and echo were repeated. Compared to the previous results, ECG showed dynamic changes in V2–V3, with the resolution of hyperacute T waves (Fig B); bedside echo remained unchanged. Considering the unresponsiveness to nitrate therapy, the cath lab was activated for a time–dependent coronary angiography. The exam showed an acute total thrombotic occlusion of the mid–segment of the circumflex branch (LCx) in the setting left–sided dominant circulation. A drug eluting stent was deployed into the culprit lesion (Fig. C), and the coronary flow was restored completely (TIMI Flow 3). The subsequent hospital stay proceeded without complications. The peak troponin level was 60’000 pg/ml. The patient was discharged on the fifth day, asymptomatic and hemodynamically stable, with instructions to continue dual antiplatelet therapy. The case report focuses on the electrocardiographic and angiographic expression of LCx total occlusion. Despite acute myocardial infarction (AMI) size was large, as confirmed by the abnormal troponin I values and the angiographic total occlusion, the first and the repeated ECGs showed only vague repolarization changes without clear ST–segment modifications. LCx occlusion is often characterized by the absence of significant ST–elevation, therefore categorized as NSTEMI. Greater awareness of the presentation of LCx–related AMI can be crucial to avoid delays in reperfusion.

LEFT BUNDLE BRANCH BLOCK AND ACUTE CORONARY SYNDROME: WHAT IS THE ROLE OF MODIFIED SGARBOSSA–SMITH CRITERIA AND THE WELLENS‘ PATTERN?

Abstract A 55–year–old man presented to the emergency room with intermittent chest pain that started the day before. His medical history included hypertension, and dyslipidemia. The initial electrocardiogram (ECG) showed sinus rhythm (75 bpm) with pre–existing left bundle branch block (LBBB), without modified Sgarbossa–Smith criteria, despite the hyperacute appearance of T waves in V2–V4 (Fig. 1). Additionally, there were alterations in ventricular repolarization in the lateral region, morphologically not fully justifiable by the mentioned conduction delay. Echocardiography revealed normal left and right ventricular systolic function and no valvular abnormalities. Laboratory tests showed a pathological release of myocardial necrosis enzymes, with a typical rise–and–fall curve (10 pg/mL, 100 pg/mL, 200 pg/mL; normal range: 1.7–34.2 pg/mL). Therefore, the patient was admitted to the intensive cardiac care unit (ICCU) with a working diagnosis of non–ST–segment elevation myocardial infarction (NSTEMI). There were no recurrent angina episodes or signs/symptoms of heart failure on physical examination. During hospitalization, ECG and echocardiography were repeated. The follow–up ECG (12 hours after admission) showed persistent LBBB with biphasic T waves in leads V2–V5 with slight negative deflection at the end. This T wave abnormality can be interpreted as Wellens’ ECG Type A (Fig. 3A). The echocardiogram remained unchanged. Consequently, the catheterization lab was activated for urgent coronary angiography. The examination revealed subocclusion of the mid–segment of the left anterior descending artery (LAD). A drug–eluting stent was deployed in the culprit lesion (Fig. 2), restoring coronary flow completely (TIMI Flow 3). The subsequent hospital stay proceeded without complications. The ECG performed before discharge showed a typical LBBB, with normalization of T waves in precordial leads (Fig 3B). The presented case is about ECGs containing a pre–existing LBBB pattern in a patient with chest pain. The modified Sgarbossa–Smith criteria were not met in either the first recorded ECG or the second, whereas Wellens’ signs were detectable. Wellens’ syndrome can be diagnosed in a case of LBBB and help detect a high–grade LAD stenosis even if modified Sgarbossa–Smith criteria are not met.

Association of Cumulative Systolic Blood Pressure With Left Atrial Function in the Setting of Normal Left Atrial Size: The Atherosclerosis Risk in Communities (ARIC) Study

Lower left atrial (LA) function is associated with increased risk for cardiovascular disease events; data on risk factors for impaired LA function are limited. We evaluated the effect of cumulative systolic blood pressure (cSBP) from midlife to older age on LA strain in adults with normal LA size. We included participants in the Atherosclerosis Risk in Communities study with LA strain measured on the visit 5 echocardiogram (2011-13), excluding those with atrial fibrillation and LA volume index >34mL/m2. The cSBP was calculated from visit 1 (1987-89) through visit 5. Linear regression models were used to evaluate associations between cSBP and LA strain measures. A total of 3,859 participants with a mean (SD) age of 75.2 (5.0) years were included in the analysis; 725 (18.8%) were Black and 2,342 (60.7%) were women. After adjusting for demographics, cardiovascular disease risk factors, heart failure, and coronary heart disease, each 10mm Hg increase in cSBP was associated with 0.32% (95% CI, -0.52%, -0.13%) and 0.37% (95% CI, -0.51%, -0.22%) absolute reduction in LA reservoir and conduit strain, respectively. Associations were attenuated after adjustment for left ventricular (LV) systolic and diastolic function and mass (-0.12%: 95% CI, -0.31, 0.06 for reservoir strain; and -0.24%: 95% CI -0.38%, -0.10% for conduit strain). In subgroup analyses, the association of cSBP with conduit strain was statistically significant among those with normal LV systolic and diastolic function. Cumulative exposure to elevated blood pressure from midlife to late life was modestly associated with lower LA reservoir and conduit strain in older adults with normal LA size, mostly related to the effect of blood pressure on LV function and mass. However, the association of cSBP and LA conduit strain in subgroups with normal LV function suggests that LA remodeling in response to hypertension occurs before LV dysfunction is detected on echocardiography.

Prevalence and prognosis of hyperdynamic left ventricular systolic function in septic patients: a systematic review and meta-analysis

PurposeThe prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis.MethodsWe searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e’ ratio.ResultsFour studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e’ (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: − 0.21 cm [95%CI − 0.33, − 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function.ConclusionThe prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function.

Characteristics of Patients With Acute Coronary Syndrome and Normal Electrocardiogram.

Patients with acute coronary syndrome (ACS) and normal electrocardiogram (ECG) may have an increased risk of late diagnosis and complications of the disease. To study the demographic, angiographic and echocardiographic characteristics of patients hospitalized for ACS in whom the ECG was normal on admission to the hospital. This retrospective study included patients who were hospitalized for ACS without ST-elevation between 2015 and 2023 and who had coronary artery disease (CAD) confirmed by coronary angiography. By further inspection of the electronic databases, patients with ACS who had a normal ECG on admission were filtered out and analyzed separately. Of the total 3137 patients with suspected ACS without ST-elevation, 129 patients (4.1%) were diagnosed as having ACS with a normal ECG. In three patients a non-atherosclerotic cause for the ACS was found. A significantly higher proportion of patients had single-vessel (54.3%) compared to two-vessel (29.5%) and three-vessel (14%) CAD. In addition to a normal ECG, 5.7% of patients with single-vessel CAD and 3.5% of patients with multi-vessel CAD had normal troponin levels and normal regional LV systolic function on echocardiography. Less than 5% of hospitalized patients with ACS without ST-elevation had a normal ECG on admission. The majority of these patients have single-vessel CAD. In about 5% of patients with single-vessel CAD, neither elevated troponin levels nor LV asynergy are detected.

Association of Atrial Fibrillation Progression With Left Atrial Functional Reserve and Its Reversibility.

Atrial fibrillation (AF) progression is closely related to heart failure occurrence, and catheter ablation carries a beneficial effect for heart failure prevention. Recently, particular attention has been given to left atrial (LA) function and functional reserve in the pathogenesis linking AF and heart failure, although its significance and reversibility is not well studied. We prospectively investigated 164 patients with AF with normal left ventricular systolic function and free from heart failure who underwent first catheter ablation and pre-/postprocedural echocardiography. Conventional and speckle-tracking echocardiography were performed at rest and during passive leg lifting to assess LA size, LA reservoir strain (LARS), and functional reserve calculated as passive leg lifting-LARS - rest-LARS. Patients were categorized into 3 AF subtypes: paroxysmal AF (N=95), persistent AF (PeAF; N=50), and long-standing persistent AF (LS-PeAF; N=19). The PeAF and LS-PeAF groups had larger LA size and reduced LARS compared with the paroxysmal AF group (all P<0.05). LA functional reserve was significantly impaired in the LS-PeAF group (P=0.003). In multivariable analysis, LS-PeAF and advanced age were significantly associated with impaired LA functional reserve. Among 149 patients with sinus rhythm 1 to 2 days after catheter ablation, LARS was significantly improved in both PeAF and LS-PeAF groups but was still lower than that in the paroxysmal AF group. Sinus rhythm restoration also led to amelioration of LA functional reserve in patients with LS-PeAF. AF progression was related to impaired LARS and LA functional reserve, and restoration of sinus rhythm might contribute to early LA reverse remodeling.

Pulmonary Embolism Successfully Treated with Tenecteplase: A case report

Acute pulmonary embolism is a life-threatening situation when presenting with hypotension is called high-risk (massive) pulmonary embolism (PE) which is associated with mortality, especially if there is hemodynamic instability, right ventricular dysfunction with thrombus. Thrombolytic therapy can be lifesaving and leads faster improvement in hemodynamics in patients with acute pulmonary embolism and cardiogenic shock which accelerates the resolution of thrombus, reduction of RV dilatation, mortality and recurrent PE. Only three fibrinolytic agents namely Recombinant tissue-type plasminogen activator (rtPA), Streptokinase and Urokinase have been approved in the treatment of PE. We report the case of a 64 years old Bangladeshi female with a history of immobilization due to unilateral cut injury of foot, who presented with shortness of breath and intermittent chest pain for a duration of 7 days during OPD visit. ECG showed sinus tachycardia (HR-120bpm, regular) and poor progression of R wave. Echocardiography revealed dilated RV, PA with RV dysfunction, presence of McConnell’s sign, RV apical &amp; PA thrombus, flattened IVS, PHT, and minimal pericardial effusion, normal LV systolic function which was reported as suspected pulmonary embolism. Urgent hospitalization and CT pulmonary angiogram (CTPA) was done for confirmatory diagnosis which revealed large pulmonary thrombus in both right and left pulmonary artery. Thrombolysis with Tenecteplase (100ml) over 2 hours was started immediately along with intravenous normal saline and norepinephrine for hypotension, although, it was not recommended by the European Society of Cardiology (ESC) guideline, resulting a successful resolution of the PA thrombus and clinical improvement. She was discharged with oral anticoagulant Rivaroxaban. Bangladesh Heart Journal 2023; 38(2): 148-154

Ultrasound Findings with Bedside Ultrasound of Heart Failure with Preserved LVEF

Heart failure with preserved ejection fraction (HFpEF), formerly termed diastolic heart failure, constitutes nearly half the heart failure cases. Patients may exhibit acute heart failure symptoms, yet bedside echocardiograms might indicate normal left ventricular systolic function, potentially leading to the premature exclusion of heart failure as a differential diagnosis. This review delves into fundamental echocardiographic principles associated with diastolic dysfunction, crucial for recognition in HFpEF patients. Specifically, it explores the VALVE protocol, a stepwise approach tailored for the exigent nature of emergency departments. Acquiring accurate imaging windows in acutely ill patients poses a challenge, emphasizing the significance of precise measurements to avoid errors. Techniques such as E-point septal separation (EPSS) must be meticulously positioned for ejection fraction determinations. The discussion focuses on key metrics outlined in the VALVE protocol, encompassing ventricular function, annular tissue Doppler imaging (TDI) measurements, left atrium volume, mitral valve velocities, and the E/e0 ratio as indicators of diastolic dysfunction in HFpEF.

Coronary flow reserve predicts response to anti-ischaemic therapy in patients with angina with non-obstructive coronary arteries

Abstract Background Half of all patients with angina have non-obstructive coronary arteries (ANOCA) and therapy is often empirical. The CorMicA trial showed improved symptom scores with a physiology-guided approach but the mechanistic relationship between physiological classification and outcome remains unclear. Purpose To assess if invasively assessed coronary flow reserve (CFR) can predict change in exercise time (ET) and angina-specific quality of life (QOL) in response to anti-ischaemic therapy in patients with ANOCA. Methods Prospective, randomised, crossover trial of consecutively evaluated patients with ANOCA. Inclusion criteria: (i) typical and limiting angina; (ii) non-obstructive coronary arteries (fractional flow reserve &amp;gt;0.80); (iii) normal left ventricular systolic function. Coronary physiological assessment was performed using a pressure and Doppler dual sensor-tipped wire in the left anterior descending artery and microvascular dysfunction defined a priori as CFR&amp;lt;2.5 in response to intravenous Adenosine. Patients, clinicians, and researchers were blinded to coronary physiology data. All patients were then sequentially treated with Amlodipine and Ranolazine (in a randomised order), in 4 week blocks with 1 week washout (Figure 1). The outcome measures are 1) Primary (objective): change in ET on exercise stress testing and 2) Secondary (subjective): change in angina-specific QOL on Seattle Angina Questionnaire (SAQ). Data are presented as mean±SD or median (IQR). Results Sixty-six patients with ANOCA were enrolled into the study [62±8 years, 64% females, CCS 3 (2, 3)]; eight patients were excluded. Forty patients had an impaired CFR (2.0±0.3), whilst 18 patients had normal CFR (3.1±0.6), with similar baseline ET (324±133 vs 321±136 seconds, respectively; p=0.94). Patients with an impaired CFR improved their exercise capacity with Ranolazine (ΔET 70±108 seconds; p&amp;lt;0.01) and Amlodipine (ΔET 70±82 seconds; p&amp;lt;0.01). However, there was no such improvement in patients with normal CFR, with either Ranolazine (ΔET 16±88 seconds; p=0.49) or Amlodipine (ΔET 21±59 seconds; p=0.18) (Figure 2). There was no evidence of a training effect (ΔET between visit 1 and visit 4 was 15±112 seconds; p=0.57). Angina-specific QOL improved in patients with impaired CFR [Ranolazine ΔSAQ 12±18 (p&amp;lt;0.01) and Amlodipine ΔSAQ 8±13 (p&amp;lt;0.01)]; the change in SAQ was less marked in patients with normal CFR [Ranolazine ΔSAQ 7±14 (p=0.07) and Amlodipine ΔSAQ 6±10 (p=0.03)]. Conclusion Patients with impaired CFR demonstrated an improved exercise capacity, whereas patients with normal CFR did not. CFR-guided management of ANOCA is likely to be superior to an empirical strategy. This type of physiology-blinded study design could act as a template for future therapy trials in patients with stable angina.Study design for therapeutic trialResponse to anti-ischaemic therapy

Association of subclinical left ventricular systolic dysfunction detected on 2d echocardiogram global longitudinal strain and in-hospital adverse clinical outcomes in covid 19 patients

Abstract Introduction There are no standardized recommendations regarding the cardiovascular evaluation of patients hospitalized with COVID-19. Transthoracic echocardiography remains a useful imaging modality for patients with COVID-19. Normal left ventricular ejection fraction (LVEF) may not be a reliable parameter for the sole assessment of LV systolic function in COVID-19 patients. LV-GLS can evaluate subclinical impairment of myocardium earlier and more accurately as well as myocardial dysfunction than the conventional echocardiography. Purpose To determine the association of LV-GLS on transthoracic 2D echocardiogram (TTE) with heart failure, ACS and arrhythmia, length of hospital stay among patients with COVID-19. Methods This was a retrospective, analytical, observational, cross-sectional study involving COVID-19 patients admitted at a tertiray hospital who underwent transthoracic 2D echocardiographic examination with normal left ventricular systolic function. Results We analyzed 449 COVID-19 patients, in whom 253 patients had normal LV-GLS and 196 patients had abnormal LV-GLS. The mean age in years was 64 with male dominance (55.68 % vs 44.32%). There were more males in the abnormal LV-GLS group (61.22% vs 51.38%, p=.044). In terms of COVID-19 severity, many patients had severe infection (42.09%), while the rest had mild (4.9%), moderate (21.38%) and critical (31.63%) infection. Many patients also had abnormal BMI of 25-29.9 kg/m2 (40.09%). The top two most common comorbidities were hypertension and diabetes mellitus. Majority (89.09%) never smoked while for the 49 patients who were former/current smokers, their median cigarette consumption was 20 pack years. Most of the patients were taking maintenance medications (68.6%) and had COVID-19 medications (91.76%). The prevalence of subclinical left ventricular systolic dysfunction among patients with COVID-19 was 43.7% (95% CI [39.0% to 48.4%]). There is no evidence of acute myocardial infarction (OR 1.29, 95% CI 018-9.27, p = 0.79), overt left systolic dysfunction (OR 2.60, 95% CI 0.23-28.86, p = 0.437), or longer hospital stay (average 11 days [7-19] p = 0.830) among patients with abnormal LV-GLS. However, abnormal LV-GLS is associated with incidence of arrhythmias requiring intervention (OR 2.00, 95% CI 1.14-3.51, p = 0.015). Arrhythmia was associated with age, COVID-19 severity, and LV-GLS. For every unit increase in age, the odds of arrhythmia increase by 5% (aOR 1.02-1.08, p &amp;lt; 0.001). Patients with critical COVID were about 18 times more likely to have an arrhythmia (aOR 17.94, 95% CI 5.21 -61.74, p&amp;lt;.001), while those abnormal GLS were twice as likely to have arrhythmia (aOR 2.32, 95% CI 1.22-4.40, p = 0.01). Conclusion The prevalence of subclinical left ventricular systolic dysfunction in COVID-19 patients was at 43.7% which was significantly associated with arrhythmias requiring treatment. Age, COVID severity, obesity, and abnormal GLS were associated with COVID 19 mortality.Patient characteristic with mortalityPredictors of mortality