Preserved Left Ventricular Function Research Articles

Impact of Anatomical and Viability-guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy.

Complete revascularization of coronary disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function. To identify the impact of complete revascularization in patients with severe LV dysfunction. Patients enrolled in the REVIVED-BCIS2 trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo) respectively, where RIcoro=[change in BCIS Jeopardy Score (BCIS-JS)] / [baseline BCIS-JS] and RImyo=[number of revascularized viable segments] / [ number of viable segments supplied by diseased vessels]. The PCI group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure. Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX scores were 8 (6 to 10) and 22 (15 to 29) respectively. In those assigned to PCI, median RIcoro and RImyo values were 67% and 85%. Compared to the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those receiving complete anatomical or viability-guided revascularization (HR 0.90, 95% CI 0.62-1.32 and HR 0.95, 95% CI 0.66-1.35 respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome. In patients with severe left ventricular dysfunction, neither complete anatomical nor viability-guided revascularization were associated with improved event-free survival compared to incomplete revascularization or treatment with medical therapy alone.

Changes in Cardiac Function Following Fulminant Myocarditis.

The natural history of myocardial dysfunction in patients with fulminant myocarditis is poorly understood. This study aims to evaluate changes in cardiac function in patients with fulminant myocarditis using a nationwide registry in Japan. This retrospective cohort study included patients with biopsy-proven fulminant myocarditis and available for left ventricular ejection fraction (LVEF). We described the LVEF on admission, at discharge, and 1 year after discharge. We divided patients into 2 groups based on LVEF at discharge (reduced ejection fraction of <50% or preserved ejection fraction of ≥50%) and analyzed changes in LVEF and prognosis according to groups. We included 214 patients (the median [first-third quartiles] age of the cohort was 48 [35-62] years, and 63 [38%] were female). Of 153 patients available for LVEF at 1 year, the median (first-third quartiles) LVEF increased from 33% (21-45%) on admission to 59% (49-64%) at discharge and further to 61% (55-66%) at 1 year. Of 153 patients, 45 (29%) and 22 (14%) had LVEF <50% at discharge and at 1 year, respectively. Comparisons between patients with LVEF <50% and those with LVEF ≥50% demonstrated that the former group had a higher adjusted probability of death or heart transplantation (hazard ratio, 8.19 [95% CI, 2.13-31.5]; P=0.002). Some patients with fulminant myocarditis had left ventricular dysfunction in the chronic phase. Patients with reduced left ventricular function at discharge had a worse prognosis than those with preserved left ventricular function. URL: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000045352; Unique identifier: UMIN000039763.

The Evolving Concept of Secondary Mitral Regurgitation Phenotypes: Lessons From the M-TEER Trials.

Conflicting results from 2 randomized clinical trials of transcatheter mitral valve edge-to-edge repair in secondary mitral regurgitation (SMR) have led to the recognition that SMR is a heterogeneous disease entity presenting with different functional and morphological phenotypes. This review summarizes the current knowledge on SMR caused primarily by atrial secondary mitral regurgitation (aSMR) and ventricular SMR pathology. Although aSMR is generally characterized by severe left atrial enlargement in the setting of preserved left ventricular anatomy and function, different patterns of mitral annular distortion cause different phenotypes of aSMR. In ventricular SMR, the relation of SMR severity to left ventricular dilation as well as the degree of pulmonary hypertension and right ventricular dysfunction are important phenotypic characteristics, which are key for a better understanding of prognosis and treatment response.

Results of the Double Switch Operation in Patients Who Previously Underwent Left Ventricular Retraining.

Congenitally corrected transposition of the great arteries (CC-TGA) is a complex form of congenital heart disease that has numerous subtypes. While most patients with CC-TGA have a large ventricular septal defect (VSD) and pulmonary stenosis, there are some patients who have either no VSD or a highly restrictive VSD. These patients will require left ventricular (LV) retraining prior to double switch. The purpose of this study was to review our experience with the double switch procedure in patients who had previously undergone LV retraining. This was a retrospective review of a single institution experience with the double switch procedure in patients who had undergone LV retraining (2002-present). Forty-five patients underwent double switch following LV retraining. Of these, 39 had an arterial switch with hemi-Mustard/bidirectional Glenn and six had a Senning. The median cross-clamp time was 135 min (range 71-272) and median bypass time was 202 min (range 140-430 min). Median hospital length of stay was eight days (range 4-108). There were no in-hospital deaths. Median duration of follow-up was 30 months (range 0-175). One patient subsequently underwent heart transplantation and died 65 months following double switch. At follow-up, 41 of the 44 survivors (93%) have normal or low normal LV function and 40 of the 44 survivors (91%) have no or trace mitral regurgitation. The data demonstrate early and mid-term survival of 100% and 97%. Ninety-three percent had preserved LV function. These results suggest that patients with CC-TGA who undergo LV retraining and double switch can have excellent clinical outcomes.

Influence of left ventricular ejection fraction in patients undergoing contemporary pLVAD-supported high-risk PCI

Left ventricular (LV) systolic dysfunction worsens outcomes in patients undergoing percutaneous coronary intervention (PCI). The objective of this study, therefore, was to evaluate outcomes of pLVAD-supported high-risk PCI (HRPCI) patients according to LV ejection fraction (LVEF). Patients from the PROTECT III study undergoing pLVAD-supported HRPCI were stratified according to baseline LVEF: severe LV dysfunction (LVEF <30%), mild and moderate LV dysfunction (LVEF ≥30% to <50%), or preserved LV function (LVEF ≥50%). Major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization), and PCI-related complications were assessed at 90 days and mortality was assessed at 1-year. From March 2017 to March 2020, 940 patients had evaluable baseline LVEF recorded in the study database. Patients with preserved LV function were older, more frequently presented with myocardial infarction, and underwent more left main PCI and atherectomy. Immediate PCI-related coronary complications were infrequent (2.7%, overall), similar between groups (P=0.98), and not associated with LVEF. Unadjusted 90-day MACCE rates were similar among LVEF groups; however, as a continuous variable, LVEF was associated with both 90-day MACCE (adj.HR per 5% 0.89, 95% CI [0.80, 0.98], P=0.018) and 1-year mortality (adj.HR per 5% 0.84 [0.78, 0.90], P <0.0001). Patients who underwent pLVAD-supported HRPCI exhibited low incidence of PCI-related complications, regardless of baseline LVEF. However, LVEF was associated with 90-day MACCE and 1-year mortality.

Evaluation of Intraoperative Left-Ventricular Diastolic Function by Myocardial Strain in On-Pump Coronary Artery Bypass Surgery

Left ventricular (LV) diastolic function strongly predicts outcomes after cardiac surgery, but there is no consensus about appropriate intraoperative assessment. Recently, intraoperative diastolic strain-based measurements assessed by transesophageal echocardiography (TEE) have shown a strong correlation with LV relaxation, compliance, and filling, but there are no reports about evaluation through the entire perioperative period. Therefore, the authors describe the intraoperative course of this novel assessment technique in patients who underwent coronary artery bypass grafting, and compare it with conventional echocardiographic measures and common grading algorithms of LV diastolic dysfunction (LVDD). Prospectively obtained data. A single university hospital. Thirty adult patients scheduled for isolated on-pump coronary artery bypass grafting surgery with preoperative preserved left and right ventricular systolic function, without significant heart valve disease and pulmonary hypertension, and an uneventful intraoperative course were included. Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Echocardiographic evaluation was performed in stable hemodynamic conditions, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤0.1 µg/kg/min. Strain-based measurements of peak longitudinal strain rate during isovolumetric relaxation (SR-IVR) and during early (SR-E) and late (SR-A) LV filling were assessed using EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway). Evaluation of conventional echocardiographic parameters included transmitral Doppler measures of early (E) and late (A) LV filling, as well as lateral-tissue Doppler velocity assessed during early (e´) and late (a´) LV filling, tricuspid regurgitation, and left atrial dilatation. Evaluation and grading of LV diastolic function by myocardial strain was feasible in all included patients at all time points of assessment. Using conventional grading algorithms, however, a substantial number of patients could not be sufficiently graded, falling into an indeterminate zone and not reliably estimating LVDD (T1, 40%; T2, 33%; T3, 36%). There was significant impairment of LV diastolic function after bypass, as measured by SR-IVR (T1 v T2, 0.28 s-1 [IQR 0.23; 0.31) v 0.18 s-1 [IQR 0.14; 0.22]; p < 0.001), SR-E (T1 v T2, 0.95 ± 0.34 s-1v 1.28 ± 0.36 s-1; p < 0.001), and E/SR-IVR (T1 v T2, 2.3 ± 1.0 m v 4.5 ± 2.1 m; p < 0.001]. Conventional echocardiographic measures remained unchanged during the same period (E/A T1 v T2, 1.27 [IQR 0.94; 1.59] v 1.21 [IQR 1.03; 1.47] [p = 1] and E/e´ T1 v T2, 7.0 [IQR 5.3; 9.6] v 6.35 [IQR 5.7; 9.9] [p = 0.9]). There were no significant changes in the values of SR-IVR, SR-E, SR-A, E/SR-IVR, E/A, and E/e´ before and after sternal closure (T2 v T3). Intraoperative assessment of strain-based measurements of LV diastolic function and strain-based LVDD grading was feasible in this group of selected patients, whereas conventional parameters failed to describe LVDD sufficiently in a substantial number of patients. Diastolic strain-based measurements showed impairment of LV relaxation and compliance after bypass, which was not detected by conventional echocardiographic parameters. Therefore, diastolic myocardial strain analysis might be more sensitive in detecting myocardial diastolic dysfunction by TEE in the perioperative setting, with its dynamic changes of loading conditions, and might provide valuable and additional information on the perioperative changes of LV diastolic function.

Ultrasound-Induced Microbubble Cavitation for Targeted Delivery of MiR-29b Mimic to Treat Cardiac Fibrosis.

Cardiac fibrosis contributes to adverse ventricular remodeling and is associated with loss of miR-29b. Overexpression of miR-29b via plasmid or intravenous injection of microRNA mimic has blunted fibrosis, but these are inefficient and non-targeted delivery strategies. In this study, we tested the hypothesis that delivery of microRNA-29b (miR-29b) using ultrasound-targeted microbubble cavitation (UTMC) of miR-29b-loaded microbubbles would attenuate cardiac fibrosis and preserve left ventricular (LV) function. Lipid microbubbles were loaded with miR-29b mimic (miR-29b-MB) or negative control (NC) mimic (NC-MB), placed with cardiac fibroblasts (CFs) and treated with pulsed ultrasound. Cells were harvested to measure downstream fibrotic mediators. Mice received angiotensin II (ANG II) infusion causing afterload increase and direct ANG II-induced cardiac fibrosis. UTMC of miRNA-loaded microbubbles was administered to the heart at days 0, 3 and 7. Serial echocardiography was performed, and hearts were harvested on day 10. UTMC treatment of CFs with miR-29b-MB increased miR-29b and decreased fibrotic transcripts compared with NC-MB treatment. In vivo UTMC+NC-MB led to increased LV mass, reduction in cardiac function and increase in fibrotic markers, demonstrating ANGI II-induced adverse cardiac remodeling. Mice treated with UTMC+miR-29b-MB had preservation of cardiac function, downregulation of cardiac fibrillin and trends of lower COL1A1, COL1A2 and COL3 mRNA and decreased cardiac α-smooth muscle protein. UTMC-mediated delivery of miR-29b mimic blunts expression of fibrosis markers and preserves LV function in ANG II-induced cardiac fibrosis.

Radical mediastinal lipectomy for tamponade-like cardiac physiology

BackgroundRe-opening the chest is an unwanted and potentially morbid complication after open heart surgery, most commonly required for refractory bleeding or tamponade. In this report, we present a unique case of a postoperative coronary artery bypass patient, demonstrating clinical features of cardiac tamponade of the right atrium and ventricle with inconclusive findings on imaging.Case presentationA 62 year-old male presented to hospital with exertional angina and a coronary angiogram found severe three-vessel coronary artery disease with preserved left ventricular function. He underwent an uncomplicated triple coronary artery bypass surgery. Over the following hours in the cardiac intensive care unit, the patient had a climbing serum lactate level and increasing vasopressor requirements. On investigations, there was evidence of compression of the right heart. The patient was taken back to the operating room where very little clot or bleeding was identified, rather there was significant amounts of mediastinal fat surrounding the heart which was subsequently resected with wide margins. The patient had complete resolution of their symptoms and an uncomplicated postoperative course thereafter.ConclusionsTo our knowledge, this case is the first reported occurrence of cardiac constriction from excessive mediastinal fat after open heart surgery. Identifying patients at high-risk for excessive pericardial fat, as well as considering alternative modalities of imaging appear to be the main stay in diagnosis at this point. Current treatment is a mediastinal lipectomy with wide margins, avoiding injury to surrounding structures such as the phrenic nerve and innominate vein. Future study might consider the value of prophylactic mediastinal lipectomy at time of surgery, and methods to improve detection with current and future imaging modalities.

Sex-Specific Disparities in Outcomes of Transcatheter Edge-to-Edge Repair for Mitral Regurgitation: A Multicenter “Real-World” Analysis

Background: mitral regurgitation (mr) is the most common valvular heart disease (vhd) in the elderly and tends to be more prevalent in women. while relevant sex differences in outcomes are evident in surgically treated collectives, there are very limited and conflicting sex-specific data for the growing cohort of patients undergoing transcatheter edge-to-edge repair (teer). Objective: to investigate whether sex impacts procedural safety and efficacy, and in-hospital- and long-term outcomes, after teer for mr. Methods: in a multicenter observational cohort study, patients who underwent teer were stratified by sex and relevant outcome measures, and analyzed using multivariable cox regression and propensity score matching (psm). Results: a total of 821 patients were analyzed, of whom 37.4% (307/821) were female. compared to male patients, females were significantly older (77 ± 8.5 vs. 80.4 ± 6.7 years, p = 0.03), and had less coronary artery disease (cad, 67.7% vs. 53.1%, p &lt; 0.0001) and a higher proportion of preserved left ventricular function (lvef &gt; 50%, 32.5% vs. 50.5%, p &gt; 0.0001). safety and efficacy of the teer procedure and in-hospital mortality did not differ between the sexes. after psm, women showed significantly better survival 3 years after teer compared to men (60.7% vs. 54.2%, p = 0.04) and a lower risk of all-cause death according to multiple cox regression (hr 0.8, 95% ci 0.6–0.9, p = 0.02). after sex-specific stratification for concomitant atrial fibrillation (af), the most common comorbidity in the present collective, women with af experience significantly worse adjusted survival compared to women without af (53.9% vs. 75.1%, p = 0.042) three years after teer and lose the survival advantage over men. Conclusions: female patients are older and less comorbid than males undergoing TEER. The TEER procedure is equally safe and effective in both sexes. While in-hospital mortality did not differ, female patients experienced a significantly better adjusted long-term survival compared to male patients. Concomitant AF offsets the prognostic advantage of females over males and, in contrast to males, significantly impairs long-term survival in women undergoing TEER. Further research is warranted to elucidate underlying causes for the observed sex disparities and to develop sex-tailored treatment recommendations.

Artificial intelligence-enabled electrocardiogram in the detection of patients at risk of atrial functional mitral regurgitation

Abstract Background Atrial functional mitral regurgitation (AFMR) is an increasingly recognized cause of functional MR thought to result from left atrial enlargement and myopathy in the setting of preserved left ventricular geometry and function. AFMR mostly occurs in patients with atrial fibrillation (AF) and/or heart failure with preserved ejection fraction. Purpose We investigated whether the use of an artificial intelligence-based electrocardiogram (AI-ECG) can identify patients with new-onset AF and sinus rhythm (SR) who are at highest risk of developing AFMR. Methods Adults with a new diagnosis of AF between 2010 and 2021 who had a transthoracic echocardiogram (TTE) within 1 month after AF diagnosis were identified. Similarly, adults in SR who never had AF diagnosis and had a TTE during the same period were identified. Exclusion criteria from both groups included &amp;gt;mild MR at baseline, primary mitral valve disease, cardiomyopathy, ≥moderate aortic valve disease, current or previous low ejection fraction, enlarged left ventricle, cardiac devices, previous cardiac surgeries, and the absence of follow-up TTE ≥6 months from baseline. Only patients who had ECG within 10 days of the TTE were included. When multiple ECGs were available, the closest was considered. A previously trained AI-ECG algorithm to detect the probability of AF was utilized. Incident AFMR was defined as &amp;gt;mild functional MR in the absence of &amp;gt;mild left ventricle enlargement or dysfunction. Diastolic dysfunction was defined according to ASE/EACVI guidelines. Results Overall, 1,570 patients with new-onset AF (median age 67 years; 34% females) and 16,802 patients in SR (median age 59 years; 46% females) were included. The median AI ECG probability for AF was 43% (IQR 26%-59%) in the new-onset AF group and 2% (0.5%-7%) in the SR group, Figure 1. Incident AFMR occurred in 152 patients in the AF group over median 3.06 (IQR 1.5-5.2) years of follow-up and in 482 patients in the SR group over median 3.0 (1.5-5.6) years of follow-up. The probability of silent AF by the AI-ECG was associated with incident AFMR in the new-onset AF group [hazard ratio 1.19 (95% CI 1.11-1.28) per 10%, p &amp;lt;.001] and the SR group [hazard ratio 1.19 (95% CI 1.12-1.25) per 10%, p &amp;lt;.001]. The AI ECG-derived AF probability remained as an independent risk factor for AFMR in multivariable analysis in both AF and SR, Table 1. Conclusion The AI ECG for AF might be able to reflect the degree of left atrial myopathy and thus the risk of incident AFMR in patients with AF and SR.Distribution of AI ECG probability of AFMultivariable risk factors for AFMR

Abstract 12851: Severe Right and Left-Sided Multi-Valvular Carcinoid Heart Disease Associated With Ovarian Carcinoid Tumor

Carcinoid tumors are neuroendocrine neoplasms that secrete vasoactive substances, primarily serotonin, and have an incidence of approximately 2 in 100,000 people. Up to 60% of carcinoid tumors result in carcinoid heart disease (CHD), and unlike other carcinoid tumors, ovarian carcinoid tumors can involve the heart without liver metastasis. By bypassing the liver, ovarian carcinoid tumors can result in CHD in the absence of liver metastasis. We present a rare case of a 40-year-old female who presented in cardiogenic shock requiring inotropic support with echocardiographic evidence of preserved left ventricular systolic function (LVEF 50-55%) and multiple retracted leaflets that exhibited poor coaptation resulting in severe mitral regurgitation, torrential tricuspid regurgitation, and moderate-to-severe aortic regurgitation. Her left heart catheterization revealed non-obstructive coronary artery disease. A non-contrast CT torso revealed an isolated large septated left ovarian cystic mass (7.1x5.2 x7.1cm) without any other mass or lesion. In the setting of an elevated CA-125 (536units/mL, normal 0-35units/mL) and 24-hour urinary 5-HIAA (12.1mg, normal 2-9mg) with a normal CEA, CHD was suspected as the most likely diagnosis given the isolated ovarian mass and severe valvular disease. She underwent triple valve surgery in which valvular pathology revealed myxoid degeneration. Her post-operative course was complicated by multi-organ failure requiring multiple inotropes and V-A ECMO shortly thereafter, but the patient unfortunately passed away. While there are a few documented cases of CHD from ovarian carcinoid (less than 0.5% of cases) and left-sided CHD (less than 10% of cases), this is the first documented case, to our knowledge, describing severe right and left-sided CHD associated with a suspected ovarian carcinoid tumor.

Abstract 16155: Achieving Coronary Artery Disease Regression: A Triumph of Lifestyle Modification and Optimal Medical Therapy

Background: Coronary artery disease (CAD) is the leading cause of death worldwide. Early recognition of risk factors and targeting them using lifestyle modifications and pharmacological measures is vital for secondary prevention. This case demonstrates the effectiveness of comprehensive management in achieving marked regression of CAD. Case presentation: A 45-year-old female with a history of type II diabetes mellitus, hypertension, and hyperlipidemia with markedly elevated lipoprotein (A) of 233 nmol/L presented with chronic coronary syndrome (CCS). She had a strong family history of CAD and denied smoking, alcohol use, and recreational drug use. Transthoracic echocardiography revealed preserved left ventricular systolic function with an ejection fraction of 50%, regional wall motion abnormalities in the form of inferior wall hypokinesia, and mild mitral regurgitation. She underwent coronary angiography (CA) which revealed significant three-vessel CAD. Figure 1 Decision making: She underwent successful percutaneous coronary intervention (PCI) to the RCA and PDA with two overlapping drug-eluted stents and plain balloon angioplasty to the PL branch. The patient adhered to strict lifestyle modification and was prescribed optimal anti-ischemic and anti-diabetic medications. She lost 22 lbs over two years, her LDL went down from 178 to 14 mg/dl and A1c from 12.2 to 6.8. During follow up, she started to complain of dyspnea on exertion for two weeks. Despite the marked laboratory improvement and despite she was found to be anemic at that time which can explain her symptoms, decision was to proceed to CA given her high pretest probability. A repeat CA showed marked regression in her CAD. Figure 2 Conclusion: Regression of coronary artery disease is a reality giving hope for not just stopping disease progression but achieving reduction in plaque size with optimal medical therapy, where pharmacological measures and lifestyle modifications work synergistically.

Abstract 17593: Betel Quid Addiction Causing Monomorphic Ventricular Tachycardia

A 44-year-old woman presented to the emergency room due to worsening shortness of breath over the past few days with accompanying dizziness, cough, and fever. Her history was significant for asthma, obstructive sleep apnea, and hypertension. Upon arrival, she was noted to be hypoxic on room air and required supplemental oxygen. Physical exam showed extensive pitting edema in the lower extremities and crackles in bilateral lung fields. Chest radiograph revealed an enlarged cardiac silhouette and increased interstitial infiltrates consistent with pulmonary edema. While in the emergency department she was noted to have frequent episodes of asymptomatic non-sustained monomorphic ventricular tachycardia. Further questioning revealed the patient had been using betel quid daily for over 20 years to improve her mood and energy levels. She had attempted to quit in the past but was unable to do so. Echocardiogram was performed which showed preserved left ventricular function and severely dilated right ventricle. BNP was elevated at 1930 pg/mL. Due to her ventricular arrhythmias and cardiomyopathy, coronary angiography was performed; this was negative for epicardial coronary artery obstruction. Case was discussed with electrophysiology who determined the arrhythmias were likely caused by the extensive betel quid consumption. She was placed on beta-blockers and betel quid cessation was strongly recommended. Betel quid is a chewing product made from of areca nut, betel leaf, slaked lime, with or without tobacco. It is commonly used in the tropical Pacific, Asia, and parts of East Africa, and is the fourth most widely consumed addictive substances in the world due to its ability to increase alertness and produce mild euphoria. Adverse effects of betel quid include tachycardia, hyperlipidemia, metabolic syndrome, hepatotoxicity, and it is a known carcinogen. The active compound is arecoline, which acts as a parasympathomimetic on muscarinic and cholinergic receptors, increasing the central sympathetic response and producing tachycardia. Betel quid has been shown to produce ventricular arrhythmias in patients with underlying cardiomyopathy, which is likely what occurred in our patient. Betel quid cessation therefore advised in these patients.

Left bundle branch pacing better preserves ventricular mechanical synchrony than right ventricular pacing: a two-centre study.

Left bundle branch pacing (LBBP) has been shown to better maintain electrical synchrony compared with right ventricular pacing (RVP), but little is known about its impact on mechanical synchrony. This study investigates whether LBBP better preserves left ventricular (LV) mechanical synchronicity and function compared with RVP. Sixty patients with pacing indication for bradycardia were included: LBBP (n = 31) and RVP (n = 29). Echocardiography was performed before and shortly after pacemaker implantation and at 1-year follow-up. The lateral wall-septal wall (LW-SW) work difference was used as a measure of mechanical dyssynchrony. Septal flash, apical rocking, and septal strain patterns were also assessed. At baseline, LW-SW work difference was small and similar in two groups. SW was markedly decreased, while LW work remained mostly unchanged in RVP, resulting in a larger LW-SW work difference compared with LBBP (1253 ± 687 mmHg·% vs. 439 ± 408 mmHg·%, P < 0.01) at last follow-up. In addition, RVP more often induced septal flash or apical rocking and resulted in more advanced strain patterns compared with LBBP. At 1 year follow-up, LV ejection fraction (EF) and global longitudinal strain (GLS) were more decreased in RVP compared with LBBP (ΔLVEF: -7.4 ± 7.0% vs. 0.3 ± 4.1%; ΔLVGLS: -4.8 ± 4.0% vs. -1.4 ± 2.5%, both P < 0.01). In addition, ΔLW-SW work difference was independently correlated with LV adverse remodelling (r = 0.42, P < 0.01) and LV dysfunction (ΔLVEF: r = -0.61, P < 0.01 and ΔLVGLS: r = -0.38, P = 0.02). LBBP causes less LV mechanical dyssynchrony than RVP as it preserves a more physiologic electrical conduction. As a consequence, LBBP appears to preserve LV function better than RVP.

Heart Failure With Preserved Ejection Fraction and the Diagnosis of Pulmonary Hypertension

Heart failure with preserved ejection fraction (HFpEF) is now the most common cause of pulmonary hypertension (PH), and the diagnosis of HFpEF should be considered in any patient with a preserved left ventricular systolic function being evaluated for PH. Accurately diagnosing HFpEF as compared with pulmonary arterial hypertension has critical treatment implications, given the vastly different treatment options available, and can be accurately guided using exercise right heart catheterization. In this review, the diagnostic approach and treatment implications of PH in patients at risk for HFpEF will be discussed.

Pacing for atrioventricular block with preserved left ventricular function: On-treatment comparison between his bundle, left bundle branch, and right ventricular pacing

Pacing for atrioventricular block with preserved left ventricular function: On-treatment comparison between his bundle, left bundle branch, and right ventricular pacing

Assessment of mitral valve geometry in nonvalvular atrial fibrillation patients with or without ventricular dysfunction: insights from high volume rate three-dimensional transesophageal echocardiography

Meticulous understanding of the mechanisms underpinning mitral regurgitation in atrial fibrillation (AF) patients is crucial to optimize therapeutic strategies. The morphologic characteristics of mitral valves in atrial functional mitral regurgitation (FMR) patients with and without left ventricular (LV) dysfunction were evaluated by high volume rate (HVR) three-dimensional transesophageal echocardiography (3D-TEE). In our study, 68 of 265 AF patients who underwent 3D-TEE were selected, including 36 patients with AF, FMR, and preserved LV function (AFMR group) and 32 patients with AF, FMR, and LV dysfunction (VFMR group). In addition, 36 fever patients without heart disease were included in the control group. Group comparisons were performed by one-way analysis of variance for continuous variables. The left atrium (LA) was enlarged in the AFMR and VFMR groups compared with the control group. The mitral annulus (MA) in the AFMR group was enlarged and flattened compared with the control group and was smaller than in the VFMR group. The annulus area fraction was significantly diminished in the AFMR and VFMR groups, indicative of reduced MA contractility. The posterior mitral leaflet (PML) angle was smallest in the AFMR group and largest in the control group, whereas the distal anterior mitral leaflet angle did not significantly differ among the three groups. LA remodeling causes expansion of the MA and reduced MA contractility, disruption of the annular saddle shape, and atriogenic PML tethering. Comparison of atrial FMR patients with and without LV dysfunction indicates that atriogenic PML tethering is an important factor that aggravates FMR. HVR 3D-TEE improves the 3D temporal resolution greatly.

Effect of Beta-Blocker on Long-Term Major Cardiovascular Events in High Atherosclerotic Risk Population.

Beta-blocker is a frequently used medication in cardiovascular diseases. However, long-term benefit of beta-blocker in patients with preserved left ventricular ejection function (LVEF) on major adverse cardiovascular events (MACEs) is uncertain. The Cohort Of patients with high Risk for cardiovascular Events (CORE-Thailand) was a prospective study that enrolled Thai patients with high atherosclerotic risk including multiple atherosclerotic risk factors and established atherosclerotic cardiovascular diseases. Baseline demographic data, co-morbidities and medication were recorded. Patients were followed for 5 years. Patients with LVEF<50% were excluded. Primary outcome was the effect of beta-blocker on the occurrence of MACEs including all-cause death, non-fatal myocardial infarction and non-fatal stroke (3P-MACEs). Propensity score matching was used to control confounding factors. There was a total of 8513 patients in the pre-matched cohort, 4418 were taking beta-blocker and 4095 were not. After adjustment of confounders, beta-blocker was an independent predictor of 3P-MACEs (adjusted HR 1.29;95% CI 1.12-1.49;p<0.001). After propensity score matching, 4686 patients remained in the post-matched cohort. Propensity score analysis showed consistent results in which patient taking beta-blocker had higher risk of 3P-MACEs (adjusted HR 1.29;95% CI 1.10-1.53;p=0.002). Subgroup analysis in patients with coronary artery disease (CAD) indicated that taking beta-blocker did not increase the incidence of 3P-MACEs (adjusted HR 0.99;95% CI 0.76-1.29) while those without CAD did (adjusted HR 1.51; 95% CI, 1.22-1.86;p-interaction=0.015). In patients with high atherosclerotic cardiovascular risk, taking beta-blockers had a higher risk of 3P-MACEs. Care should be taken when prescribing beta-blockers to patients without a clear indication. TCTR20130520001 registered in Thai Clinical Trials Registry (TCTR) https://www.thaiclinicaltrials.org/ , date of registration 20 May 2013.

Abstract P2010: Relationship between echocardiographic parameters and invasively measured left ventricular filling pressure in the persistent atrial fibrillation with preserved left ventricular systolic function

Background: Among patients with normal systolic function, elevated left ventricular end diastolic pressure (LVEDP) could represent early diastolic dysfunction or could be the main physiological consequence of diastolic dysfunction. However, the evaluation of LVEDP using classic echocardiographic assessment has been challenging in the setting of atrial fibrillation (AF). The aim of this study was to investigate the methods for predicting LVEPD in patients with persistent AF. Methods: Clinical data, laboratory data, and echocardiography findings were assessed in 90 patients with chronic AF who were undergoing diagnostic left-heart catheterization. LVEDP and standard echocardiographic measurements including pulmonary arterial systolic pressure (PASP) were evaluated. Results: E/e’ (r=0.448, p&lt;0.001), E/Vp (r=0.471, p&lt;0.001) and PASP (r=0.421, p&lt;0.001) correlated well with LVEDP (figure 1). Using receiver operating characteristic analysis, the optimal cut-off for E/e’ was 13 (sensitivity, 88%; specificity, 65%) to predict LVEDP of &gt;15 mmHg (figure ). Conclusion: E/e’, E/Vp and PASP were well correlated with LVEDP in patients with AF with preserved EF. E/e’ greater than 13 may suggest elevated LVEDP (&gt;15 mmHg) in patients with persistent AF.

Assessment of subclinical left ventricular systolic dysfunction in patients with asymptomatic severe aortic stenosis with preserved left ventricular systolic function by three-dimensional speckle tracking echocardiography.

Left ventricular dysfunction and remodeling can occur as a result of aortic valve stenosis (AS). Three-dimensional speckle tracking echocardiography (3D-STE) can detect early left ventricular myocardial dysfunction even before ejection fraction declines. The purpose of this study was to look at the relationship between various myocardial strain parameters measured by 3D-STE in asymptomatic severe AS patients from Bangladesh. This study included 46 patients with asymptomatic severe AS but preserved LV systolic function (mean age 50.11±12.66 years, LVEF 63.78±3.95%, AS group) and 33 healthy subjects with no cardiovascular disease (mean age 48.21±4.53 years, LVEF 65.15±3.13%, control group). 3D-STE was used to measure left ventricular global myocardial strain parameters such as peak systolic longitudinal strain (PSLS), circumferential strain, radial strain, and area strain. The AS group had significantly thicker interventricular septum and posterior ventricular wall than the control group (1.49±.19cm vs. .81±.09cm, p<.001; 1.73±1.71cm vs. .81±.10cm, p=.003, respectively.) In the AS group, the Indexed Aortic Valve Area (AVA) was significantly lower than in the control group. (.29±.10vs. 2.03±.18, p<.001, respectively). In terms of LVEF (p=.102), left ventricular end diastolic volume (p=.075), or left ventricular end systolic volume (p=.092), no significant inter-group difference was found. However, global PSLS (-10.75±2.27vs. -16.42±2.76, p<.001), circumferential strain (-14.26±3.40vs. -16.64±2.56, p=.001), area strain (-22.70±4.19vs. -26.45±9.90, p=.024) and radial strain (32.20±8.77vs. 41.00±7.52, p<.001) in the AS group were significantly lower than in the control group. Our findings showed reductions in left ventricular global myocardial strains, particularly PSLS in patients suffering from asymptomatic severe AS in Bangladesh; this is consistent with other studies. Reduced area strain, detectable with 3D-STE, is also consistent with that pattern.