Standard Echocardiographic Parameters Research Articles

Right Ventricle Myocardial Work in ToF-repair survivors: no longer behind the scenes

Abstract Funding Acknowledgements Type of funding sources: None. Background Tetralogy of Fallot is the most common cyanotic CHD and survivors after ToF repair are growing rapidly. Children and, more frequently, young adults spToF develop late complications: life-threatening ventricular arrhythmias and SCD remain a great concern in these patients. This study has the aim to analyse advanced Right Ventricle echocardiographic and CMR features sp-ToF in the long-term follow-up, finding non-invasive predictors of adverse prognosis. Methods This is a retrospective cohort study. 240 patients sp-ToF were included (mean age 13 ± 11 years). The electrocardiographic, echocardiographic, CMR and CPET data were reviewed retrospectively. Non-invasive RV Global myocardial Work Index (RVGWI) was calculated as the area of the RV pressure-strain loops. RV Global Constructive Work (RVGCW), RV Global Wasted Work (RVGWW) and RV Global Work Efficiency (RVGWE) were estimated. Patients were screened according to age at surgery, time since the radical repair at the follow-up, increased estimated RV systolic pressure, differences in instrumental findings after PVrep. A composite end-point of MACEs (syncope, sustained and non-sustained ventricular tachycardia, sudden cardiac death) was used. Results Older patients at surgery (≥12 months) have significantly reduced VO2 max at CPET, larger RA and LA areas and larger RV basal diameter. CPET values are not significantly different in patients with more than 25 years since the corrective surgery but echo and CMR-LVEF measured are slightly but significantly reduced and RVGWE is significantly lower. Patients with RVSP ≥ 60 mmHg have significantly higher RVGWW, worst RV FWLS, lower RVGCW and RVGWE. Patients who have undergone PVrep show improvement in RV GLS, RV FWLS and RVGWE and a RVGWW reduction. As reguards the CMR RV volume evaluation sp-ToF, patients with RVESVi ≥80ml/m2 have lower RVGWE and show an inverse correlation between RVEDVi and RVGWE. Sp-ToF patients with borderline/impaired predicted VO2 max at CPET have a reduced RV FWLS, higher RVGWW and an inverse correlation between METs and RVGWW. Patients who have suffered MACEs (2 NS-TV, 3 S-TV, 7 syncopes, 8 sudden deaths) hadsignificant impairment of RV systolic function (FAC, RV FWLS, CMR-RVFE), significantly higher RVGWW, lower RVGWE and RVGWI. Conclusion Long-term survival and clinical condition sp-ToF in infancy are generally good and late functional status in survivors could be excellent up to 25 years after radical correction. However, older patients at surgery have relative reduced functional status compared with those undergoing early repair. The advanced echocardiographic and CMR evaluation of RV function sp-ToF are usually related to worse prognosis, VT and reduced functional status. RV myocardial work evaluation is feasible in patients with repaired ToF, it may be a more sensitive indicator of RV fuctional impairment compared with standard echocardiographic parameters and is able to predict exercise capacity.

Evaluation of myocardial work index in predicting in-hospital complication in patients with Takotsubo syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Backgrounds Tako-tsubo syndrome (TTS) is a reversible heart failure pathology characterized by transient myocardial left ventricular (LV) dysfunction. Although traditionally considered a benign condition, in-hospital complications are frequent in this cohort of patients. Non-invasive myocardial work (MW) parameters are considered as emerging indexes in evaluating global and regional myocardial systolic function. Aim The aim of this TTS study was to investigate the potential association of MW with in-hospital complications, and to compare MW with standard (LVEF) and advanced (GLS) echocardiographic parameters of LV systolic function Methods thirty-eight patients (mean age, 68 ± 12 years, 35 women) with TTS diagnosed with Takotsubo Italian Network criteria were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours from hospital admission. Clinical and echocardiographic characteristics during the index event were reported in table 1. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating into its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted myocardial work (WMW) were measured. LV GLS and LV EF were also measured. In hospital complications were defined as a composite of apical LV thrombosis, hypokinetic arrhythmias (HA), supraventricular tachycardia (SVT), acute heart failure (AHF), ventricular tachycardia/fibrillation (VT/VF), cardiogenic shock (CS), respiratory arrest (RA), stroke and cardiac death (CD). Results Hospital complications occurred in 16 TTS patients (26% with AHF; 10% with SVT; 8% with CS; 5% with apical LV thrombosis; 5% with HA; 2,6 % with RA; 2,6% with stroke; 2% with VT/VF). The WMW parameter appear to have the best performance in predicting in-hospital complications (odds ratio for having HC: 8.4 (95% confidence interval: 1.5 to 46.1), figure 2). Conclusion global and regional myocardial performance is transiently impaired in TTS and significantly associated with hospital complication. Although limited by the low number of patients, these results suggest that myocardial work parameters may have a better performance than the EF value in predicting intra-hospital complications. Larger studies will be necessary to confirm these preliminary results.

Left atrial function assessed by speckle tracking echocardiography as a marker of atrial reverse remodeling in patients with mitral regurgitation treated with transcatheter edge-to-edge repair

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial reverse remodeling has been defined relying on changes in left atrial volume following specific procedures. Little is known about functional assessment of the left atrium by left atrial strain and left atrial emptying fraction (LAEF) following edge-to-edge mitral repair. Purpose The aim of this study is to assess left atrial function by speckle tracking echocardiography and changes in LAEF, as markers of atrial reverse remodeling, in patient with mitral regurgitation treated with edge-to-edge repair technique. Methods A total of 35 patients diagnosed with severe functional or organic mitral regurgitation who underwent trans-catheter edge-to-edge mitral valve repair were selected. Demographic, clinical and echocardiographic data were collected at the time of enrollment and after a minimum follow-up of six months. The primary endpoint was to assess if left atrial speckle tracking echocardiographic parameters (LASr, LAScd, LASct) and changes in LAEF were reliable indicators of left atrial reverse remodeling, defined as a reduction in indexed left atrial volume ≥ 15% with respect to basal assessment. Collaterally, we tried to identify clinical and standard echocardiographic parameters significantly related to atrial reverse remodeling. Changes between baseline and follow-up parameters were assessed using paired t-test. Results LASr, LASct and LAEF improved significantly in patients with left atrial remodeling during follow-up (LASr: 15,8%±8,43 vs 19,7%±12,22 - P 0,047; LASct: −6,4%±6,21 vs − 9,9%±8,52 - P 0,036; LAEF: 35,5%±14,17 vs 44,1%±15,17 - P 0,003). Collaterally, among all demographics, clinical and echocardiographic data, the absence of coronary artery disease, a systolic dominant pulmonary vein flow, as assessed with pulse-wave-Doppler after the repair, therapy with ACEi/ARB, lower increases in mitral valve pressure gradient after the procedure and lower pulmonary artery systolic pressure at discharge significantly correlated with reverse atrial remodeling. Conclusions In patients with mitral regurgitation treated with edge-to-edge repair, the assessment of left atrial function by speckle tracking echocardiography and left atrial emptying fraction correlates with atrial reverse remodeling, after a minimum follow-up of six months from the procedure. Further studies are needed to better clarify the impact of left atrial remodeling on strong clinical outcomes in patient with mitral regurgitation treated with edge-to-edge repair technique and the role of functional parameters in the definition of the optimal candidate and timing for the repair.

Myocardial work in children with Wolff-Parkinson-White syndrome.

Wolff-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardial deformation, and when left ventricular dysfunction is present, catheter ablation of the accessory pathway may be required, even in asymptomatic patients. We aimed to evaluate the diagnostic value of non-invasive myocardial work in predicting subtle abnormalities in myocardial performance in children with WPW.Seventy-five paediatric patients (age 8.7 ± 3.5years) were retrospectively recruited for the study: 25 cases with manifest WPW and 50 age- and sex- matched controls (CTR). Global myocardial work index (MWI) was measured as the area of the left ventricle (LV) pressure-strain loops. From MWI, global Myocardial Constructive Work (MCW), Wasted Work (MWW), and Work Efficiency (MWE) were estimated. In addition, standard echocardiographic parameters of LV function were evaluated. Despite normal LV ejection fraction (EF) and global longitudinal strain (GLS), children with WPW had worse MWI, MCW, MWW, and MWE. At multivariate analysis, MWI and MCW were associated with GLS and systolic blood pressure, and QRS was the best independent predictor of low MWE and MWW. In particular, a QRS > 110ms showed good sensitivity and specificity for worse MWE and MWW values. In children with WPW, myocardial work indices were found significantly reduced, even in the presence of normal LV EF and GLS. This study supports the systematic use of myocardial work during the follow-up of paediatric patients with WPW. Myocardial work analysis may represent a sensitive measure of LV performance and aid in decision-making.

Left atrial strain as an independent predictor of sinus rhythm maintenance after catheter ablation for paroxysmal atrial fibrillation in HFpEF patients

Abstract Funding Acknowledgements Type of funding sources: None. Background The early AF treatment by radio-frequency catheter ablation is very important for improving clinical outcome in patients with history of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Left atrial (LA) strain showed to be a useful index to monitor atrial function in AF and HFpEF states. However, the accuracy of LA strain to predict the long-term maintenance of sinus rhythm (SR) in HFpEF patients with paroxysmal AF undergoing catheter ablation is still under debate. Aims To define the best echocardiography derived parameters to predict the long-term maintenance of SR in paroxysmal AF patients with high probability of HFpEF undergoing catheter ablation. Methods We prospectively enrolled (between September 2017 and May 2019) 200 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%). All patients had a H2FPEF score suggesting high probability of HFpEF. During sinus rhythm, all patients underwent comprehensive transthoracic echocardiography at baseline, including assessment of left ventricular (LV) global longitudinal strain (GLS), left atrial (LA) reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) using two-dimensional speckle tracking in apical views. Results After 42+/-8 months follow-up, a total of 34 (17%) patients had a documented recurrence of AF. Patients with AF recurrence had lower LASr (22.2% vs. 28.3%, p < 0.001) and LASct (10.9% vs. 13.2%, p < 0.01) compared to patients who keep on SR. Among speckle tracking derived LA phasic strain indices, LASr showed the largest area under the curve (AUC = 0.8, p < 0.001) and the strongest independent predictive value (LASr > 22%) of long-term maintenance of SR with sensitivity of 80% and specificity of 66% (Figure 1). Other parameters of LA function, LA diameter, maximum or minimum LA volume index, LV GLS or ejection fraction, and indices of LV diastolic function had lower area under the curve. Using multivariable logistic regression, only LASr (OR 0.89, 95% CI 0.81-0.97, p=0.013) was independently associated with long-term SR maintenance while other LA size and function indices were not. Conclusion In HFpEF patients with paroxysmal AF undergoing catheter ablation, LASr is more accurate predictor of SR maintenance than other standard echocardiographic parameters in long-term follow-up. Figure 1: Receiver-operating characteristic curves of left atrial reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct), LA emptying fraction (LAEF), LA expansion index (LAEI), LA end-systolic (LAES) and end-diastolic (LAED) volume index (VI) to predict long-term maintenance of sinus rhythm.

P125 LEFT ATRIAL AND VENTRICULAR STRAIN, AND 3D–ECHOCARDIOGRAPHY FOR SUBCLINICAL CHEMOTHERAPY–RELATED CARDIAC DYSFUNCTION IDENTIFICATION IN PATIENTS WITH BREAST CANCER

Abstract Cardio–oncology is a recent rapid–developing multidisciplinary approach created by oncologists in accordance with cardiologists with the objective to minimize the adverse cardiovascular effects of contemporary cancer therapy and to maximize the benefits that can be obtained from it. Pre–treatment cancer therapy–related cardiovascular toxicity (CTR–CVT) risk assessment can be performed using HFA–ICOS risk assessment tools, in addition to a careful clinical history analysis, physical examination, ECG, biomarkers, and echocardiography. In our study, the analysis of standard and advanced echocardiographic parameters (left atrial strain or LAS, left ventricular global longitudinal strain or GLS, and 3D echocardiography) were performed at baseline, at three, six, and 12 months timepoints. A number of 53 female patients with breast cancer, scheduled to receive chemotherapy, was enrolled. All patients had basal 3D LVEF values ≥ 50% and a basal GLS > –18,5%. Statistically significant reductions (p<0,001) in 3D LVEF at three, six, and 12 months compared to baseline were found, and in all cases 3D LVEF levels were within the reference values (3D LVEF ≥ 50%). GLS and atrial strain parameters (LASr and LASct) were significantly reduced compared to the baseline at 3 months (GLS p<0.01; LASr p<0,001; LASct p<0,001), 6 months (GLS p<0.05; LASr p<0,001; LASct p<0,001) and 12 months (GLS p<0.01; LASr p<0,05; LASct p<0,01). Moreover, 10 patients out of 53 (18,87%) had asymptomatic cardiotoxicity (expressed by >15% of GLS reduction compared to baseline) after 12 months, and 17 out of 53 patients (32,08%) had atrial dysfunction (expressed by >15% of LASr reduction compared to baseline) after three months. Although atrial dysfunction was not statistically significant in predicting asymptomatic cardiotoxicity (p=0.12), patients with atrial dysfunction at three months have a 3,7 times greater risk of developing asymptomatic cardiotoxicity at 12 months. With our analysis, we found that HFA–ICOS risk score could be considered a predictor of cardiotoxicity at 12 months (p<001). Further studies will be conducted, in order to expand the population and to confirm our results.

Evaluating the pure effect of weight on cardiac function in patients with cardiac syndrome X.

Obese patients have more coronary artery disease (CAD) risk factors that may affect myocardial function. We aimed to assess the ability of echocardiography-derived conventional parameters, left atrial strain, and global longitudinal strain to detect early diastolic and systolic dysfunction in obese individuals with almost no CAD risk factors. We studied 100 participants with structurally normal hearts, ejection fractions above 50%, almost normal coronary arteries in coronary angiogram (syndrome X), and no cardiovascular risk factor except dyslipidemia. Participants were classified as normal-weight (BMI<25.0kg/m2 , n=28) and high-weight (BMI≥25.0kg/m2 , n=72). Conventional echocardiographic parameters and two-dimensional speckle tracking (2DSTE) were used to measure peak LA strain and global longitudinal strain to evaluate diastolic and systolic function, respectively. There was no significant difference in the standard and conventional echocardiographic parameters between the two groups. 2DSTE echocardiographic parameters of the longitudinal deformation of the LV myocardium were not significantly different within the two groups. However, there were significant differences between the subjects with normal-weight and high-weight in terms of LA strain (34.51±8.98% vs. 39.06±8.62%, p=.021). The normal-weight group had lower LA strain, in compression with the high-weight group. All echocardiographic parameters were in the normal range. In the present study we demonstrated that global longitudinal subendocardial deformations, for the evaluation of systolic function, and conventional echocardiographic parameters, for the evaluation of diastolic function, were not significantly different between normal- and high-weight groups. Although LA strain was higher among overweight patients, it was not above the normal range of diastolic dysfunction.

Phasic left atrial strain to predict worsening of diastolic function: Results from the prospective Berlin Female Risk Evaluation follow-up trial.

The predictive value of maximum left atrial volume index (LAVI), phasic left atrial strain (LAS) and other standard echocardiographic parameters assessing left ventricular (LV) diastolic function to discriminate a future worsening of diastolic function (DD) in patients at risk is unclear. We aimed to prospectively assess and compare the clinical impact of these parameters in a randomly selected study sample of the general urban female population. A comprehensive clinical and echocardiographic evaluation was performed in 256 participants of the Berlin Female Risk Evaluation (BEFRI) trial after a mean follow up time of 6.8 years. After an assessment of participants' current DD status, the predictive impact of an impaired LAS on the course of DD was assessed and compared with LAVI and other DD parameters using receiver operating characteristic (ROC) curve and multivariate logistic regression analyses. Subjects with no DD (DD0) who showed a decline of diastolic function by the time of follow-up showed a reduced LA reservoir (LASr) and conduit strain (LAScd) compared to subjects who remained in the healthy range (LASr 28.0% ± 7.0 vs. 41.9% ± 8.5; LAScd -13.2% ± 5.1 vs. -25.4% ± 9.1; p < 0.001). With an area under the curve (AUC) of 0.88 (95%CI 0.82-0.94) and 0.84 (95%CI 0.79-0.89), LASr and LAScd exhibited the highest discriminative value in predicting worsening of diastolic function, whereas LAVI was only of limited prognostic value [AUC 0.63 (95%CI 0.54-0.73)]. In logistic regression analyses, LAS remained a significant predictor for a decline of diastolic function after controlling for clinical and standard echocardiographic DD parameters, indicating its incremental predictive value. The analysis of phasic LAS may be useful to predict worsening of LV diastolic function in DD0 patients at risk for a future DD development.GRAPHICAL ABSTRACT.

Which is the best Myocardial Work index for the prediction of coronary artery disease? A data meta-analysis.

Early diagnosis of Coronary Artery Disease (CAD) plays a key role to prevent adverse cardiac events such as myocardial infarction and Left Ventricular (LV) dysfunction. Myocardial Work (MW) indices derived from echocardiographic speckle tracking data in combination with non-invasive blood pressure recordings seems promising to predict CAD even in the absence of impairments of standard echocardiographic parameters. Our aim was to compare the diagnostic accuracy of MW indices to predict CAD and to assess intra- and inter-observer variability of MW through a meta-analysis. Electronic databases were searched for observational studies evaluating the MW indices diagnostic accuracy for predicting CAD and intra- and inter-observer variability of MW indices. Pooled sensitivity, specificity, and Summary Receiver Operating Characteristic (SROC) curves were assessed. Five studies enrolling 501 patients met inclusion criteria. Global Constructive Work (GCW) had the best pooled sensitivity (89%) followed by GLS (84%), Global Work Index (GWI) (82%), Global Work Efficiency (GWE) (80%), and Global Wasted Work (GWW) (75%). GWE had the best pooled specificity (78%) followed by GWI (75%), GCW (70%), GLS (68%), and GWW (61%). GCW had the best accuracy according to SROC curves, with an area under the curve of 0.86 compared to 0.84 for GWI, 0.83 for GWE, 0.79 for GLS, and 0.74 for GWW. All MW indices had an excellent intra- and inter-observer variability. GCW is the best MW index proving best diagnostic accuracy in the prediction of CAD with an excellent reproducibility.

966 ADVANCED ECHOCARDIOGRAPHIC AND CMR FEATURES OF PATIENTS WITH REPAIRED TETRALOGY OF FALLOT IN THE LONG-TERM FOLLOW-UP

Abstract Advanced echocardiographic and CMR features of patients with repaired Tetralogy of Fallot in the long-term follow-up. Anna Gozzi1, Jolanda Sabatino1, Elena Cuppini1, Irene Cattapan1, Alessia Basso1, Jennifer Fumanelli1, Angela Di Candia1, Martina Avesani1, Domenico Sirico1, Biagio Castaldi1, Elena Reffo1, Alessia Cerutti1, Roberta Biffanti1, Giovanni Di Salvo1 1Department for Women's and Children's Health, University Hospital of Padova, Pediatric and Congenital Cardiology Unit, Via Nicolo` Giustiniani, 2, 35128 Padova, Italy Background Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease and the population of ToF repair survivors is growing rapidly. Children and, more frequently young adults, with repaired ToF develop late complications. Sudden cardiac death and life-threatening ventricular arrhythmia remain a concern in patients with repaired tetralogy of Fallot. The aim of this study was to describe and analyse advanced echocardiographic and CMR features of patients with repaired ToF in the long-term follow-up and to find non-invasive predictors of adverse prognosis. Methods This is a retrospective cohort study. Consecutive 200 patients with repaired ToF who did not undergo pulmonary valve replacement were included. Mean age of all patients was 19 ± 8. The electrocardiographic (ECG), cardiopulmonary exercise testing (CPET), echocardiographic and cardiac magnetic resonance (CMR) data were reviewed retrospectively. Right myocardial work index (RWI) was calculated as the area of the right ventricular pressure strain loops. From RWI, Right Constructive Work (RCW), Wasted Work (RWW) and Work Efficiency (RWE) were estimated. Patients were screened according the age at surgery (&amp;lt;12 months and &amp;gt;12 months) and the time since the repair (&amp;lt; 25 years and ≥ 25 years). A composite end-point of major adverse cardiovascular events (sudden cardiac death, sustained and non-sustained ventricular tachycardia, resuscitated sudden cardiac death, or syncope) was used. Results CPET values were not significantly different in patients with more than 25 years since the corrective surgery. Left ventricular ejection fraction measured either by CMR or echocardiography were slightly but significantly reduced in patients with more than 25 years since the corrective surgery. Patients with older age at surgery (&amp;gt;12 months) have significantly reduced V02max at CPET, larger RA and LA areas and larger RV basal diameter. During a median follow-up of 2.9 years, 1 patient died suddenly, 5 had documented ventricular tachycardia, and other 4 had syncope. On univariate analysis, echocardiographic left atrial area/BSA (P=0.044) and right ventricular longitudinal strain (P=0.010) were significantly related to the combined end point. Patients with reported VT at Holter ECG presented significantly reduced right ventricular function in terms of CMR-EF, echocardiographic FAC and RWI. Finally, TOF patients with borderline/impaired predicted VO2 max at CPET presented with significantly reduced RV freewall longitudinal strain and right ventricular myocardial work index. Conclusion Long-term survival and clinical condition after surgical correction of ToF in infancy is generally good and the late functional status in ToF - operated patients could be excellent up to 25 years after the repair. However, patients with older age at surgery have relative reduced functional status compared with those undergoing early repair. The echocardiographic and CMR evaluation of RV function are usually related to worse prognosis, recurrency of VT and reduced functional status in patients with repaired TOF. Right ventricular myocardial work index is feasible in patients with repaired TOF; disadvantageous right ventricular work may be a more sensitive indicator of right ventricular impairment compared with standard echocardiographic parameters, and is able to predict exercise capacity.

235 COMPARISON OF THE PROGNOSTIC RELEVANCE OF DIFFERENT ECHOCARDIOGRAPHIC PARAMETERS OF RIGHT VENTRICULAR SYSTOLIC FUNCTION IN CHRONIC HEART FAILURE

Abstract Background Right ventricular (RV) systolic function is an important predictor of prognosis in heart failure (HF). Several RV echocardiographic functional parameters have been described as sensitive prognostic markers. Aim To compare the predictive value of different RV systolic echocardiographic parameters in patients with HF. Methods One hundred and sixty patients with stable HF and left ventricular ejection fraction (LV EF) &amp;lt;45% were assessed for the following: (1) tricuspid annular plane systolic excursion (TAPSE), (2) RV fractional area (RVFA), (3) tissue Doppler-derived RV peak systolic velocity (PSVtdi), (4) RV free wall longitudinal 2D-strain (RVFWS); and (5) 3D-RVEF. The primary endpoint was death and/or HF-hospitalization. Results During a mean follow-up of 16.9±10 months, 35 patients reached the primary endpoint. Each of the RV echocardiographic parameters was significantly associated with outcome at univariable analysis. After adjusting for age, eGFR, logNTproBNP, LVEF, restrictive filling pattern, pulmonary artery systolic pressure, and RV end-diastolic volume, by Lasso Cox multivariable analysis, RVFWS (HR 1.09, 95%CI: 1.02-1.18, P=0.0093) and 3D-RVEF (HR 0.95, 95%CI: 0.91-0.99, P=0.0076) remained the only parameters independently associated with outcome with a cut-off of -18.6% and 43.6% respectively, without any difference in C-statistic between the two models (0.826 versus 0.812, p=0.3255). Conclusions RVFWS and 3D-RVEF are strong independent predictors of outcome in HF and appear to be superior to other standard RV systolic echocardiographic parameters.

1095 WHICH IS THE BEST MYOCARDIAL WORK INDEX FOR THE PREDICTION OF CORONARY ARTERY DISEASE? A DATA METANALYSIS

Abstract Background Early diagnosis of Coronary Artery Disease (CAD) plays a key role to prevent adverse cardiac events such as myocardial infarction and Left Ventricular (LV) dysfunction. Myocardial Work (MW) indices derived from echocardiographic speckle tracking data in combination with non-invasive blood pressure recordings are able to predict CAD even in the absence of impairments of standard echocardiographic parameters. Our aim was to compare the diagnostic accuracy of MW indices to predict CAD and to assess intra-observer and inter-observer variability of MW through a metanalysis. Methods Electronic databases were searched for observational studies evaluating the MW indices diagnostic accuracy for predicting CAD and intra-observer and inter-observer variability of MW indices. Pooled sensitivity, specificity, and Summary Receiver Operating Characteristic (SROC) curves were assessed. Results 5 studies enrolling 501 patients met inclusion criteria. Global Constructive Work (GCW) had the best pooled sensitivity (89%) followed by GLS (84%), Global Work Index (GWI) (82%), Global Work Efficiency (GWE) (80%) and Global Wasted Work (GWW) (75%). GWE had the best pooled specificity (78%) followed by GWI (75%), GCW (70%), GLS (68%) and GWW (61%). GCW had the best accuracy according to SROC curves, with an Area Under The Curve of 0.86 compared to 0.84 for GWI, 0.83 for GWE, 0.79 for GLS and 0.74 for GWW (Figure 1). All MW indices had an excellent intra-observer and inter-observer variability. Conclusions GCW is the best MW index proving best diagnostic accuracy in the prediction of CAD with an excellent reproducibility. Figure 1: Pooled sensitivity, pooled specificity, SROC curves and AUC of Myocardial Work indices and GLS

Abstract 15177: Speckle-Tracking Echocardiography Improves Risk Stratification in Patients With Chagas Cardiomyopathy

Introduction: Chagas cardiomyopathy is an important cause of death in endemic areas. Speckle-tracking echocardiography (STE)-derived strain is a sensitive tool for evaluating myocardial function which may be helpful to improve risk stratification of Chagas cardiomyopathy patients. This study evaluated whether STE has incremental value for prognosis over traditional clinical and echocardiographic parameters in patients with Chagas cardiomyopathy. Methods: Patients with Chagas disease who had evidence of heart failure were selected for the study. Clinical evaluation, electrocardiogram (ECG), and echocardiogram were performed at the time of enrollment. STE-derived global longitudinal strain (GLS) was analyzed offline. The outcome was all-cause mortality. Results: A total of 317 patients were enrolled, mean age was 66 ± 13 years and 184 (58%) were women. During a mean follow-up of 2.6 years, 114 patients died (36%) with overall mortality incidence rate of 14.0 deaths per 100 patient-years (95% CI 11.6-16.8). GLS was an important predictor of death (HR 0.90; 95% CI 0.86 to 0.95; P&lt;0.001), adding incremental prognostic value to standard echocardiographic parameters including right ventricular (RV) end-diastolic area, E/e’ ratio, left atrial (LA) volume, and left ventricular ejection fraction (LVEF). In overall population, the model including GLS had better accuracy in predicting mortality than the model including only conventional echocardiographic variables (P = 0.015). When the patients were stratified according to LVEF, GLS provided incremental prognostic information in patients with preserved (n=84; HR 0.80; 95% CI 0.64 to 0.98) or with mild to moderate reduced LVEF (n=166; HR 0.92; 95% CI 0.85 to 0.98), whereas in those who had severe LV dysfunction (n=67), GLS was no longer associated with mortality. Conclusions: In a cohort of patients with Chagas cardiomyopathy living in remote areas, GLS was a strong predictor of death, improving risk stratification beyond that provided by standard echocardiographic measurements, especially in patients with non-severe LV dysfunction. STE assessment may be used in a clinical setting to improve the risk prediction model for mortality in patients with Chagas cardiomyopathy.

Diastolic function in heart transplant: From physiology to echocardiographic assessment and prognosis.

Heart transplant (HTx) still represents the most effective therapy for end-stage heart failure, with a median survival time of 10 years. The transplanted heart shows peculiar physiology due to the profound alterations induced by the operation, which inevitably influences several echocardiographic parameters assessed during these patients' follow-ups. With these premises, the diastolic function is one of the main aspects to take into consideration. The left atrium (LA) plays a key role in this matter, and that same chamber is significantly impaired with the transplant, with different degrees of altered function based on the surgical technique. Therefore, the traditional echocardiographic evaluation of diastolic function applied to the general population might not properly reflect the physiology of the graft. This review attempts to provide current evidence on diastolic function in HTx starting from defining its different physiology and how the standard echocardiographic parameters might be affected to its prognostic role. Furthermore, based on the experience of our center and the available evidence, we proposed an algorithm that might help clinicians distinguish from actual diastolic dysfunction from a normal diastolic pattern in HTx population.

Left atrial phasic volumes and functions changes in asymptomatic patients with sarcoidosis: evaluation by three-dimensional echocardiography

Background Cardiac involvement is the leading cause of morbidity and death in patients with sarcoidosis. However, many patients remain asymptomatic until the late-stage. In this study, we investigated the left atrial (LA) phasic volumes and functions changes by three-dimensional (3D) echocardiography measurements in asymptomatic patients with sarcoidosis, which has good correlation with cardiac magnetic resonance imaging. Methods In this cross-sectional study, 44 asymptomatic patients with sarcoidosis and 40 age, sex and BMI-matched healthy volunteers underwent two-dimensional (2D) and 3D-echocardiograpy. Standard echocardiographic and tissue Doppler imaging parameters were obtained. LA phasic volumes were assessed by 3D-echocardiography. From the 3D-echocardiography derived values, LA active, passive, and total emptying fraction (EF) were calculated. Results All left ventricular ejection fractions (LVEF) obtained by 2D and 3D-echocardiography were normal (≥50%). While LA diameters (33.36 ± 4.23 vs. 30.57 ± 5.43) and E/e’ septal annulus ratios (10.82 ± 1.79 vs. 9.27 ± 1.81) were significantly higher, A-wave (70.80 ± 5.81 vs. 74.51 ± 5.41) and e’septal annular velocities (6.48 ± 1.58 vs. 9.03 ± 1.63) were significantly lower in the sarcoidosis group as compared with control group, respectively. While 3D-echocardiography derived LA-minimum volume indices (LAVImin) (13.89 ± 2.75 vs. 12.23 ± 1.73) were significantly higher, 3D-echocardiography derived LA active EFs (AAEF) (30.78 ± 3.52 vs. 38.52 ± 4.75) and LA total EFs (TAEF) (47.71 ± 7.47 vs. 53.32 ± 5.81) were found to be significantly lower in the sarcoidosis group as compared with control group, respectively. Conclusion LAVImin, AAEF and TAEF calculated based on LA phasic volumes obtained by 3D-echocardiography may be promising indicators of subclinical cardiac involvement in asymptomatic patients with sarcoidosis.

Left atrial appendage mechanical dispersion assessed by speckle-tracking echocardiography as a determinant of left atrial appendage stasis in patients with non-valvular atrial fibrillation

Abstract Background We sought to investigate the relationship of left atrial appendage (LAA) mechanical dispersion (MD) with LAA dense spontaneous echo contrast (SEC) or thrombus, and to compare its usefulness in the identification of thrombogenesis with left atrial (LA) MD or LA/LAA strain parameters in patients with nonvalvular atrial fibrillation (AF). Methods We conducted a cross-sectional study of 493 consecutive patients with AF (median age 65, male 66.9%) who underwent echocardiography prior to catheter ablation. We measured the LAA and LA global longitudinal strain (GLS) using speckle-tracking echocardiography (STE). LAA MD and LA MD was defined as the standard deviation (SD) of time to peak positive strain corrected by the R-R interval. Results Patients with LAA dense SEC/thrombus (n=70) had significantly higher LAA MD than controls (n=423) (median 14.20% vs 9.35%). Areas under the receiver-operating curve for CHA2DS2-VASc score plus LAA MD, LAA GLS or LA GLS were comparable (0.830, 0.843 and 0.809) and superior to that combined with LA MD (0.762, all p&amp;lt;0.01). Multivariable analysis showed that LAA MD was an independent determinant of LAA dense SEC/thrombus in four different models (Odds ratio, 1.23–1.24; P&amp;lt;0.001), and provided additional diagnostic value over clinical and standard echocardiographic parameters. Whereas LA MD was not independently associated with LAA dense SEC/thrombus and had no incremental predictive value. Conclusion LAA mechanical dispersion provided incremental information over conventional risk factors in the identification of LAA dense SEC or thrombus in AF patients and is superior to LA mechanical dispersion. Funding Acknowledgement Type of funding sources: None.

Left atrial strain analysis improves non-invasive estimation of left ventricular filling pressures in takotsubo syndrome

Abstract Background Takotsubo syndrome (TTS) is associated with a non-negligible risk of in-hospital (IH) complications. Elevated left ventricular filling pressures (LVFP), measured invasively as LV end-diastolic pressure (LVEDP), showed to predict adverse IH outcomes in this population. Recently, novel indexes of left atrial (LA) function, including LA reservoir and LA pump strain, demonstrated a close correlation with increased LVFP in unselected patients. Purpose To assess the ability of LA reservoir and LA pump strain to improve non-invasive estimation of LVFP and to predict IH complications in TTS patients. Methods We retrospectively enrolled patients with confirmed TTS diagnosis at invasive left heart catheterization and coronary angiography. LVEDP was assessed invasively at the time of catheterization. Transthoracic echocardiography was performed with 48 hours from hospital admission. IH complications were collected, including occurrence of acute heart failure (pulmonary oedema/cardiogenic shock; Killip class III/IV), death from any cause and life-threatening arrhythmias. Results A total of 62 patients were analysed (72.2±10.1 years, female 80%). IH complications occurred in 25 (40.3%). Patients who experienced IH complications had higher LVEDP and lower LVEF, LA reservoir strain and LA pump strain values compared to patients without IH complications (all P≤0.001). At multivariate analysis, EF and LVEDP were independent predictors of worse IH outcomes (P≤0.001 and P=0.004 respectively). Correlation analysis proved that lower values of both LA reservoir and pump strain were associated with increasingly higher LVEDP (r −0.859, P≤0.001 and r −0.848, P≤0.001 respectively). Receiving operating characteristic (ROC) curve analysis showed that the AUC for LVEDP to predict IH complications was 0.814 (95% CI 0.679–0.949, P≤0.001) with an optimal cut-off value of 24.5 mmHg (sensitivity 77%, specificity 53%). Therefore, we performed ROC curve analysis to compare the ability of LA strain values and standard echocardiographic parameters currently used for non-invasive LVFP assessment to predict LVEDP ≥24.5 mmHg. As a result, we obtained higher AUC for LA reservoir and pump strain [0.909 (95% CI 0.818–0.999, P≤0.001) and 0.889 (95% CI 0.789–0.988, P≤0.001), respectively] vs E/e' 0.800 (95% CI 0.663–0.937, P≤0.001), LAVi 0.666 (P=0.092) and tricuspid regurgitation (TR) peak velocity 0.582 (P=0.596). The incorporation of LA strain values in a multivariable model including E/e' ratio, LAVi and TR peak velocity to predict a LVEDP ≥24.5 mmHg led to a significant incremental predictive value (changes in χ2=11.99; P=0.002). Conclusion In patients with TTS, lower LA reservoir and pump strain values correlate with increased LVEDP and improve non-invasive estimation of LVFP. LA strain analysis may be an easy tool to individuate subjects at higher risk of IH complications. Funding Acknowledgement Type of funding sources: None.

Myocardial work impairment in children with Wolff-Parkinson-White syndrome

Abstract Background Wolf-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardium deformation during systole. According to guidelines, when the left ventricle (LV) dysfunction is present catheter ablation of the accessory pathway may be required, even in asymptomatic patients. Purpose The study aimed to assess the diagnostic value of non-invasive myocardial work in predicting subtle myocardial abnormalities in children with WPW. Methods Eighty pediatric patients (age 7.91±3.2 years) were included in the study: 20 cases with manifest WPW and 60 age- and sex-matched controls (CTR). Global myocardial work index (MWI) was measured as the area of the LV pressure-strain loops. From MWI, global Constructive Work (MCW), Wasted Work (MWW) and Work Efficiency (MWE) were estimated. In addition, standard echocardiographic parameters of LV function were evaluated. Results Patients characteristics are summarized in the table. Despite normal LV EF and GLS, children with WPW had worse MWI (WPW 1292.90±307.67 mmHg% vs CTR 1658.73±241.74 mmHg%, p=0.0000005), MCW (WPW 1844.15±267.96 mmHg% vs CTR 2104.90±237.85 mmHg%, p=0.00009), MWW (WPW 101.5 [85–148.25] mmHg% vs CTR 72 [54.75–109.25] mmHg%, p=0.004) and GWE (WPW 94 [91.75–95] mmHg% vs 96 [95–97] mmHg%, p=0.00012) (table). In the WPW group, MWE (r=−0.6, p=0.009) and MWW (r=0.6, p=0.01) was found to correlate with a prolonged QRS (figure). A multiple regression model was generated to identify the relation between abnormal myocardial work indices (worst interquartile range as dependent variable) and several independent variables. QRS was the best independent predictor of impaired myocardial work. In particular, a QRS&amp;gt;110 msec showed an 86% sensibility and 85% specificity for abnormal MWE (AUC of 0.85), and a 75% sensibility and 83% specificity for abnormal MWW (AUC of 0.83) (figure). Conclusion In children with WPW, myocardial work indices were found significantly reduced, even in presence of normal LV EF and GLS. Prolonged QRS independently predicted myocardial impairment. In pediatric patients with WPW, myocardial work may represent a sensitive measure of LV dysfunction and help in the decision-making. Funding Acknowledgement Type of funding sources: None.

Speckle tracking-derived left atrial strain rate – undervalued and useful predictor of adverse events

Abstract Background Strain rate reflects the rate of change of the distance between two points of the myocardium occurring in the cardiac cycle. It is a time-dependent parameter requiring higher temporal resolution than standard strain assessment. Because of this limitation, speckle tracking-derived left atrial (LA) strain rate analysis is of less interest in the literature. Purpose To analyze the prognostic value of LA strain rate during 2-years follow-up in patients with atrial fibrillation (AF). Methods The prospective study involved 80 patients with nonvalvular AF scheduled for elective electrical cardioversion (mean age 63.5±13 years, 60% male). All patients underwent echo before cardioversion and 24 hours after conversion to sinus rhythm. We analyzed standard echocardiographic parameters. Using the speckle-tracking method, we assessed LA strain rate during ventricular systole LA-SSR, in the early stage of ventricular diastole LA-ESR, and during atrial active pump phase LA-ASR. The last one is possible to measure only in the sinus rhythm. The analysis included 4-chamber and 2-chamber views. The clinical endpoint was predefined as AF recurrence. Results Median time of the current AF episode was 2.1 (IQR 0.5–5) months. Standard echo measurements revealed a median left ventricular ejection fraction of 55% (IQR 46–58) and the median of LA volume indexed to body surface area 42 ml/m2 (IQR 33–51). The successful cardioversion rate was 90%. During follow-up, we noticed AF recurrence in 49 (68%) patients. The median time-to-event was 2 (IQR 1 to 6.9) months. Receiver operating characteristic curve analysis revealed that LA-SSR &amp;lt;−0.73 s–1 (AUC=0.745; p=0.0004) and LA-ESR &amp;gt;−1 s–1 (AUC=0.703; p=0.0015) assessed during AF as well as LA-ESR &amp;gt;−0.88 s–1 (AUC=0.644; p=0.04) and LA-ASR &amp;gt;−1 s–1 (AUC=0.837; p&amp;lt;0.0001) measured in sinus rhythm were the optimal cut-off values for predicting AF recurrence. The figure presents Kaplan-Meier survival analysis for AF recurrence. Conclusions Speckle tracking-derived LA strain rate predicts the recurrence of AF after successful electrical cardioversion. Funding Acknowledgement Type of funding sources: None.

Assessment of global longitudinal strain in pediatric survivors of childhood cancer who received cardiotoxic chemotherapy

Cardiotoxicity induced by chemotherapy is the cause of long-term morbidity and mortality, particularly with child exposure. Early detection is essential, as clinical signs are often delayed. In adults, the global longitudinal strain has proven its effectiveness as an early marker of cardiac dysfunction but its place in paediatric management is not yet established. The aim of our study was to analyse the echocardiographic parameters of cardiac function including global longitudinal strain (GLS) in asymptomatic children who received cardiotoxic chemotherapy, at the University Hospital of Amiens, from April to November 2020. The included cases were compared to healthy controls more than one year after their last exposure. We included 22 pediatric childhood cancer survivors and 27 controls with comparable characteristics. The cases had a median age of 11.5 [9.5] years, a median of 3 [1] years from the chemotherapy and a median cumulative anthracycline dose of 234.77 (±105.88) mg/m 2 . Almost a third of our patients were classified as high risk according to CCSS Cardiovascular Risk Calculator score. All myocardial function values were within normal limits. Standard echocardiographic parameters were not different between cases and controls, respectively EF (%) 66.29 (±5.04) vs. 68.14 (±5.37) P < 0.22. As well, Strain 2D values were not significantly different (GLS (%) −20.10 (±2.59) vs. −19.80 (±2.34) P = 0.67). Furthermore, the interobserver reproducibility of GLS was good (intra-class correlation coefficient 0.82 (0.62;0.92) P < 0.01) ( Fig. 1 ). There was no difference of cardiac function echocardiographic parameters, between children who received chemotherapy and controls. There are several limitations, such as the limited number of patients, the monocentric trial and the exclusion of symptomatic patients. The results seem to be in favour of a long free interval between exposure and the onset of altered echocardiographic parameters. Further studies are needed to develop individualised prognostic tools for the follow-up of these patients.