Abnormalities Of Right Ventricle Research Articles

Enhanced echocardiographic assessment of intracardiac flow in congenital heart disease.

4D flow magnetic resonance imaging (4D flow MRI) can assess and measure the complex flow patterns of the right ventricle (RV) in congenital heart diseases, but its limited availability makes the broad application of intracardiac flow assessment challenging. Color Doppler imaging velocity reconstruction from conventional echocardiography is an emerging alternative, but its validity against 4D flow MRI needs to be established. To compare intracardiac flow parameters measured by color Doppler velocity reconstruction (DoVeR) against parameters measured from 4D flow MRI. We analyzed 20 subjects, including 7 normal RVs and 13 abnormal RVs (10 with repaired Tetralogy of Fallot, and 3 with atrial-level shunts). Intracardiac flow parameters such as relative pressure difference, vortex strength, total kinetic energy, and viscous energy loss were quantified using DoVeR and 4D flow MRI. The agreement between the two methods was determined by comparing the spatial fields and quantifying the cross-correlation and normalized difference between time-series measurements. The hemodynamic parameters obtained from DoVeR and 4D flow MRI showed similar flow characteristics and spatial distributions. The time evolutions of the parameters were also in good agreement between the two methods. The median correlation coefficient between the time-series of any parameter was between 0.87 and 0.92, and the median L2-norm deviation was between 10% to 14%. Our study shows that DoVeR is a reliable alternative to 4D flow MRI for quantifying intracardiac hemodynamic parameters in the RV.

Right ventricular global strain in patients with hypertrophic cardiomyopathy with and without right ventricular hypertrophy

PurposeRegardless of whether there are morphological abnormalities of right ventricle in hypertrophic cardiomyopathy (HCM) patients, the exact contribution of right ventricular (RV) global strains remains unresolved. We aimed to study the prognostic value of RV global strains in HCM patients with and without RV hypertrophy (RVH). MethodA total of 358 HCM patients who underwent the CMR examination and carried out the follow-up were finally included in this retrospective study. The endpoint was a composite of all-cause mortality, aborted SCD, and heart failure readmission. RV hypertrophy (RVH) was defined as maximal RVWT ≥ 5 mm at end-diastole. RV global strains (RV global longitudinal strain (GLS) and RV global circumferential strain (GCS) were measured in HCM patients by cardiac MRI feature tracking technique. The intraobserver and interobserver reproducibility were evaluated. Receiver-operating characteristic curves and Kaplan–Meier curves, cox proportional hazards regression, Likelihood ratio test and Integrated Discrimination Improvement (IDI) analysis were performed. P-value were corrected for multiple testing when using many covariables by a false discovery rate adjustment. ResultsOver a median follow-up of 25 (range 3–54) months, 49 patients reached the composite endpoints. HCM patients were divided into the RVH group and non-RVH groups. In the multivariate cox proportional hazards regression, after adjusting multiple clinical and imaging variables, RV GLS and RV GCS were independently associated with the composite endpoints in the RVH group (HR: 1.123; 95 % CI: 1.048–1.205; P = 0.002) and non-RVH group (HR: 1.174; 95 % CI: 1.031–1.337; P = 0.015), respectively. And The IDI index of models improved when adding RV GLS (IDI = 0.030, p < 0.001) and RV GLS (IDI = 0.056, p = 0.020), respectively. ConclusionsRV GLS and RV GCS are independent predictors of HCM with RVH and without RVH, respectively. RV GLS in the RVH group and RV GCS in the non-RVH group provide additional values for predicting the risk of adverse events.

Development of an Expert-Level Right Ventricular Abnormality Detection Algorithm Based on Deep Learning.

Studies relating to the right ventricle (RV) are inadequate, and specific diagnostic algorithms still need to be improved. This essay is designed to make exploration and verification on an algorithm of deep learning based on imaging and clinical data to detect RV abnormalities. The Automated Cardiac Diagnosis Challenge dataset includes 20 subjects with RV abnormalities (an RV cavity volume which is higher than 110mL/m2 or RV ejection fraction which is lower than 40%) and 20 normal subjects who suffered from both cardiac MRI. The subjects were separated into training and validation sets in a ratio of 7:3 and were modeled by utilizing a nerve net of deep-learning and six machine-learning algorithms. Eight MRI specialists from multiple centers independently determined whether each subject in the validation group had RV abnormalities. Model performance was evaluated based on the AUC, accuracy, recall, sensitivity and specificity. Furthermore, a preliminary assessment of patient disease risk was performed based on clinical information using a nomogram. The deep-learning neural network outperformed the other six machine-learning algorithms, with an AUC value of 1 (95% confidence interval: 1-1) on both training group and validation group. This algorithm surpassed most human experts (87.5%). In addition, the nomogram model could evaluate a population with a disease risk of 0.2-0.8. A deep-learning algorithm could effectively identify patients with RV abnormalities. This AI algorithm developed specifically for right ventricular abnormalities will improve the detection of right ventricular abnormalities at all levels of care units and facilitate the timely diagnosis and treatment of related diseases. In addition, this study is the first to validate the algorithm's ability to classify RV abnormalities by comparing it with human experts.

Radial and Circumferential CMR-Based RV Strain Predicts Low R Wave Amplitude after ICD Implantation in Patients with Arrhythmogenic Cardiomyopathy.

Inadequate R wave amplitude (RWA) after implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) was suspected to relate to right ventricle impairment. However, little data-based evidence was provided to quantify the association. We retrospectively enrolled ACM patients receiving CMR examinations before transvenous ICD implantation from Fuwai Hospital. The RWA was obtained within 24 h and at 2-6-month follow-up after the operation. Structural, functional, as well as tissue characterization of the left ventricle (LV) and right ventricle (RV), were analyzed in relation to RWA. Among the 87 ACM patients (median RWA: 8.0 mV), 19 (21.8%) patients were found with low initial RWA (<5 mV) despite attempts in multiple positions. RV end diastolic diameter (RVEDD), (r = -0.44), RV ejection fraction (RVEF, r = 0.43), RV end diastolic volume index (RVEDVi, r = -0.49), RV end systolic volume index (RVESVi, r = -0.53), RV global circumferential (RVGCS, r = -0.64), and radial strain (RVGRS, r = 0.61, all p < 0.001) rather than LV metrics correlated strongly with initial RWA. RVGCS, RVESVi, and RVGRS were decent predictors of low RWA (areas under the curve AUC: 0.814, 0.769, 0.757, respectively) early after implantation and during 2-6-month follow-up. To summarize, low RWA of ICD lead in ACM patients was associated with RV abnormalities. The RVGCS, RVGRS, and RVESVi can be valuable predictors for identifying low RWA prior to ICD implantation.

Right Ventricular Remodeling Assessed by MRI in Duchenne Muscular Dystrophy.

In Duchenne muscular dystrophy (DMD), the right ventricle (RV) tends to be relatively well preserved, but characterization remains difficult due to its complex architecture. Tissue phase mapping (TPM) is a phase contrast cine MRI technique that allows for multidirectional assessment of myocardial velocities. To use TPM to elucidate relationships between myocardial structure, function, and clinical variables in DMD. Retrospective. A total of 20 patients with muscular dystrophy (median age: 16 years); 18 age-matched normal controls (median age: 15 years). Three-directional velocity encoded cine gradient echo sequence (TPM) at 1.5T, balanced steady-state free procession (bSSFP), T1 mapping with extracellular volume (ECV), and late gadolinium enhancement (LGE). TPM in basal, mid, and apical short-axis planes was performed as part of a standard MRI study with collection of clinical data. Radial, circumferential, and longitudinal velocities (Vr, Vφ, and Vz, respectively) and corresponding time to peak (TTP) velocities were quantified from TPM and used to calculate RV twist as well as intraventricular and interventricular dyssynchrony. The correlations between TPM velocities, myocardial structure/function, and clinical variables were assessed. Unpaired t-test, Wilcoxon rank-sum test, Bland-Altman analyses were used for comparisons between DMD patients and controls and between DMD subgroups. Pearson's test was used for correlations (r). Significance level: P< 0.05. Compared to controls, DMD patients had preserved RV ejection fraction (RVEF 53% ± 8%) but significantly increased interventricular dyssynchrony (Vφ: 0.49 ± 0.21 vs. 0.72 ± 0.17). Within the DMD cohort, RV dyssynchrony significantly increased with lower LV ejection fraction (intraventricular Vr and Vz: r=-0.49; interventricular Vz: r=0.48). In addition, RV intraventricular dyssynchrony significantly increased with older age (Vz: r=0.67). RV remodeling in DMD occurs in the context of preserved RVEF. Within DMD, this abnormal RV deformation is associated with older age and decreased LVEF. 4. Stage 2.

Echocardiography findings in COVID-19 patients admitted to intensive care units: a multi-national observational study (the ECHO-COVID study).

PurposeSeverely ill patients affected by coronavirus disease 2019 (COVID-19) develop circulatory failure. We aimed to report patterns of left and right ventricular dysfunction in the first echocardiography following admission to intensive care unit (ICU).MethodsRetrospective, descriptive study that collected echocardiographic and clinical information from severely ill COVID-19 patients admitted to 14 ICUs in 8 countries. Patients admitted to ICU who received at least one echocardiography between 1st February 2020 and 30th June 2021 were included. Clinical and echocardiographic data were uploaded using a secured web-based electronic database (REDCap).ResultsSix hundred and seventy-seven patients were included and the first echo was performed 2 [1, 4] days after ICU admission. The median age was 65 [56, 73] years, and 71% were male. Left ventricle (LV) and/or right ventricle (RV) systolic dysfunction were found in 234 (34.5%) patients. 149 (22%) patients had LV systolic dysfunction (with or without RV dysfunction) without LV dilatation and no elevation in filling pressure. 152 (22.5%) had RV systolic dysfunction. In 517 patients with information on both paradoxical septal motion and quantitative RV size, 90 (17.4%) had acute cor pulmonale (ACP). ACP was associated with mechanical ventilation (OR > 4), pulmonary embolism (OR > 5) and increased PaCO2. Exploratory analyses showed that patients with ACP and older age were more likely to die in hospital (including ICU).ConclusionAlmost one-third of this cohort of critically ill COVID-19 patients exhibited abnormal LV and/or RV systolic function in their first echocardiography assessment. While LV systolic dysfunction appears similar to septic cardiomyopathy, RV systolic dysfunction was related to pressure overload due to positive pressure ventilation, hypercapnia and pulmonary embolism. ACP and age seemed to be associated with mortality in this cohort.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-022-06685-2.

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE).

Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

Motion Extraction of the Right Ventricle from 4D Cardiac Cine MRI Using A Deep Learning-Based Deformable Registration Framework.

Cardiac Cine Magnetic Resonance (CMR) Imaging has made a significant paradigm shift in medical imaging technology, thanks to its capability of acquiring high spatial and temporal resolution images of different structures within the heart that can be used for reconstructing patient-specific ventricular computational models. In this work, we describe the development of dynamic patient-specific right ventricle (RV) models associated with normal subjects and abnormal RV patients to be subsequently used to assess RV function based on motion and kinematic analysis. We first constructed static RV models using segmentation masks of cardiac chambers generated from our accurate, memory-efficient deep neural architecture - CondenseUNet - featuring both a learned group structure and a regularized weight-pruner to estimate the motion of the right ventricle. In our study, we use a deep learning-based deformable network that takes 3D input volumes and outputs a motion field which is then used to generate isosurface meshes of the cardiac geometry at all cardiac frames by propagating the end-diastole (ED) isosurface mesh using the reconstructed motion field. The proposed model was trained and tested on the Automated Cardiac Diagnosis Challenge (ACDC) dataset featuring 150 cine cardiac MRI patient datasets. The isosurface meshes generated using the proposed pipeline were compared to those obtained using motion propagation via traditional non-rigid registration based on several performance metrics, including Dice score and mean absolute distance (MAD).

Cardiac computed tomography tissue tracking of the right ventricle longitudinal strain in patients with pulmonary thromboembolism

Abstract Background Pulmonary embolism (PE) represents a common entity with a broad clinical spectrum. Right ventricle (RV) dysfunction remains the leading cause of mortality. Current guidelines recommend a multimodal stratification, including echocardiographic or computed tomography and high-sensitive cardiac troponin (hs-cTn) for stratification of the risk. It is of utmost importance to identify those patients at highest risk for clinical deterioration. Longitudinal Strain (LS) is a new generation technique that quantifies the myocardial deformation without geometric assumptions, allowing the assessment of the RV myocardial function. Purpose Firstly, we aim to detect early RV abnormalities in patients with acute PE, with the LS value. Secondly, evaluate if there is a significant difference between Right Ventricle Longitudinal Strain (RVLS) in patients with acute PE versus controls without any cardiac pathology. Methods Observational retrospective single-centre study from patients 18 years or older admitted to the ER with proved PE by multiphase CT angiogram from 2016 to 2020. We included a control group from non-cardiac chest pain causes with multiphase CT angiogram negative for PE, without evidence of valvular disease and a coronary calcium score of 0. We evaluated the RV in the four-chamber views to obtain the LS value using tissue tracking CT software. A ROC curve assessed the LS performance for RV dysfunction detection. We calculated the Youden index for every value to identify the best cut-point. We considered a P value of &amp;lt;0.05 for statistical significance with a confidence interval of 95%. Results From a total of 53 patients with PE diagnostic only 10 fulfilled all the inclusion criteria. For the control group there were 500 patients with CT angiogram of which only 33 had a complete multiphase sequence. 63% of the patients included in the PE group were considered of high-risk PE with expression of hs-cTn, the rest were classified as intermediate risk. Average hs-cTn in the high-risk group was 149.3 ng/dL, which correlated with a lower RVLS in comparison to the intermediate risk PE without being statistically significative. Brain Natriuretic Peptide (BNP) had a higher correlation between lower RVLS in patients with intermediate and high-risk PE, respectively (80.56 pg/mL vs 466.02 pg/ml). There is an overt tendency for alteration of the RVLS in patients with PE compared to the control group (−8.41% vs. −21.09%; P&amp;lt;0.001). The AUC for the cut-point of −18.25% for the LS was 0.89 (CI 95%, 0.70–1.00), with a sensibility of 90.9% and specificity of 90% for RV dysfunction. Conclusion There is no reference value of RVLS in the general population. We propose the cut-point value of −18.25% for LS by cardiac CT to detect early RV dysfunction in patients with PE. Based on our findings we proposed a LS value of −21.09% cut-off point for patients with no cardiac disease. The correlation and clinical impact as prognostic factors, is yet to be studied. Funding Acknowledgement Type of funding sources: None.

267 Development and Validation of a Prognostic Tool: Pulmonary Embolism Short-Term Clinical Outcomes Risk Estimation

Develop and validate a prognostic prediction model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. We used data from the PE Short-term Clinical Outcomes Registry populated by emergency departments in six states. The primary composite outcome was death, cardiac arrest, respiratory failure, dysrhythmia, sustained hypotension treated with fluid boluses or adrenergic agents, or reperfusion intervention within 5 days after PE. Candidate predictors were demographics, vital signs, comorbidities, and immediate right ventricle (RV) assessments (biomarkers and imaging). The prediction rule was developed from 935 PE patients using univariate analyses of 107 candidate variables followed by penalized and standard logistic regression on retained variables and tested on a validation database (N = 801). Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected sepsis, syncope, medico-social reason for admission, abnormal heart rate [< 50 or > 100 bpm], and two points for renal disease. In the development database, 22.4% had the primary outcome. Predictive accuracy of logistic regression versus PE-SCORE models: 0.83 vs. 0.78 using area under receiver operating curve (AUC) and 0.61 vs. 0.50 using precision recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 and AUCpr 0.63. As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had > 69.6% outcomes. In the validation dataset, scores of six and above had 100% outcomes. PE-SCORE model identifies PE patients at low and high-risk for clinical deterioration and may guide decisions about early outpatient management versus need for hospital-based monitoring and considerations for escalated PE interventions.

Insulin Resistance Is Associated with Right Ventricular Dysfunction.

Rationale: The effect of insulin resistance on left ventricular function is well documented; however, less is known regarding its effect on the right ventricle (RV). Objectives: To evaluate the association between insulin resistance and RV function by echocardiography in a cohort of adults without baseline cardiovascular disease. Methods: We performed a retrospective cohort study in the MESA (Multi-Ethnic Study of Atherosclerosis). Linear regression was used to examine the association between overall insulin resistance measured by the mean triglyceride (TG) to high-density lipoprotein (HDL) cholesterol ratio (TG:HDL) and change in TG:HDL over time for each participant with echocardiographic RV function. Logistic regression was used to calculate the odds ratios (ORs) of RV systolic and diastolic dysfunction. Results: Among 3,032 participants, higher mean TG:HDL was associated with lower (worse) absolute RV longitudinal strain (β, -0.38; 95% confidence interval [CI], -0.64 to -0.13; P < 0.01), tricuspid annular plane systolic excursion (β, -0.05; 95% CI, -0.07 to -0.04; P < 0.001), and higher odds of abnormal RV strain (OR, 1.26; 95% CI, 1.08 to 1.47; P < 0.01) and abnormal tricuspid annular plane systolic excursion (OR, 1.31; 95% CI, 1.14 to 1.51; P < 0.001). TG:HDL was also associated with lower ratio of tricuspid early to late ventricular filling velocities (E/A) (β, -0.03; 95% CI, -0.04 to -0.01; P < 0.01), higher ratio of early diastolic tricuspid inflow to tricuspid lateral annular velocity (E/e') (β, 0.15; 95% CI, 0.07 to 0.23; P < 0.001), and higher odds of graded RV diastolic dysfunction (OR, 1.19; 95% CI, 1.03 to 1.39; P < 0.05). These associations remained following multivariable adjustment. Conclusions: Insulin resistance was associated with decreased RV systolic and diastolic function after adjusting for alternative causes of RV dysfunction, suggesting that insulin-resistant individuals are at risk for early RV dysfunction, even in the absence of cardiovascular disease.

Loss of Pulmonary Vascular Volume as a Predictor of Right Ventricular Dysfunction and Mortality in Acute Pulmonary Embolism.

In acute pulmonary embolism, chest computed tomography angiography derived metrics, such as the right ventricle (RV): left ventricle ratio are routinely used for risk stratification. Paucity of intraparenchymal blood vessels has previously been described, but their association with clinical biomarkers and outcomes has not been studied. We sought to determine if small vascular volumes measured on computed tomography scans were associated with an abnormal RV on echocardiography and mortality. We hypothesized that decreased small venous volume would be associated with greater RV dysfunction and increased mortality. A retrospective cohort of patients with intermediate risk pulmonary embolism admitted to Brigham and Women's Hospital between 2009 and 2017 was assembled, and clinical and radiographic data were obtained. We performed 3-dimensional reconstructions of vasculature to assess intraparenchymal vascular volumes. Statistical analyses were performed using multivariable regression and cox proportional hazards models, adjusting for age, sex, lung volume, and small arterial volume. Seven hundred twenty-two subjects were identified of whom 573 had documented echocardiography. A 50% reduction in small venous volume was associated with an increased risk of RV dilation (relative risk: 1.38 [95% CI, 1.18-1.63], P<0.001), RV dysfunction (relative risk: 1.62 [95% CI, 1.36-1.95], P<0.001), and RV strain (relative risk: 1.67 [95% CI, 1.37-2.04], P<0.001); increased cardiac biomarkers, and higher 30-day and 90-day mortality (hazard ratio: 2.50 [95% CI, 1.33-4.67], P=0.004 and hazard ratio: 1.84 [95% CI, 1.11-3.04], P=0.019, respectively). Loss of small venous volume quantified from computed tomography angiography is associated with increased risk of abnormal RV on echocardiography, abnormal cardiac biomarkers, and higher risk of 30- and 90-day mortality. Small venous volume may be a useful marker for assessing disease severity in acute pulmonary embolism.

Echocardiographic deformation imaging unmasks global and regional mechanical dysfunction in patients with idiopathic ventricular fibrillation: A multicenter case-control study

Idiopathic ventricular fibrillation (IVF) is diagnosed in patients with sudden onset of ventricular fibrillation of unidentified origin. New diagnostic tools that can detect subtle abnormalities are needed to diagnose and treat patients with an underlying substrate. The purpose of this study was to explore echocardiographic deformation characteristics in IVF patients. Echocardiograms were analyzed with deformation imaging by 2-dimensional speckle tracking. Global and regional measurements of the left ventricle (LV) and right ventricle (RV) were performed. Regional LV deformation patterns were evaluated for the presence of postsystolic shortening. Regional RV deformation patterns were classified as type I (normal) or type II/III (abnormal). In total, 47 IVF patients (mean age 45 years; left ventricular ejection fraction [LVEF] 56%) and 47 healthy controls (mean age 41 years; LVEF 60%) were included. IVF patients showed more global deformation abnormalities as indicated by lower LV global longitudinal strain (18.5% ± 2.6% vs 21.6% ± 1.8%; P <.001) and higher LV mechanical dispersion (41 ± 12 ms vs 26 ± 6 ms; P <.001). In addition, IVF patients showed more regional LV postsystolic shortening compared to healthy controls (50% vs 11%; P <.001). Abnormal RV deformation patterns were observed in 16% of IVF patients and in none of the control subjects (P <.001). We were able to show both regional and global echocardiographic deformation abnormalities in IVF patients. This study provides evidence that localized myocardial disease is present in a subset of IVF patients.

Serum lactate levels are an independent marker for complications in acute pulmonary embolism: from the PERT registry

Abstract Introduction Serum lactate is a marker for the presence and severity of imbalances between tissue oxygen supply and demand. There are only scare data regarding the significance of arterial lactate in PE patients. Purpose We sought to explore the significance of venous serum lactate as a short- and long-term predictor of adverse outcomes. Methods We prospectively enrolled 570 patients with topographically-confirmed pulmonary embolism, hospitalized in our center during 2016–2019. Patient's data was collected using an electronic medical record and follow-up interviews via telephone. The combined end point of hemodynamic instability, shock, mechanical ventilation, or need for CPR was prospectively documented during hospitalization as well as 1-year mortality. Results The analysis included 461 consecutive patients with available clinical data including venous lactate. The median age was 69 years, and 262 (58%) were female. Median serum lactate levels were 21 mg/dL (IQR 16–31). The composite endpoint was documented in 92 patients (20%), and lactate levels above 21 mg/dl had a higher incidence of the composite end point (26% vs, 14%, p=0.002). Similar findings were seen when adding either the need for escalating therapy (44% vs. 24%, p&amp;lt;0.001), in-hospital mortality (31% vs. 16%, p=0.001) or 30-day mortality (27% vs. 21%, p&amp;lt;0.001) to the previous composite. One-year mortality was significantly higher in the higher lactate group (17% vs 5%, p&amp;lt;0.001), and a lactate level above 21 mg/dL was independently associated with 1-year mortality in a Cox-regression model adjusted for age, gender and a history of heart failure or malignancy, HR 2.5 (95% CI 1.7–3.9). In subgroup analyses, lactate levels were associated with 1-year mortality regardless of age or gender. Similar predictive trends for 1-year mortality were seen in patients stratified by diabetes status, a current malignancy, PE risk and right-ventricle abnormalities (see figure). Conclusions Venous serum lactate levels are associated with a myriad of in-hospital adverse outcomes, as well as long-term mortality. In a 1-year follow-up, a higher lactate level was predictive of mortality across various subgroups, with higher hazard ratios seen specifically in lower-risk patients. Further studies are needed in order to evaluate the possible prognostic role of the change in serum lactate during PE management. Elevated lactate and 1-year mortality Funding Acknowledgement Type of funding source: None

INCIDENTAL RIGHT VENTRICULAR ABNORMALITIES ON SINGLE PHOTON EMISSION CT SCAN SIGNIFICANTLY PREDICTS DEVELOPMENT OF PULMONARY HYPERTENSION IN BLACK FEMALES

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Single Photon Emission Computed Tomography (SPECT) imaging is a diagnostic tool used to risk-stratify patients presenting with chest pain for myocardial ischemia. While SPECT abnormalities of the right ventricle (RV) are known to correlate with invasive hemodynamic measures of disease severity and prognosis in patients with pulmonary hypertension (PH), the prognostic significance of isolated RV abnormalities on SPECT studies in black females who do not carry a PH or cardiac diagnosis is unknown. METHODS: This was a retrospective study. Using the electronic medical record search engine (EMERSE) tool, we identified 12,000 SPECT studies completed at our center between 1/1/07 and 1/1/20. After excluding studies with abnormalities of left ventricular perfusion, elevated cardiac risk, and previous diagnoses of PH, and focusing on black females, we identified 943 unique studies for analysis, and categorized them by the presence or absence of RV abnormalities, including hypertrophy, dilation, or increased uptake. Patient characteristics, including age and body mass index (BMI) at the time of index SPECT study (time zero), were obtained from the medical record, and patients were followed until either an event occurred or the study period ended (2/1/20). The primary outcome was mortality, secondary outcomes included hospital admission and a diagnosis of PH, defined as an estimated right ventricular systolic pressure (RVSP) > 35 mmHg on echocardiogram. Patients lost to follow-up were censored at the time of their last clinical encounter. Multivariable Cox Proportional Hazards models and logistic regression models, adjusted for age and BMI, were used in the analysis. This study was reviewed and approved by the UC Institutional Review Board (IRB 2019-1282). RESULTS: A total of 943 black females were included in this analysis, with a median age of 52 years and a median BMI of 33. The median duration of follow-up was 10.5 years, and 10.3% of patients died during the follow-up period. In the full cohort, RV abnormalities were present in 4% of patients, and PH was subsequently diagnosed in 18.3% of patients during follow-up (median RVSP 45 mmHg). Age was the only significant predictor of readmission (HR 1.01, p=0.007) or mortality (HR 1.07, p=1E-14). RV abnormalities (OR 3.2, p=0.001), age (OR 1.04, p=4E-8), and BMI (OR 1.02, p=0.004) all significantly and independently predicted development of PH. CONCLUSIONS: RV abnormalities incidentally found on otherwise normal SPECT studies were significantly predictive of the development of PH in black females, even after adjustment for age and BMI. The combination of these factors may be useful in risk-stratification of black female patients for PH, and identify high-risk patients who would benefit from a more comprehensive workup for PH and serial echocardiographic evaluation. CLINICAL IMPLICATIONS: RV abnormalities on SPECT imaging may help risk-stratify black females for PH DISCLOSURES: no disclosure on file for Rachel Baker; Chair of a Committee relationship with PHA Please note: PHA Medically Led Sessions, PHA Preceptorship Added 05/22/2020 by Jean Elwing, source=Web Response Removed 05/22/2020 by Jean Elwing, source=Web Response Educator relationship with PH CME Programs - PHA, Simply Speaking, Impact PH Please note: Intermittent, Ongoing Added 05/22/2020 by Jean Elwing, source=Web Response, value=Honoraria Principal Investigator relationship with Actelion, Arena, Reata, United Therapeutics Please note: Ongoing - University is Paid Directly Added 05/22/2020 by Jean Elwing, source=Web Response, value=Grant/Research Support Advisory Committee Member relationship with United Therapeutics Please note: $5001 - $20000 Added 06/05/2020 by Jean Elwing, source=Web Response, value=Consulting fee Principal Investigator relationship with Lung LLC, Liquidia, Phase Bio, Complexa, Gossamer Bio Please note: Ongoing - University is Paid Directly Added 05/22/2020 by Jean Elwing, source=Web Response, value=Grant/Research Support Member of a Committee relationship with PHA Please note: PHA Education Committee Added 05/22/2020 by Jean Elwing, source=Web Response Removed 05/22/2020 by Jean Elwing, source=Web Response Advisory Committee Member relationship with Liquidia, Acceleron Please note: $1001 - $5000 Added 06/05/2020 by Jean Elwing, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Acceleron Please note: $5001 - $20000 Added 06/05/2020 by Jean Elwing, source=Web Response, value=Consulting fee Removed 06/05/2020 by Jean Elwing, source=Web Response Grant - Entelligence Award relationship with Actelion Please note: >$100000 Added 05/25/2020 by Arun Jose, source=Web Response, value=Grant/Research Support No relevant relationships by Francis McCormack, source=Web Response No relevant relationships by Humna Abid Memon, source=Web Response

LONGITUDINAL EVALUATION OF RIGHT VENTRICLE FUNCTION USING SPECKLE TRACKING ECHOCARDIOGRAPHY IN PATIENTS WITH ACUTE HYPOXEMIC RESPIRATORY FAILURE

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Right ventricle (RV) dysfunction occurs in approximately 22-25% of ARDS patients despite lung protective ventilation and is associated with increased mortality. This mortality increase is thought due to acute cor pulmonale wherein increased pulmonary vascular resistance (PVR) causes RV chamber dilation and systolic dysfunction. Distorted RV geometry compromises cardiac output and can lead to circulatory failure. Determination of PVR directly by pulmonary artery catheter is difficult to apply uniformly at bedside and previous beside echocardiography measurements such as acute cor pulmonale have failed to demonstrate consistent accuracy in predicting mortality. Speckle tracking echocardiography (STE) is a validated technique used to detect subclinical LV dysfunction before global ejection fraction is measurably impaired. STE is easily applied at beside and could prove useful for monitoring RV function in patients with ARDS on positive pressure ventilation. METHODS: We studied 9 patients with acute hypoxemic respiratory failure (PF ratio <300, PEEP >5) admitted to our ICU within 96 hours of intubation. We performed an RV focused echocardiogram with speckle tracking software (ECHOPAC) using GE Vivid 9.5 machines to assess RV function every 2-3 days until the patient was extubated, received tracheostomy or expired. TAPSE, TDI, right atrial pressure (calculated from TR jet maximum velocity and IVC % change), and 2 dimensional EF were also performed on each study. RESULTS: 4/9 patients had new RV dysfunction (RV FWLS >-23%) identified by STE at baseline echocardiogram. 5/9 patients died during the study and those that died had either abnormal RV function at baseline or had worsening function worsened over time despite stable PEEP settings and plateau pressure <30 cm H20. In survivors (4/9), RV function generally improved or remained stable. TDI and TAPSE did not correlate well with predicting mortality. In total, 24 RV echocardiograms were performed; RV dysfunction by strain was identified in 11/24 (44%) compared to TDI 1/24 (4%) and TAPSE 6/24 (25%). CONCLUSIONS: In mechanically ventilated patients with ARDS 5/9 patients died and were found to have either impaired RV function at baseline echocardiogram or had worsening in function overtime. Traditional markers such as TAPSE and TDI, that assess only longitudinal motion of RV performed poorly. CLINICAL IMPLICATIONS: This is the first study to date using speckle tracking echocardiography (STE) to prospectively evaluate RV function over time in patient with acute hypoxemic respiratory failure. STE of RV function correlated better with survivors and non-survivors compared to conventional measurements (TDI and TAPSE). A larger cohort of patients is needed to further characterize the relationship of RV function overtime in ARDS. DISCLOSURES: No relevant relationships by Alice Gallo De Moraes, source=Web Response No relevant relationships by Cameron Long, source=Web Response No relevant relationships by Richard Oeckler, source=Web Response No relevant relationships by Brandon Wiley, source=Web Response

Mid and Long Term Echocardiographic and Clinical Follow up of Treated Rheumatic Mitral Stenosis Patients

Introduction: Rheumatic mitral stenosis (MS) is a common valvopathy in developing countries that requires invasive or minimally invasive treatment. There is scarcity of data regarding the long term follow up of treated MS patients.&#x0D; &#x0D; Aim: The aim of this study was to compare the long-term outcomes of biologic and mechanical prosthesis and percutaneous transvenous mitral commissurotomy (PTMC) in treated MS patients.&#x0D; &#x0D; Materials and Methods: This historical cohort study was conducted on treated MS patients who underwent treatment in a tertiary hospital in Mashhad, Iran. Treated MS patients were identified and asked to refer to the center for follow up. Demographic characteristics and type of treatment intervention were obtained from patient records. The follow up assessment included history of PTMC, readmission and echocardiography to assess trans mitral gradient (MG), size and function of right ventricle (RV) and the presence and severity of other valvopathies.&#x0D; &#x0D; Results: A total of 135 patients (21.5% males and 78.5% females) with the mean age of 43.68 &amp;plusmn; 11.17 years old participated in the study. The most common intervention method was mechanical valve (61.5%) followed by PTMC (24.4%) and biologic valve (14.1%). Median follow up duration was 4 years. Majority of subjects (52.6%) remained asymptomatic and the functional class was reduced significantly compared to baseline. MG was significantly higher in PTMC and biological valve group compared to mechanical valve p&amp;lt;0.001). Mitral regurgitation (MR) was more prevalent in PTMC group (p&amp;lt;0.001) while abnormal RV size and function the least common in PTMC group (p=0.014 and p=0.002 respectively).&#x0D; &#x0D; Conclusions: All intervention groups resulted in improved functional class of MS patients but high prevalence of MR and lower prevalence of abnormal RV size and function were observed in PTMS group compared to surgical groups.

P3683Diagnosis of arrhythmogenic cardiomyopathy and overlap with cardiac adaptation to exercise: insights from a cardiac magnetic resonance study

Abstract Background The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging and some structural abnormalities typical of the disease may overlap with changes reflective of cardiac adaptation to exercise. Purpose The aim of the study was to assess the performance of the cardiac magnetic resonance (CMR) 2010 Task Force Criteria (TFC) in a cohort of patients with definite diagnosis of ARVC and define the overlap with a cohort of highly trained athletes of similar age and sex. Methods We compared the CMR features of 43 patients (mean age 49±17 years, 49% males, 32 (74%) genotyped) with a definite diagnosis of ARVC according to the revised TFC to 97 (mean age 45±16 years, 61% males) highly-trained athletes of similar age and sex, in whom cardiac disease was excluded after comprehensive work-up. Results The CMR was abnormal in 37 (86%) patients. The right ventricle (RV) was affected in isolation in 17 (39%) patients, with 18 (42%) patients exhibiting biventricular involvement and 2 (5%) patients showing isolated left ventricular (LV) involvement. The most common RV abnormalities were regional wall motion abnormalities (RWMA) (n=34; 79%), RV dilatation fulfilling a major or minor volume TFC (n=18; 42%), impaired systolic function (RV ejection fraction (EF) ≤45%: n=17; 40%) and myocardial fibrosis (n=13; 30%). The predominant LV abnormality was myocardial fibrosis (n=20; 47%), with a small proportion of patients exhibiting RWMA (n=6; 14%) and impaired systolic function (LVEF &lt;50%: n=6; 14%). Twenty-three (53%) patients fulfilled a major (n=14; 32%) or a minor (n=9; 21%) CMR TFC. Sixteen (16%) athletes exceeded the cut-off values for RV volumes used as a major (n=10; 10%) or a minor (n=6; 6%) TFC with an inverse relationship between age and RV volumes (r=−41, p=0.001). None of the athletes fulfilled the TFC for RV ejection fraction. Applying the CMR TFC to the ARVC patient population showed a sensitivity of 33% for the major and 28% for the minor criteria. Applying the RV volume and systolic function TFC values in the entire study population showed a sensitivity of 53%, a specificity between 83% and an accuracy of 0.68. Conclusions The great majority (86%) of patients with ARVC demonstrates structural abnormalities suggestive of cardiomyopathy on CMR but only 53% fulfills any of the CMR TFC. Only a small proportion (16%) of older athletes demonstrate significant RV dilatation that overlaps with the volume criteria for ARVC, in juxtaposition to younger athletes who exhibit a greater degree of overlap. The emergence of ARVC as a biventricular disease provides an opportunity to re-evaluate the diagnostic criteria and include LV involvement in conjunction with RV involvement to improve diagnostic accuracy. Acknowledgement/Funding CRY (Cardiac Risk in the Young) charity

Impact of Severe Pulmonary Arterial Hypertension on the Left Heart and Prognostic Implications

Severe pulmonary arterial hypertension (sPAH) results in a dilated and dysfunctional right ventricle (RV) together with a small left ventricle (LV) with preserved systolic function. RV size and function parameters have an established association with poor prognosis in sPAH. We sought to determine the impact of RV geometry and function on LV mechanics and its relationship with mortality. We studied 114 patients (54±13years) with sPAH, normal LV ejection fraction (LVEF), and complete two-dimensional transthoracic echocardiograms (TTE) and compared them with 70 normal controls of similar age and gender distribution. TTE measurements of atrial sizes, ventricular volumes and function, tricuspid and mitral regurgitation (TR, MR), and LV diastolic function were performed. Speckle-tracking strain was measured in all four chambers, including LV global longitudinal strain (GLS). Cox proportional hazards regression with forward selection was performed to determine the associations between measured indices and mortality over a 20-month follow-up period. Kaplan-Meier curves were generated for variables most associated with death. Compared with controls, sPAH patients had greater TR severity and right-chamber size with worse function. Of note, LVEF was normal in both groups. Left atrial peak strain and LV GLS were reduced in sPAH, with greater reductions in nonsurvivors. In multivariate analysis, right atrial volume index (hazard ratio [HR]=1.02 [CI, 1.01-1.04], P<.01), RV free-wall strain (HR=1.08; CI [1.01-1.15]; P=.03), and LV GLS (HR=1.11 [CI, 1.01-1.22]; P=.04) were independently associated with mortality. Although PAH is predominantly a right heart disease, in our cohort of sPAH with normal LVEF, LV GLS was independently associated with death in addition to RV and right atrial abnormalities. These findings indicate that the role of left heart dysfunction in sPAH may be underappreciated in clinical practice.

Longitudinal Annular Systolic Displacement Compared to Global Strain in Normal Fetal Hearts and Those With Cardiac Abnormalities.

The purpose of this study was to compare a new technique that measures the midventricular basal-apical longitudinal diastolic and systolic lengths, computes the longitudinal displacement fractional shortening, and compares it to global strain. Two hundred control fetuses were examined between 20 and 40 weeks' gestation, in whom the longitudinal displacement fractional shortening was computed from end-diastolic and end-systolic lengths measured from the apex to the mid portion of the distance between the level of the basal lateral and septal walls using 2-dimnsional speckle tracking. In addition, global strain was computed using speckle tracking. A correlation analysis was used to compare the longitudinal displacement fractional shortening to global strain. The longitudinal displacement fractional shortening of the right ventricle (RV) and left ventricle (LV) was measured in 10 fetuses with heart abnormalities. The longitudinal displacement fractional shortening for the RV (mean ± SD, 22.94% ± 4.73%) and LV (21.05% ± 4.21%) was independent of gestational age and other biometric growth parameters, as was global strain (RV, -22.7% ± 4.07%); LV, -22.93% ± 3.52%). The RV longitudinal displacement fractional shortening was greater than that of the LV (P < .024). The correlations between the longitudinal displacement fractional shortening and global strain were 0.95 for the RV and 0.97 for the LV. Comparing the longitudinal displacement fractional shortening and global strain in fetuses with abnormal cardiac findings showed concordant findings in 9 of 10 fetuses. The RV and LV longitudinal displacement fractional shortening can be computed from 2-dimensional images of the 4-chamber view and correlated with global strain. The longitudinal displacement fractional shortening was significantly greater for the RV than the LV and was abnormal in fetuses with RV and LV cardiac abnormalities.