Severe Left Ventricle Systolic Dysfunction Research Articles

Echocardiographic parameters in COVID-19 patients and their association with ICU mortality: a prospective multicenter observational study

BackgroundEchocardiography has become an integral part of the management of critically ill patients. It helps to diagnose and treat various conditions. COVID-19 patients can develop cardiac dysfunction. We planned to study the echocardiographic parameters in COVID-19 patients.MethodsWe conducted a prospective observational multicenter study after institutional ethical committee approval. COVID-19 pneumonia patients admitted to the intensive care unit (ICU) were enrolled. The echocardiographic evaluation was done within 24–48 hours of admission. Assessment of the left and right heart with systolic and left ventricular diastolic function evaluation was done. The primary outcome was ICU mortality. The secondary outcomes were the length of ICU stay and duration of mechanical ventilation.ResultsAmong 573 patients mean age was 57.17 (14.67) with 68.60% being males. On day 1 of ICU, invasive mechanical ventilation was used in 257 (45%) patients. One hundred and forty-eight (25.83%) patients were on vasopressors when echocardiography was performed. Severe left ventricle (LV) systolic dysfunction was seen in 8.7% of patients and had higher odds of mortality [2.48(1.058–5.807), p = 0.037] followed by E and e′ with odds ratio of [0.984(0.971–0.998), p = 0.021] and 0.897 (0.805–0.998), p = 0.046], respectively. E/e′ indicative of filling pressure of the LV was not found to be significant. Troponin I, E/A, and RV dilatation were similar among survivors and non-survivors.ConclusionEchocardiographic evaluation in COVID-19 patients showed severe LV systolic dysfunction was associated with ICU mortality. E/e′ was not found to be significant but lower e′ was associated with higher mortality.Trial registration IEC 131/2020, CTRI/2020/06/025858 date 13th June 2020

The additive role of cardiac CT in a patient with cardiogenic shock and suspected mechanical complication of myocardial infarction.

A 69-year-old woman with previous hypertension and type-2 diabetes was admitted to the emergency department with syncope, referring continuous chest pain in the last 4 days. At hospital admission, the patient was in cardiogenic shock. The initial electrocardiogram showed Q waves in the anterior wall and ST-segment elevation on the anterior, lateral, and inferior walls. A bedside echocardiogram was immediately performed (panels A and B; Supplementary data online, Video S1) which showed a dilated left ventricle (LV) with severe LV systolic dysfunction and akynesia of the mid-apical segments of all ventricular walls. The patient had pericardial effusion (PE) with images suggesting clots near to the right ventricle free wall, with tamponade criteria. Although no rupture of the LV wall was clearly visible on echocardiogram, there was a high clinical suspicion of this complication. Cardiac computed tomography (CT) angiography confirmed myocardial rupture at the distal segment of the anterior wall and a mild circumferential PE, with a fluid density suggestive of haematic content (panels C, D, and E; Supplementary data online, Video S2). The patient underwent emergent surgery (panel F; Supplementary data online, Video S3) to correct the LV free wall rupture.

The prognostic impact of magnesium in acute heart failure is different according to the presence of diabetes mellitus.

Hypermagnesemia predicts mortality in chronic heart failure (HF); however, in acute HF, magnesium does not seem to be outcome-associated. Diabetes mellitus (DM) frequently associates with altered magnesium status. We hypothesized that DM might influence the prognostic impact of magnesium in acute HF. This is a retrospective cohort study of hospitalized patients with acute HF. Patients without data on admission serum magnesium were excluded. Follow-up: 1 year from hospital admission. Primary end point: all-cause mortality. Patients were divided according to median serum magnesium (1.64 mEq/L). The Kaplan-Meier survival method was used to determine survival curves according to magnesium levels. The analysis was stratified according to the presence of DM. A multivariable Cox regression analysis was used to study the prognostic impact of magnesium. We studied 606 patients. The mean age was 76 ± 12 years, 44.1% were male, 50.7% had DM, and 232 (38.3%) died during follow-up. Median magnesium was 1.64 (1.48-1.79) mEq/L. Patients with magnesium ≥1.64 mEq/L had higher 1-year mortality [141 (46.4%) vs 91 (30.1%), P < .001]. After adjustments for age, sex, history of atrial fibrillation, systolic blood pressure, heart rate, ischemic etiology, B-type natriuretic peptide, estimated glomerular filtration rate, alcohol consumption, antihyperglycaemic agents or glycated hemoglobin, admission glycemia, New York Heart Association class IV, and severe left ventricle systolic dysfunction, serum magnesium ≥1.64 mEq/L was associated with higher mortality only in patients with DM: HR 1.89 (95% confidence interval: 1.19-3.00), P = .007, and 1.27 (95% confidence interval: 0.83-1.94) and P = .26 for non-DM patients. The results were similar if magnesium was analyzed as a continuous variable. Per 0.1 mEq/L increase in magnesium levels, patients with DM had 13% increased risk of 1-year mortality. Higher magnesium levels were associated with worse prognosis only in HF patients with DM.

778 Acute clinical valve thrombosis after transcatheter mitral valve-in-valve replacement

Abstract Aims Transcatheter heart valve (THV) thrombosis is a frequent and potentially life-threatening complication of transcatheter mitral valve replacement (TMVR), occurring in approximately 12% of patients (mainly within the first 3 months after the procedure). The majority of THV thromboses is non-obstructive and subclinical, and remains undetected until a routine echocardiogram is performed. Methods A 65 years old male was suffering from post-ischaemic dilated cardiomyopathy and severe left ventricle systolic dysfunction (LVEF 28%), secondary to a previous STEMI in 2010 treated with primary PCI on proximal LAD; after the STEMI he developed a left ventricle aneurysm and a subsequent severe secondary mitral regurgitation. In late 2020 he underwent a surgical valve replacement with a biologic valve (Perimount Magna Mitral Ease n. 27), alongside a left ventricle reshaping (Dor procedure). After a few months, the patient developed worsening dyspnoea and severe exercise intolerance; a transesophageal echocardiogram (TEE) showed an extensive valve degeneration with diffuse leaflet thickening determining severe valve stenosis and regurgitation. The patient was then admitted to the Cardiology department. A coronary angiography was performed, showing good result of previous PCI and excluding other critical stenoses. The patient then underwent a transcatheter valve-in-valve replacement with a Sapien S3 n. 29 in mitral position. The patient was already in chronic therapy with acetilsalicilic acid (ASA), and after the procedure anticoagulant therapy with Warfarin was started. In the post-procedural period the patient developed an acute worsening of the LVEF with severe hypotension, likely due to after-load mismatch; hence, supportive inotropic therapy with Adrenalin and Enoximone was required. A TEE performed 7 days after the procedure showed absence of diastolic excursion of posterior and lateral cusps and leaflet thickening with a 4 mm thrombotic apposition on the ventricular side, determining severe valve stenosis with markedly increased transvalvular gradients (peak gradient 20 mmHg, mean gradient 11 mmHg). A CT scan of the heart confirmed the valve thrombosis on the inferior and lateral leaflets. Results Unfractioned heparin (UFH) was then added to ASA and Warfarin (INR target of 3.0). After 11 days of aggressive antithrombotic therapy a new TEE was performed, showing marked reduction in transvalvular gradients (peak gradient 10 mmHg, mean gradient 5 mmHg) due to partial dissolution of the thrombotic formation. Warfarin was then stopped, and after switching from UFH to Enoxaparin the patient was discharged asymptomatic and in good general conditions, with indication of follow-up with TEE at 1 month. Conclusions Valve-in-valve TMVR is a relatively new and still infrequent procedure, therefore few evidences about its complications are currently available. Thrombosis on these valves is not rare (12%), but usually develops on the atrial side of the leaflets; interestingly, in this patient the thrombosis was on the ventricular side, likely due to an acute reduction in flow velocity caused by the after-load mismatch and the subsequent cardiogenic shock.

OC02.08: Percutaneous fetal aortic valvuloplasty for critical aortic stenosis

To describe our experience with fetal aortic valvuloplasty (FAV) in fetuses with critical aortic stenosis (AS) regarding indications, complications and postnatal outcomes. All FAV performed for critical AS between 2010 and 2019 in our institution were included. Selection criteria included retrograde flow in the aortic arch, left-to-right shunt across foramen ovale, left ventricle (LV) and mitral dimensions >-2SD, moderate or severe LV systolic dysfunction, < 30 weeks' gestation, moderate or severe endocardial fibroelastosis and impaired severe LV diastolic dysfunction. FAV were performed under ultrasound (US) guidance. Balloon inflation across the aortic valve (AV) and amelioration of the anterograde aortic flow across AV defined a technical success. At birth, cardiac US were performed and biventricular circulation (BVC) strategy was decided when the LV systolic and diastolic function were good enough to ensure systemic circulation. In those cases, no treatment or postnatal valvuloplasty were considered. When LV function or size were not suitable for biventricular repair, univentricular circulation (UVC) strategy was chosen and Norwood palliation was performed at birth. 48 procedures were performed in 43 fetuses at 26.3 ± 2.7 weeks of gestation. FAV was successful in 79.2% of the cases. Complications that required in utero reanimation occurred in 29.2% of the cases. Early post-operative intrauterine fetal demise occurred in 11.6% of the cases and 23.2% patients opted for termination of pregnancy (7/10 after a technically successful FAV). 24 patients delivered live born infants at 37.4 ± 3.2 weeks, with BVC in 54.1%. Liveborn infants with a technically successful FAV were more likely to have BVC (70.6%) than those with technically unsuccessful FAV (14.3%, p = 0.04). In our experience, 70.6% of fetuses with critical AS who undergo technically successful FAV have BVC postnatally.

89 Simultaneous ocurrence of hammock mitral valve and no-compaction cardiomyopathy

Abstract We report a 62-year-old man with a past medical history of dyslipidemia, paranoid schizophrenia and permanent atrial fibrillation. A ATTE performed at his district hospital revealed rheumatic mitral valve disease with double lesion: severe regurgitation and mild stenosis, plus moderate tricuspid regurgitation and a mean PAP of 32mm Hg. Cardiac catheterization showed no abnormalities of the coronary arteries. He was transferred to our hospital and scheduled for mitral valve replacement and tricuspid ring valvuloplasty. Preoperative transesophageal echocardiography showed an abnormal subvalvular mitral apparatus, with false tendons and multiple papillary muscles, resembling a hammock mitral valve. Most cordae tendinae arose from a single dominant papillary muscle at a posterior medial region, which provoke severe mitral regurgitation due to coaptation defect and mild subvalvular mitral stenosis. It could also be appreciated hypertrabeculation in the lateral medial, basal and apical segments. This suggested no-compaction cardiomyopathy associated with hammock mitral valve. Left ventricular systolic function was preserved. No evidence of rheumatic mitral valve disease was found in transesophageal echocardiographic study performed at our hospital. On the 30th April 2019 he underwent mechanic mitral valve replacement (Bicarbon 29mm) and tricuspid ring valvuloplasty (Edwards Physio 32mm) surgery. Once the patient was weaned from cardiopulmonary bypass, severe left ventricle systolic dysfunction ensued, predominantly localized in the anterior, inferior septal, inferior lateral basal and medial segments. Apical segments had preserved mobility An adrenalin infusion prior weaning from CBP was initiated. Preserved mobility of the mitral prosthesis discs was observed. The patient developed cardiogenic shock in spite of high doses of dobutamin and adrenaline infused. IACB was implanted with 1:1 assistance. The patient was transfered to the hemodynamic room in order to rule out coronary complications. Cardiac catheterization showed no significant angiographic lesions. During the first postoperative hours, the patient was stabilized allowing progressive lowering of the drugs (adrenaline, dobutamine). TTE showed normally functioning prosthetic mitral valve and preserved left ventricle systolic function. An MRI was performed demostrating no-compaction cardiomyopathy Conclusion This case report describes a rare presentation of simultaneous ocurrence of hammock mitral valve and no-compaction cardiomyopathy. Perioperative left ventricle dysfunction in no-compaction cardiomyopathy is related to subendocardial ischemia caused during extracorporeal circulation in the multiple prominent ventricular trabeculations with deep intertrabecular recesses corresponding to non-compacted myocardium .This must be taken account in those patients with no-compaction cardiomyopathy scheduled for cardiac surgery in order to take preventive measures. Abstract 89 Figure. non - compacted myocardium

414 Ventricular-arterial interaction predicts response to cardiac resynchronization therapy: a link with improvement of endothelial function and arterial elastic properties

Abstract Background Endothelial dysfunction (ED) is a hall mark of chronic heart failure and has been linked to disease progression, hospitalizations and mortality. Purpose to evaluate the impact of cardiac resynchronization therapy (CRT) in ED and to determine predictors of response to CRT Methods CRT recipients from 19/07/2016 until 19/10/2018 were studied at baseline and 3 months after. In each visit we evaluated a 12 lead ECG, carotid to femoral pulse wave velocity (cfPWV), flow-mediated dilatation of the brachial artery (FMD), left ventricle ejection fraction (LVEF) and left ventricle (LV) global longitudinal strain (GLS). We evaluated arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography and the ratio of cfPWV to GLS, as valid markers of ventricular-arterial interaction. We also assessed the layer of endothelial glycocalyx by measurement of Perfused Boundary Region (PBR) of the sublingual microvessel range:5-25 microns. Results 32 patients with a mean age 65.5 (±10.9) years and severe LV systolic dysfunction were enrolled. During follow-up, LVEF, GLS, LVESV and all ED markers exhibited significant improvement (table 1). 23 patients were responders. Among the baseline vascular function markers, only the ratio cfPWV/GLS predicted response to CRT (OR: 0.245, 95%CI: 0.042-0.759, p = 0.044).Threshold analysis showed that the best threshold of cfPWV/GLS for response to CRT was 2.75 (specificity: 0.67%, sensitivity: 0.94%). Conclusions After 3 months of CRT, endothelial function, arterial elasticity and ventricular arterial interaction are improved. The baseline ratio cfPWV/GLS, a novel marker of ventricular arterial interaction, can be applied to predict response to CRT. table 1 Baseline Follow-up Change Measurement mean (sd) mean (sd) mean (sd) p-value SBP (mmHg) 126 (19) 128 (16) 2.18 (11.98) 0,465 DBP (mmHg) 79 (9) 80 (9) 1.06 (8.58) 0,618 LVEF (%) 27 (7) 35 (9) 7.50 (4.77) &amp;lt;0.001 LVESV (mL) 151 (42) 120 (46) -26.91 (17.20) &amp;lt;0.001 GLS (%) 6.47 (2.89) 9.33 (4.18) 2.85 (2.28) &amp;lt;0.001 FMD (%) 5.88 (2.79) 10.25 (3.67) 4.37 (3.34) &amp;lt;0.001 Ea/Ees 2.81 (1.10) 2.04 (0.99) -0.77 (0.47) &amp;lt;0.001 cfPWV 11.11 (2.61) 10.01 (2.45) -1.10 (1.56) 0,003 PBR 5-25(microns) 2.26 (0.20) 2.14 (0.24) -0.13 (0.25) 0,028 cfPWV/GLS 2.18 (1.46) 1.45 (1.11) -0.73 (0.55) &amp;lt;0.001 Measurements at baseline, follow-up and their change during study Abstract 414 Figure. picture 1

An urgent open surgical approach for left ventricle venting during peripheral veno-arterial extracorporeal membrane oxygenation for refractory cardiac arrest: case report

The objective of the study is to describe an emergency procedure for left ventricle venting during veno-arterial extracorporeal life support for refractory cardiac arrest. Veno-arterial extracorporeal membrane oxygenation is widely used in refractory cardiac arrest but is characterized by an increase in left ventricle afterload, which may impair cardiac contractility improvement. Different left ventricle venting techniques are available. We report the use of a surgical approach with sternotomy for left ventricle venting in a 21-year-old patient who was placed under veno-arterial extracorporeal membrane oxygenation for refractory cardiac arrest with severe pulmonary edema, respiratory failure, and left ventricle stasis. A 21-year-old woman was admitted for laparoscopic sleeve gastrectomy. In the recovery room, she developed a refractory circulatory shock. Transthoracic echocardiography revealed a dilated cardiomyopathy with severe left ventricle systolic dysfunction (left ventricle ejection fraction at 20%). Coronary angiogram was normal. On day 2, she underwent laparotomy for sepsis and she presented cardiac arrest secondary to ventricular tachycardia. We proceeded to peripheral veno-arterial extracorporeal membrane oxygenation as the cardiac arrest was refractory. A miniaturized veno-arterial extracorporeal membrane oxygenation system was implanted into the right femoral vessels onsite .The low flow duration was 40 minutes. Veno-arterial extracorporeal membrane oxygenation blood flow was set to 3 L min-1, resulting in a closed aortic valve and a massive pulmonary edema. Transesophageal echocardiography showed left ventricular ejection fraction at 5% without aortic valve opening. We first implanted an intra-aortic balloon pump without clinical improvement. Transesophageal echocardiography revealed massive thrombus formation into the aortic root. We decided to perform an open surgical approach for left ventricle unload using a transmitral cannula (22 Fr) via the right superior pulmonary vein connected to the inflow tube of the veno-arterial extracorporeal membrane oxygenation with Y connection. Transesophageal echocardiography showed a full opening of aortic valve and elimination of valve aortic thrombus. Chest radiography showed a significant decrease of pulmonary congestion. We were able to withdraw extracorporeal life support organization on day 10 and discharged on day 54. Clinical explorations reveal a fulminant rocuronium-related hypersensitivity myocarditis. This salvage surgical technique using a modified central veno-arterial extracorporeal membrane oxygenation cannulation technique has efficiently decreased blood stasis and permitted rapid recovery.

Eosinopenia as an Adverse Marker of Clinical Outcomes in Patients Presenting with Acute Myocardial Infarction

BackgroundEosinopenia is considered a surrogate of inflammation in several disease settings. Following ST-segment elevation myocardial infarction, eosinopenia is presumed to be a marker of infarct severity. We sought to study the relationship between eosinopenia and infarct severity and how this relationship determined the long-term outcomes following ST-segment elevation myocardial infarction. MethodsSix hundred and six consecutive patients undergoing primary percutaneous coronary interventions from a large volume single center were enrolled. Low eosinophil count was defined as < 40 cells/mL from samples within 2 hours after reperfusion. Primary endpoint was defined as composite of death, myocardial infarction, stroke, unplanned revascularization, and readmission for heart failure over 3.5 years’ follow-up. ResultsSixty-five percent of the patients had eosinopenia. Patients in the low eosinophil group had larger infarct size as measured by troponin value (2934 vs 1177 ng/L, P < .001) and left ventricle systolic function on echocardiography (48% vs 50%, P = 0.029). There was a weak correlation between eosinophil count and both troponin (r = -0.25, P < 0.001) and ejection fraction (r = 0.10, P = .017). The primary endpoint was higher in eosinopenic patients (28.8% vs. 20.4%; hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.05 to 2.13, P = .023). A discordance between eosinopenia and severe left ventricle systolic dysfunction was observed in 55.6% of cases. Compared with normal count, eosinopenia was associated with worse clinical outcomes in patients with non-severe left ventricle dysfunction (24.1% vs 16.2%; HR 1.58, 95% CI 1.01 to 2.45, P = .044) but not in those with severe left ventricle dysfunction (42.3% vs. 38.9%; HR 1.10, 95% CI 0.59 to 2.03, P = .77) (P < .01 for interaction). ConclusionsEosinopenia is an easily determined marker that reflects worse clinical outcomes over long-term follow-up.

Coronary sinus as a site for stable temporary atrial pacing to tide over premature ventricular complex–triggered recurrent ventricular fibrillation in a patient with severe left ventricular dysfunction after coronary bypass surgery

Use of atrial pacing has been known, yet underutilized tool for effective temporary pacing whenever needed early after cardiac surgery. The reasons may be frequent failures of epicardial wires (fixed over atria intra-operative) leading to loss of capture. Endocardial atrial pacing sites for temporary pacing are unstable and hence continuous pacing with acceptable thresholds is impossible. We describe a case of ischemic cardiomyopathy and severe left ventricle systolic dysfunction who required atrial pacing post coronary artery bypass grafting (CABG) surgery for around 48–72 hours starting 4th day post operation when he had multiple episodes of ventricular fibrillation (VF) needing many defibrillation shocks. VF episodes were triggered by premature ventricular complexes (PVC) falling on as R on T. Episodes were refractory to anti-arrhythmic drugs and general anesthesia. These PVC were successfully overdriven by atrial pacing by fluoroscopically placing pacing lead in coronary sinus. This led to complete suppression of PVC induced VF for next 48–72 hours while the antiarrhythmic drugs were continued. Subsequently the patient was discharged in stable state. Atrial pacing, though quite valuable during the post-operative period after cardiac surgery, is underutilized, especially when pacing through surgically placed epicardial wire fails. This report is helpful in drawing attention towards coronary sinus (CS) as an alternate site for achieving stable, temporary atrial pacing during the post-operative period. This site can also be utilized for short term dual chamber pacing if required in post-operative state using transvenous CS site for atrial pacing and intraoperatively placed epicardial wire for ventricular pacing.

Hemodynamic effects of the vasodilation in different vascular regions on patients with severe left ventricle systolic dysfunction

Objective. To determine the specificity of the vasodilation of isosorbide dinitrate (ID), nitric oxide (NO), inhaled iloprost (iIlo). Materials and methods. Study included 190 vasoreactivity tests (ID, NO or iIlo, Swan-Ganz catheter) performed in 124 candidates for heart transplantation. Results. In the ID group mean PAP decreased by 22.8±14.7 %, in the NO - by 5.9±17.4 %, in the iIlo - by 14.6±15 %, PAWP in the ID group decreased by 29±17 %, in the iIlo - by 3.9±27.2 %, but in NO PAWP increased by 11±33.7 %. When using NO, SVI decreased from 23.8±7.9 to 22.4±6.7 ml/m 2 . When using D, SVI increased by 29.2±27.7 %, as well as in the iIlo by 20.6±24.5 %. Conclusion. Selective vasodilation of pulmonary vessels by NO caused LV overload and a decrease in LV output.

Can chronotropic incompetence predict life-threatening ventricular arrhythmias in patients with stable ischemic heart disease?

Background:Chronotropic incompetence has prognostic value of all-cause and cardiovascular mortality in both patients with asymptomatic and symptomatic ischemic heart disease (IHD), regardless of traditional risk factors. The aim of this study was to investigate the relationship between chronotropic response during exercise test and the development of ventricular arrhythmias.Methods:153 patients with stable ischemic heart disease were screened and observed during the 24 months since October 2014 in a university hospital in Astana Kazakhstan. They underwent bedside electrocardiography, 24h heart rate Holter monitoring, echocardiography, exercise stress test (treadmill) for assessment of chronotropic index calculating at first contact. Holter- electrocardiography was repeated three times (at 3, 6, 12 months of follow-up period) to reveal life-threatening ventricular arrhythmias.Results:The quantity of the ventricular extrasystoles was higher in the group with low chronotropic index. Low chronotropic index increased the risk of high grade ventricular extrasystoles more than two times (P=0.015); episodes of non-sustained VT more than three times (p<0.001); and episodes of sustained VT more than nine times (p<0.001).Conclusions:Chronotropic index less than 35.6 increases the risk for life-threatening ventricular arrhythmias in patients with stable chronicle ischemic heart disease irrespectively of severe left ventricle systolic dysfunction.

75 Inherited left ventricular non-compaction in spontaneous monochorionic diamniotic twin pregnancy

IntroductionPregnancy in Left Ventricular Non-Compaction (LVNC) can increase the risk of heart failure, arrhythmias and systemic embolic events. LVNC carries an autosomal dominant trait and incomplete penetrance. This case study...

Ethnicity and the risk of ventricular arrhythmias due to stable ischemic heart disease

Objective: determination of the of life-threatening ventricular arrhythmias risk in native nationality patients with stable ischemic heart disease. Methods. The cohort study included 216 patients with stable ischemic heart disease with left ventricular ejection fraction not less than 40%. All participants initially underwent anthropometric measurements, laboratory routine tests, 6-minute walking test, ECG, 24-hours ECG monitoring, echocardiography. After 3, 6 and 12 months, participants were invited to repeat 24-hours ECG monitoring procedure for life-threatening ventricular arrhythmias episodes detection. Results. Participants cohort included 130 native nationality persons (Kazakhs) and 86 Caucasian patients. Characteristics of the sample: 181 men (84%), the average age of 62 [57; 66], the average follow-up period - 12,7 ± 1,2 months. Increased relative risk of ventricular arrhythmias in Kazakh patients was revealed: high grading ventricular premature beats RR 1.98 (95% CI 1,02-3,84), P = 0.010); non-sustained ventricular tachycardia RR 2.80 (95% CI 1,07-8,97), P <0.001). Signifcant independent influence on life-threatening ventricular arrhythmias development in patients Kazakh nationality had anemia, obesity, diabetes and limitation in 6-minute walking test performing. Conclusion. Arrhythmic events in native nationality patients with stable ischemic heart disease without severe left ventricle systolic dysfunction are different from those of Caucasians, that should be considered when predicting the individual risk of arrhythmic events and sudden cardiac death in native nationality patients.

CLINICAL CHARACTERISTICS,ECHOCARDIOGRAPHIC PROFILE AND OUTCOME OF PERIPARTUM CARDIOMYOPATHY AT BPKIHS, A TERTIARY CARE HOSPITAL IN NEPAL

Background: Peripartum Cardiomyopathy (PPCM) is a pregnancy assosciated myocardial disease. It is a rare disease with unknown etiology. Certain characteristics are risk factors for the disease. Recognition of its risk factors is important for prevention and treatment. Objectives: To determine clinical characteristics, echocardiographic profile and in hospital outcome of patients with peripartum cardiomyopathy. Methods: This is a descriptive retrospective study. All patients files with the diagnosis of peripartum cardiomyopathy from 1 st November 2009 to 30 th December 2014 were studied. Demographic data, echocardiogram and in hospital outcome of patients were reviewed. Results: Sixty five patients were diagnosed with PPCM during the study period. Mean age was 28 ± 6.5yrs. Fifty eight patients (89%) were multigravida and only seven (11%) were primigravida. Only two patients had twin pregnancy. Fourty four (68%) presented after delivery and twenty one (32%) presented during pregnancy. Most of the patients 57 (88%) were in NYHA class III and IV. Fifty seven (88%) patients had moderate to severe Left ventricle systolic dysfunction. Five (8%) had preeclampsia, four (6%) had eclampsia and two developed gestational hypertension. Two patients were diabetic. None of the multiparous patients had history of PPCM. No maternal mortality was there. Fetal outcomes were good with all resulting live births and most were appropriate for gestational age.

37. Restoration of normal left ventricular geometry after percutaneous mitral annuloplasty – Case report and review of literature

Surgical mitral valve intervention is not considered suitable in patients with severe functional mitral regurgitation due to severe dilated cardiomyopathy and severe systolic dysfunction. In such patients percutaneous mitral valve intervention is the next best alternative. We are presenting case report of a patient who presented with severe dyspnea progressing to orthopnea and paroxysmal nocturnal dyspnea. He was found to have severe functional mitral regurgitation and severe left ventricle systolic dysfunction. Surgical mitral intervention was not considered suitable and percutaneous mitral annuloplasty was done. At one month follow-up significant improvement in symptoms were noted with improvement in severity of mitral regurgitation severity. At six months follow-up further improvement in symptoms were noted along with significant improvement in the severity of mitral regurgitation and normalization of left ventricle geometry. At one year follow-up his symptoms further improved, left ventricle geometry remained normal and mitral regurgitation severity remained mild to moderate. Our case demonstrate that in patient with severe LV systolic dysfunction, severe mitral regurgitation and LBBB percutaneous mitral annuloplasty can obviate the need for CRT-D due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months.

Iatrogenic reverse takotsubo cardiomyopathy.

A 47-year-old woman with a history of ischemic stroke and dyslipidemia presented with severe gastrointestinal (GI) symptoms that lasted for a week. The abdominal CT was normal, but due to persistent complaints, she was admitted for clinical monitoring. Intravenous β-blockers were administered for a sinus tachycardia. Soon after esmolol, acute cardiac failure ensued with prompt progression to cardiogenic shock. Owing to acute respiratory failure, the patient was mechanically ventilated and inotropes were started. Electrocardiogram showed no signs of myocardial ischemia (Fig. 1), with a slight prolongation of the QTc interval (479 ms). A mild troponin I elevation was detected (8.2 μg/l) and the nt-pro BNP levels were 12 706 pg/ml. Figure 1 ECG after acute heart failure onset. Sinus tachycardia. No signs of myocardial ischemia. The transthoracic echocardiogram (TTE) was performed after the clinical diagnosis of acute heart failure, which revealed a non-dilated left ventricle (LV) with severe systolic dysfunction. Apical segments had a preserved contractility, contrary to the mid-basal ones, which was not supportive of a coronary event. Moderate functional mitral regurgitation (MR) was identified (Figs 2, ​,33 and Videos 1, 2). Video 1 Initial TTE sub-costal view. Non-dilated LV and severe LV dysfunction, normal LV wall thickness, preserved LV apical contractility, and mid- to base akinesis of the LV are indicated. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0009-v1 Download Video 1 Video 2 TTE apical three-chamber view, showing functional MR. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0009-v2 Download Video 2 Figure 2 Initial TTE sub-costal view, end-systolic frame. Non-dilated LV and severe LV systolic dysfunction are observed. Preserved contractility of the apical segments can be noticed (asterisk). Figure 3 Initial TTE apical three-chamber view. Functional MR can be noticed. A coronary angiogram revealed no significant disease and a LV angiogram confirmed severe systolic dysfunction, with MR. Similar to the TTE, a wall motion pattern of preserved apical contractility was recognized (Fig. 4 and Video 3). Video 3 LV angiogram. There is a preserved LV apical contractility, in contrast to the mid- to base akinesis. Functional MR can also be noticed. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0009-v3 Download Video 3 Figure 4 LV angiogram end-diastolic (A) and end-systolic (B) frames. Akinesis of the mid- and base segments of the LV anterior and inferior walls (white asterisks) is indicated. Preserved apical contractility (black asterisks) and MR (yellow asterisks) can also ... The subsequent clinical evolution was excellent. The TTE, performed 72 h after admission, showed a normal LV systolic function with no wall motion abnormalities and no MR (Videos 4 and 5). The nt-pro BNP decreased to 6917 pg/ml. Improvements were also registered two weeks later through cardiac MRI evaluation, and no myocardial edema, fibrosis, or infarction was identified (Fig. 5 and Video 6). Video 4 TTE apical four-chamber view 48 h after heart failure onset, with complete recovery of LV dysfunction and wall motion abnormalities. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0009-v4 Download Video 4 Video 5 TTE apical three-chamber view, 48 h after heart failure onset. Complete resolution of the MR can be noticed. Download Video 5 via http://dx.doi.org/10.1530/ERP-14-0009-v5 Download Video 5 Video 6 Cardiac MRI after 2 weeks. True fast imaging with steady-state free precession four-chamber view. Normal LV systolic function and no wall motion abnormalities could be observed. Download Video 6 via http://dx.doi.org/10.1530/ERP-14-0009-v6 Download Video 6 Figure 5 Two weeks after acute heart failure onset, no significant changes were noted in the cardiac late gadolinium enhancement imaging. We hypothesize that the cause of the non-apical ballooning syndrome was a combination of esmolol and a preceding stress, due to a GI illness with sympathetic stimulation.

126 Inter-ventricular delay at peak exercise is independently correlated with left ventricular remodeling at three months in heart failure patients selected for cardiac resynchronisation therapy

Cardiac resynchronisation therapy (CRT) is known to improve survival and to induce beneficial left ventricle (LV) remodeling in heart failure (HF) patients presenting with severe LV systolic dysfunction and prolonged QRS interval. Using those selection criteria, about 35 to 40% of patients remain non-responders to CRT. We assessed whether exercise inter-ventricular dyssynchrony could be a relevant index for the prediction of response to CRT. Eighteen HF patients performed a semi-supine symptom-limited exercise echocardiography before device implantation. Inter-ventricular dyssynchrony, assessed by inter-ventricular mechanical delay (IVMD) in pulsed wave doppler, was recorded both at rest and peak exercise. We determined correlations between IVMD at exercise and cardiac output, mitral regurgitation, assessed by the effective regurgitant orifice area (ERO), and right ventricular (RV) longitudinal systolic function, assessed by tissue doppler imaging. We looked for correlations between those parameters and the degree of LV reverse remodeling at three months follow-up assessed by the percentage of change in LV end-sytolic volume (%ΔESV) and absolute value of change in ejection fraction (ΔLVEF). 39% of patients were non-responders according to LV remodeling. Exercise-induced changes in IVMD only significantly correlated with RV longitudinal systolic function (r= - 0.602; p = 0.01) at peak exercise. In a multivariate analysis by stepwise regression, IVMD at peak exercise was independently correlated with %ΔESV (β = 0.418; p = 0.01) and ΔLVEF (β = -0.563, p = 0.03) at follow-up. Peak exercise ERO was the only other independent factor correlated with %ΔESV (β = 0.808, p < 0.001) and ΔLVEF (β = -0.404, p = 0.02). In HF patients, IVMD at peak exercise seems to be a relevant independent predictor of mid-term LV remodeling after CRT. Its relation with RV longitudinal systolic function during exercise could provide a pathophysiological explanation.

Resultados maternos e perinatais em pacientes com disfunção sistólica grave

The objective of this study was to evaluate maternal and fetal outcome in patients with severe left ventricle systolic dysfunction followed in a tertiary-care hospital. We retrospectively evaluated 12 pregnant women with severe systolic dysfunction, defined as a ejection fraction<40%. Follow-up data included functional class evaluation, occurrence of cardiac and obstetric events, labor data and neonatal outcome. Cardiac events were defined as new onset of arrhythmias, stroke, pulmonary thrombosis, pulmonary edema, cardiac arrest, and death. The mean ejection fraction was 28.9+/-6.47%. Four patients were in the NYHA class III, and 8 in class I or II on presentation. Ten patients had deteriorated during pregnancy. The most common cardiac event was pulmonary edema (3 patients). Three of the four patients with class III on presentation had a good evolution during pregnancy, and the other one had preterm delivery due to worsening symptoms. There were 2 vaginal spontaneous deliveries and 10 cesarean sections. Small-for-gestational-age birthweight occurred in 10 pregnancies. There was no maternal or neonatal death. Pregnancy in patients with severe left ventricle systolic dysfunction increases the risk of maternal complications and compromises fetal growth. It is important to follow this women in a tertiary-care hospital.

Is Chagas cardiomyopathy an independent risk factor for patients with heart failure?

Some studies showed increased mortality in chagasic patients but most of these studies did not perform statistical adjustments to socioeconomic variables. The main objective of this study was to investigate if there is an independent association between Chagas etiology and mortality in patients with heart failure and moderate to severe left ventricle systolic dysfunction. Stratified analysis by the variables associated to chagasic etiology and multivariate analysis through logistic regression were performed to evaluate the relationship between Chagas cardiomyopathy and one-year mortality. Among 417 patients initially evaluated, 191 had the inclusion criteria. The mortality was higher in patients with Chagas cardiomyopathy than in the patients with other etiologies (log rank test; p = 0.036). At one-year follow-up, the mortality in chagasic patients was 21.6% versus 10.6% in the remaining (relative risk = 2.03; 95% CI = 0.98–4.2; p = 0.05). At logistic regression, educational level was identified as a confounder variable of the association between Chagas cardiomyopathy and one-year mortality. This association was no more statistically significant after adjustment for educational level (odds ratio = 1.67; 95% CI = 0.63–4.41). In this study, Chagas cardiomyopathy was a marker of worse prognosis, but was not independently associated to increased one-year mortality in outpatients with heart failure and moderate to severe systolic dysfunction.