Standard Echocardiographic Parameters Research Articles

Right ventricular myocardial work in heart failure with preserved ejection fraction: insights from invasive cardiopulmonary exercise testing

Abstract Backgrounds Symptoms of heart failure with preserved ejection fraction (HFpEF) is closely related to elevated pulmonary capillary wedge pressure (PCWP) during exercise. The understanding of right ventricle myocardial work, assessing of right ventricular (RV) function utilizing RV pressure–strain loops, in HFpEF is lacking. Methods The study population underwent invasive cardiopulmonary exercise tests, measuring pressures at rest and during exercise to identify HFpEF. Echocardiography assessed LV and RV parameters. Right ventricular myocardial work was calculated using strain-rate and pressure curves, matching them with ECG data. RV global constructive work (RVGCW), RV global work index (RVGWI), RV global wasted work (RVGWW), and RV global work efficiency (RVGWE) were analysed and compared with invasively measured PCWP at resting and peak exercise. Results Between November 2017 and July 2023, 41 patients with adequate data were enrolled, and 21 were diagnosed with HFpEF. There were no significant differences in various echocardiographic parameters between HFpEF and non-HFpEF groups, except higher post-exercise PCWP and mean pulmonary artery pressure. HFpEF patients had higher RVGWW and lower RVGWE. RVGWW and RVGWE had higher predictive ability for HFpEF diagnosis compared to other echocardiographic parameters. While RVGCW (r = 0.0.504, P = 0.001 and r = 0.430, P = 0.006, respectively) and RVGWW correlated (r = 0.408, P = 0.008 and r = 0.621, P <0.001, respectively) with post-exercise ∆PCWP and exercise PCWP, only RVGWW (β=1.981, P=0.044 and β=4.323, p<0.001) being independently associated with both after adjustment for confounding factors. Conclusions RVGWW is a novel parameter that provides an integrative analysis of RV systolic function and correlates more closely with post-exercise ∆PCWP than other standard echocardiographic parameters in HFpEF.

Can examining shear wave elastography predict elevated filling pressures? - A comparative evaluation against the current guideline algorithm

Abstract Background The clinical assessment of left ventricular diastolic function is complex, as there is no single non-invasive parameter that provides a direct measurement of myocardial relaxation, myocardial compliance, or–as a surrogate-LV filling pressure. The estimation of diastolic function involves therefore a combination of various parameters. Shear wave (SW) elastography (SWE) is a novel method based on high frame rate echocardiography. SWs are generated following mechanical excitation of the myocardium, such as after mitral valve closure (MVC), and their propagation velocity is directly linked to myocardial stiffness (MS) and is therefore a potential marker of diastolic function. Purpose The aim of this study was to investigate if the propagation velocities of natural shear waves are related to invasively measured mid-(LVMDP) and end-diastolic LV filling pressures (LVEDP) and, thus, could be used as echocardiographic estimate of left ventricular diastolic function. Methods We prospectively enrolled 95 patients with a wide range of diastolic function, scheduled for heart catheterization so that LVMDP and LVEDP could be invasively measured. Patients with myocardial pathology or dysfunction of the anteroseptal wall, as well as severe aortic stenosis, and a more than moderate mitral regurgitation were excluded. Echocardiography was performed immediately after catheterization. SW elastography in parasternal long axis views of the left ventricle (LV) was performed using an experimental scanner (HD-PULSE) at 1040±200 frames per second. An anatomical M-mode was extracted from the midline of the LV septum and color coded for tissue acceleration. The SW propagation velocity at MVC was measured as slope on the M-mode (A). Standard echocardiographic parameters were obtained with a high-end ultrasound machine (Vivid 95, GE Vingmed Ultrasound). The algorithm for evaluating diastolic dysfunction as recommended by the European Association of Cardiovascular Imaging expert consensus 2021 was applied to categorize LV filling pressure as normal or elevated. Results SW velocities correlated significantly with both, LVMDP (r=0.47; p<0,001) and LVEDP (r=0.71, p<0.001). They could excellently detect elevated LVEDP (AUC=0.95, Sensitivity=0.92, Specificity=0.94) and detected elevated LVMDP with AUC=0.79, Sensitivity=0.87, Specificity= 0.65, similar to the guideline approach (AUC=0.78, Sensitivity=0.62, Specificity=0.94). Conclusions SW velocities, measured by high frame rate echocardiography, show a strong correlation with the end-diastolic and a good correlation with mid-diastolic filling pressures. The method could excellently distinguish normal and elevated LVEDP and could–through a single measurement-differentiate normal and elevated LVMDP as good as the current guideline algorithm with its combination of four parameters in a decision tree. Our data suggest a potential clinical value of the new method for the non-invasive assessment of diastolic function.

Assessment of right ventricular function in patients with severe secondary tricuspid regurgitation, following to the TVARC recommendations: association with outcome

Abstract Introduction Severe tricuspid regurgitation (TR) is associated with increased mortality if left untreated. Recently, the Tricuspid Valve Academic Research Consortium (TVARC) has published standardized definitions of disease aetiology and severity, as well as endpoints for future clinical trials. Right ventricular (RV) function assessment represents one of the cornerstones for risk stratification in these patients, but current guidelines do not propose specific cut-off values for the echocardiographic measures. Also, the thresholds proposed by the TVARC have been derived from normative value and not yet validated in large cohorts of TR patients. Purpose To test the prognostic value of the TVARC proposed echocardiographic cut-offs for grading RV-dysfunction (figure1) in a large real-world cohort of patients with severe secondary TR (STR). Methods Consecutive patients from a single centre with first diagnosis of severe secondary STR, and without a cardiac implantable electronic device, were included. Tricuspid annulus plane systolic excursion (TAPSE), RV global and free wall strain (RVGLS and RVFWLS) and fractional area change (FAC) were used to measure RV function. The study endpoint was all-cause mortality, censored for tricuspid valve intervention. Results A total of 1043 patients (mean age 69 ± 13 years, 43% male), were included. Approximately half of the population (45%) was in NYHA class III or IV and 52% was treated with loop diuretics. Overall patients showed mild RV-dilatation (RV end-diastolic area indexed 12.2 [10.1-15.2cm2/m2]) and moderate-to-severe right atrial dilatation (right atrial maximal area indexed: 13.9 [11.0-17.5cm2/m2]). Using the proposed cut-off values, strain analysis identified a higher number of patients with impaired RV function as compared to standard echocardiographic parameters (89% based on RVGLS; 80% based on RVFWS, 61% based on TAPSE and 54% based on RVFAC). During a median follow-up of 51 [IQR 6 - 98] months, 445 (43%) patients died. The Kaplan-Meier survival curves for each echocardiographic parameter of RV-function are shown in Figure 1. TAPSE, which is the most widely used RV-function parameter, was able to clearly identify patients at high and intermediate risk when mildly, moderately and severely impaired. However, patients with normal TAPSE were still at intermediate risk when RVFWLS was (even mildly) reduced (figure 2). We therefore propose a stepwise practical approach including the measure of RVFWLS when measuring normal TAPSE, in order to possibly re-stratify patients into a higher risk group (Figure 2). This novel grading approach remained independently associated with all-cause mortality after correcting for relevant clinical and echocardiographic variables on multivariable analysis. Conclusion Novel TAVRC cut-off values for RV function show prognostic value in patients with severe STR; particularly the combination of TAPSE and RVFWLS could be use in clinical practice for risk stratification.Figure 1Figure 2

The diagnostic role of myocardial work indices in stable coronary disease - global wasted work as a novel important non-invasive parameter?

Abstract Introduction Although the non-invasive diagnostic tools for stable coronary artery disease (CAD) have developed significantly over the past years, there is no resting parameter available to recognize functionally significant CAD. The role of the novel myocardial work index (myocardial work index - MWI) calculated by the pressure-strain loop created with the help of speckle-tracking analysis and blood pressure measurement in the diagnosis of ischemic heart disease is not yet fully clarified. In our research, we examined the parameters of myocardial work analysis in stable coronary disease patients. Purpose Clarification of the diagnostic role of the myocardial work analysis, in patients with stable coronary artery disease. Methods In our prospective, single-center study, we examined 13 patients who had at least moderate stenosis (≥50%) in one main coronary branch detected on coronary CTA. A fractional flow reserve (FFR) test was performed for functional coronary assessment. Based on this measurement, we divided our patients into FFRneg (FFR value>0.8) and FFRpos groups. Echocardiography was performed before coronary angiography in all patients. In addition to the standard echocardiographic parameters, global myocardial work index (GWI), global constructive work (GCW) and global wasted work (GWW) were calculated. In the case of the FFRpos group, we performed the above examination both before and after revascularization (2 months). Results Our results show that neither the standard parameters (GLS, EF), nor the GWI and GCW showed any difference between the FFRpos and FFRneg groups. However, there was a significant difference regarding GWW (172.3±21.8 FFRneg vs. 258.2±38.4 FFRpos, p=0.048) at baseline. In the case of the FFRpos group, the analysis of our data showed that there was no significant difference in EF, GLS, GWI and GWE parameters before and after revascularization. However, global wasted work (GWW) showed a significant improvement after revascularization (preGWW 258.2±38.4 vs. postGWW 139.5±14.5, p=0.041). NT-proBNP levels were normal in our patient population and we could not detect. Conclusion Based on our results, the GWW may be suitable for non-invasive assessment of the functional significance of stable coronary disease, as it showed a significant difference in the case of functionally significant and non-significant stenosis and improved after revascularization in patients with single-vessel CAD.

Impact of empagliflozin on cardiac structure and function assessed by echocardiography after myocardial infarction: a post-hoc sub-analysis of the emmy trial

Abstract Background Empagliflozin administered after acute myocardial infarction proofed to improve cardiometabolic parameters and biomarkers, but the impact on cardiac function is still largely unknown. The aim of this post-hoc echocardiographic sub-analysis of the EMMY trial was to provide in-depth echocardiographic analysis on the effects of empagliflozin versus placebo on standard and novel echocardiographic structural and functional parameters after acute myocardial infarction. Methods In this post-hoc analysis of the EMMY trial a subset of 313 patients (157 empagliflozin vs. 156 placebo) was enrolled for post-processing analysis of echocardiographic structural and functional parameters. On top of two-dimensional and Doppler parameters, myocardial deformation analyses were performed to assess ventricular and atrial strain values. Results Left ventricular volumes showed significant differences in favor of empagliflozin over the course of the trial (change in left ventricular end-diastolic volume median [interquartile range] 8 [−3;19]% versus 13 [0;29]%, p = 0.048; left ventricular end-systolic volume −3 [−15;12]% versus 4 [−12;18]%, p = 0.044). This effect persisted after adjusting for baseline values, age, and sex. Left ventricular systolic and diastolic function overall improved over the course of the trial and parameters for diastolic function showed a distinct trend between groups but did not meet statistical significance in this cohort. Conclusion In this post-hoc analysis among patients with acute myocardial infarction, treatment with empagliflozin resulted in a significant beneficial effect on left ventricular end-diastolic and end-systolic volume, without significantly improving left ventricular or right ventricular functional parameters compared to placebo after 26 weeks. ClinicalTrials.gov registration NCT03087773. Graphical abstract

Assessment of Left Ventricular Reverse Remodeling by Echocardiography After 90 Days of Sacubitril/Valsartan Therapy in Patients of Heart Failure with Reduced Ejection Fraction

Abstract Background: The present study aimed to assess the response of sacubitril/valsartan therapy on cardiac reverse remodeling (CRR) by standard and advanced echocardiographic parameters in patients of heart failure with reduced ejection fraction (HFrEF). Methods: One hundred and fifty patients ≥18 years of age with symptomatic heart failure with left ventricular ejection fraction (LVEF) <40.0% were included in this prospective observational study. All patients underwent baseline electrocardiography and standard echocardiographic examination. Patients were given sacubitril/valsartan maximal tolerated dose. Echocardiographic measurements were done after 90 days. The primary outcome measure was a change in LVEF, whereas the secondary outcome measures were changes in left ventricular dimensions and volumes, E/e’, pulmonary artery systolic pressure (PASP), and global longitudinal strain (GLS). Comparisons between two discrete variables and medians were performed using the Chi-square test/Fisher’s exact test and the Wilcoxon signed–rank test, respectively. Results: The median LVEF (32.5% vs. 30.0%) was significantly higher, whereas left ventricular end-diastolic volume (180 vs. 177.5 mL), left ventricular end-systolic volume (127.5 vs. 122.5 mL), left ventricular end-diastolic diameter (59 vs. 58 mm), left ventricular end-systolic diameter (51 vs. 50 mm), PASP (38 vs. 35), E/e’ (15 vs. 14), and GLS (−9.0 vs. −10.0) were significantly lower at 3-month follow-up as compared to baseline levels. Sacubitril/valsartan therapy leads to CRR as early as 90 days in patients with HFrEF. Conclusions: In HFrEF patients, sacubitril/valsartan significantly improved CRR.

Autonomic Dysfunction and Cardiac Performance in Pregnant Women with Hypertensive Disorders: A Comparative Study Using Heart Rate Variability and Global Longitudinal Strain.

(1) Background: Pregnancy induces significant physiological adaptations with substantial impacts on the cardiovascular system. Hypertensive disorders of pregnancy (HDPs) are connected to significant risks of maternal and fetal complications, contributing significantly to morbidity and mortality across the globe. This study focuses on evaluating autonomic dysfunction by analyzing heart rate variability (HRV) and assessing cardiac performance through global longitudinal strain (GLS) using speckle tracking echocardiography, as well as examining diastolic function in pregnant women with HDP compared to healthy pregnant controls. (2) Methods: A case-control study was conducted involving pregnant women diagnosed with gestational hypertension (GH), preeclampsia (PE), or severe preeclampsia (SPE) as the case group, and healthy pregnant women as the control group. HRV was measured to evaluate autonomic function, GLS was assessed using speckle tracking echocardiography, and diastolic function was evaluated through standard echocardiographic parameters. Data were analyzed to compare cardiac performance and autonomic regulation between the HDP and control group, as well as among the different HDP subgroups. (3) Results: The HDP group exhibited significantly reduced HRV parameters compared to healthy controls, indicating notable autonomic dysfunction. Speckle tracking echocardiography revealed lower GLS among women with HDP, particularly in those with SPE, compared to the control group. Diastolic dysfunction was also present in the HDP group. (4) Conclusions: HRV and GLS are valuable non-invasive tools for detecting autonomic dysfunction and cardiac performance impairments in pregnant women with hypertensive disorders. These findings suggest that autonomic and cardiac dysfunctions are prevalent in HDP.

Pressure-dimension index and left ventricular sphericity index following HeartMate II and HeartMate 3 implantation.

This study aimed to compare the changes in the left ventricle (LV) and right ventricle (RV) geometry and performance after the implantation of HeartMate II (HMII) and HeartMate 3 (HM3). In addition, we investigated whether the echocardiographic parameters LV sphericity index (LVSI) and the novel pressure-dimension index (PDI) can predict post-operative right ventricular failure (RVF). Between 2012 and 2020, 46 patients [HMII (n=22) and HM3 (n=24)] met the study's criteria and had echocardiography tests pre-operatively, 6 and 12months post-operatively. The LVSI and PDI were calculated together with the standard LV and RV echocardiographic parameters. The mean follow-up was 24±7months. In both groups, the LV end-diastolic diameter (LVEDD) significantly decreased 12months post-operatively compared with the pre-operative values (HMII: 6.4±1.4cm vs. 5.7±0.9cm, P=0.040; HM3: 6.7±1.3cm vs. 5.5±0.9cm, P<0.01, respectively). RV function 12months post-operatively was better in the HM3 group than in the HMII group, as indicated by a significantly higher RV fractional area change (RVFAC) in the HM3 group than in the HMII group 12months post-operatively (35±12% vs. 26±16%, P=0.039), significantly higher tricuspid annular plane systolic excursion (TAPSE) in the HM3 group 12months post-operatively compared with the HMII group (13.9±1.9mm vs. 12.0±2.1mm, P=0.002), and the tissue Doppler estimated tricuspid annular systolic velocity (TASV) was also significantly higher in the HM3 group 12months post-operatively compared with the HMII group (11.5±2.7mm/s vs. 9.9±1.5mm/s, P=0.020). The LVSI value was significantly higher 12months post-operatively in the HMII group than in the HM3 group (1.2±0.4 vs. 0.8±0.2, P=0.001, respectively), indicating worse geometric changes. The PDI decreased 12months post-operatively in the HM3-group compared with the baseline (3.4±1.4mmHg/cm2 vs. 2.0±0.8mmHg/cm2, P<0.001). In the univariate and multivariate analyses, only the pre-operative PDI was a predictor of post-operative RVF [odds ratio: 3.84 (95% CI: 1.53-18.16, P=0.022)]. The area under the curve for pre-operative PDI was 0.912. The 2year survival was significantly better in the HM3 group (log-rank, P=0.042). The design of HM3 offered better geometrical preservation of the LV and enabled normal PDI values, leading to improved RV function, as indicated by better RVFAC, TAPSE, and TASV values. The use of pre-operative PDI as an additional tool for established risk scores might offer a better pre-operative predictor of RVF.

A novel method for the evaluation of right ventricular dysfunction in acute pulmonary embolism: Myocardial work indices.

The presence of right ventricular dysfunction indicates a higher risk status in patients with pulmonary embolism (PE). The RV strain evaluated by speckle-tracking echocardiography seems to be more reliable method in the evaluation of RV dysfunction as compared to standard echocardiographic measures. In this study, we aimed to determine the value of myocardial-work indices in evaluating serial changes of RV function in acute PE. Our study comprised 83 consecutive acute PE patients who admitted to our tertiary cardiovascular hospital. Echocardiography was performed within the first 24-hours of hospitalization, and RV and LV myocardial-work parameters were obtained along with standard echocardiographic parameters. The change in the RV/LVr detected on tomography was selected as the primary outcome measure, and its' predictors were analyzed with classical linear regression and a generalized additive model (GAM). Among the LV-RV strain and myocardial work parameters, the RV global longitudinal strain (GLS) has borderline statistical significance in predicting the RV/LVr change whereas the RV global work efficiency (RV-GWE) strongly predicted RV/LVr change (p: 0.049 and <0.001, respectively). In this study, classical linear regression and GAM analyses showed that RV-GWE seems to offer a better prediction of RV/LVr change in patients with acute PE.

Left Ventricle Myocardial Work Correlated with Functional Capacity in Severe Rheumatic Mitral Stenosis with Preserved Left Ventricular Ejection Fraction.

Functional capacity is reduced in mitral stenosis (MS) patients. Previous studies showed a correlation between left atrial strain and functional capacity in this population. However, currently, no left ventricle (LV) echocardiographic parameters were associated with functional capacity in patients with MS. Noninvasive LV pressure-strain loop analysis is a new echocardiographic method for evaluating LV function, integrating longitudinal strain from speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work (MW) that overcomes the preload-dependent characteristics conventional parameters by integrating afterload. This study aimed to evaluate the association between MW and functional capacity measured using exercise tests in patients with severe MS and preserved LV ejection fraction (LVEF). Adult patients with symptomatic severe rheumatic MS (mitral valve area <1.5 cm2), and preserved LVEF (>50%) and sinus rhythm who underwent echocardiography and exercise stress test in our hospital from 2019 to 2021 were included. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, significant mitral regurgitation or aortic valve lesions, coronary artery disease, intracardiac shunt, and atrial fibrillation. Standard echocardiographic parameters were measured, and all MW parameters were included. Exercise treadmill testing was performed using the modified Bruce protocol. A total of 33 individuals with isolated severe rheumatic MS in sinus rhythm (age 39.8 ± 9.8 years) were included in the study. Patients with severe isolated MS showed significantly impaired LV-global longitudinal strain values compared to normal reference values. Furthermore, patients with severe MS showed significantly lower values of global work index, global constructive work, and efficiency compared to normal values and higher wasted work. Global work efficiency was significantly correlated to the duration of exercise (P = 0.025, Pearson's r = 0.389). In stable patients with isolated severe mitral stenosis, MW efficiency significantly correlated with functional capacity measured objectively through exercise testing.

Right heart and left atrial strain to differentiate cardiac amyloidosis and Fabry disease

Echocardiographic differentiation of cardiac amyloidosis (CA) and Fabry disease (FD) is often challenging using standard echocardiographic parameters. We retrospectively analyzed the diagnostic accuracy of right heart and left atrial strain parameters to discriminate CA from FD using receiver operating characteristic curve analyses and logistic regression models. A total of 47 FD and 88 CA patients with left ventricular wall thickening were analyzed. The comparison of both cardiomyopathies revealed significantly reduced global and free wall longitudinal right ventricular strain (RVS; global RVS: CA − 13 ± 4%, n = 67, vs. FD − 18 ± 4%, n = 39, p < 0.001) as well as right atrial strain (RAS; reservoir RAS: CA 12 ± 8%, n = 70, vs. FD 26 ± 9%, n = 40, p < 0.001) and left atrial strain (LAS) in CA patients. Individually, global RVS as well as phasic LAS and RAS showed the highest diagnostic accuracy to distinguish CA and FD. The best diagnostic accuracy was achieved by combining the age, basal RV diameter, global RVS, and reservoir and conduit RAS (area under the curve 0.96 [95% CI 0.90–1.00]). Differential echocardiographic diagnostic work-up of patients with suspected CA or FD can be improved by integrating structural and functional parameters of the right heart and the left atrium.Trial registration: DRKS00027403.

Prognostic value of deep echocardiographic phenotyping in pulmonary arterial hypertension.

A novel approach to derive prognostic information from echocardiography in pulmonary arterial hypertension (PAH) is to define a phenotype of right heart function combining standard echocardiographic parameters which describe right ventricular pump function and systemic venous congestion. We tested the hypothesis that the combination of advanced strain imaging parameters could yield high prognostic accuracy. This was a prospective observational study with a single centre derivation cohort and a second centre validation cohort. The derivation cohort included 49 naive PAH patients who underwent right heart catheterisation and echocardiographic evaluation at baseline and 4-12 months after diagnosis. The validation cohort included 83 prevalent PAH patients who underwent the same examinations at 12 months after diagnosis. We stratified the risk of the derivation cohort according to three models: Model 1, based on haemodynamic parameters; Model 2, based on standard echocardiographic parameters; and Model 3, based on advanced echocardiographic parameters. The median follow-up period was 21 months; the end point of the analysis was clinical worsening. In the derivation cohort, haemodynamic and echocardiographic parameters obtained at diagnosis were not associated with outcome, whereas a significant association was observed at first reassessment. Model 3 yielded a better predictive accuracy (Harrell's C index 0.832) as compared to Model 2 (Harrell's C index 0.667), and to Model 1 (Harrell's C index 0.713). The validation cohort confirmed the accuracy of Model 3. A comprehensive assessment of right heart function using right ventricular strain, right atrial reservoir strain and degree of tricuspid regurgitation provides accurate prognostic information in prevalent PAH patients.

The right ventricle outflow tract systolic function could predict the severity of the cirrhosis.

The distinctive liver framework is converted into structurally abnormal nodules as a consequence of tissue fibrosis in cirrhosis. Cardiac dysfunction in cirrhosis was described, and the term "cirrhotic cardiomyopathy (CCM)" was coined to describe this syndrome. Recent research has shown that the contractile characteristics of the right ventricular outflow tract (RVOT) have a significant impact on right ventricular functions. The right ventricular outflow tract-systolic excursion is an important systolic function marker of RVOT (RVOT-SE). There has yet to be published research on RVOT function in cirrhotic patients. We looked at the relationship between cirrhosis severity and the RVOT-SE. Sixty-nine consecutive hepatic cirrhotic patients were recruited for the research between June 1, 2018 and January 1, 2022. A medical history, thorough physical examination, laboratory investigations, echocardiographic evaluation, and RVOT-SE were obtained. The patients were separated into two groups: those with compensated cirrhosis (Child-Pugh class 1) and those with decompensated cirrhosis (Child-Pugh class 2 and 3). On the numerous standard echocardiographic parameters that examined the diameter and function of the left ventricle, we observed no significant difference between groups. Nevertheless, a statistically significant difference in Right Ventricle Wall (RVW) (p = 0.014), systolic pulmonary artery pressure (sPAP) (p = 0.034), RVOT-SE (p = 0.003), and Tricuspid Annular Plane Systolic Excursion (TAPSE) (p = 0.042) was detected across cirrhosis groups. The RVOT-SE had a positive correlation with cirrhosis severity (OR: 0.607; 95% CI: 0.425-0.866; p = 0.006), according to multiple logistic regression studies. According to the ROC curve study, RVOT-SE 8.8 cm/s predicted decompensated cirrhosis with 72% sensitivity and 72.7% specificity (AUC = 0.715, p: 0.001). In the current study, we found that RVOT-SE was related to the severity of cirrhosis. Larger patient cohorts and multi-center investigations will provide light on the notion.

Changes in Cardiac Structure and Function Following Fistula Ligation in Kidney Transplant Recipients (Cohort Study)

Purpose: International guidelines recommend that haemodialysis access is provided by an arteriovenous fistula (AVF), which enables frequent, reliable access to the circulation, but there are no guidelines to suggest whether these AVFs need to be ligated after kidney transplantation. Cardiovascular morbidity and mortality remain high in recipients of a kidney transplant, the persistence of a patent arteriovenous fistula (AVF) after transplantation may contribute to ongoing maladaptive cardiovascular remodelling. The ability to reverse this maladaptive remodelling by ligation of this AVF is unknown. We conducted this trial to evaluate the effect of AVF ligation on cardiac structure and function in stable kidney transplant recipients. Also we studied the ability of preoperative echocardiographic and non-invasive hemodynamic measurements, including the effects of acute temporary occlusion of the fistula, to predict postoperative left ventricular diameter and mass reduction, by the closure of the fistula.&#x0D; Materials and Methods: Nonrandomized controlled trial. kidney transplant recipients (&gt;12 months after transplantation with stable graft function) were divided into 2 groups. The first referred for surgical arteriovenous fistula closure. The second group didn’t receive Fistula closure (control). Standard echocardiographic parameters, heart rate, and blood pressure were assessed preoperatively (fistula closure) at baseline. These measurements were repeated 6 months after surgical closure.&#x0D; Findings: Seventeen kidney transplant patients were prospectively studied with 11 case and 6 controls with no fistula closure. Surgical fistula closure decreased left ventricular end-diastolic diameter and mass indexes (29.9_2.4to 27.4_2.1 mm/m2, P&lt;0.001, and 141_37 to 132_39 g/m2, P&lt;0.05, respectively), whereas no changes were seen in controls after a similar delay. Postoperative left ventricular end-diastolic diameter and mass reductions correlated best with the increases in total peripheral resistance (r_0.85, P&lt;0.0001) and mean arterial blood pressure (r_0.64, P_0.006), respectively.&#x0D; Conclusions. Surgical closure of arteriovenous fistula reduces left ventricular diameter and mass in kidney transplant recipients. The best predictors of those morphological changes are the rise in blood pressure and total peripheral resistance induced by temporary occlusion of the fistula.&#x0D; Implications to Theory, Practice and Policy: Surgical closure of persistent AV fistula after renal transplantation to correct LV geometry and improve symptoms in terms of exertional dyspnea and palpitations.

Predicting heart failure and cardiovascular mortality after myocardial infarction: UCCS-HF risk score

Abstract In spite of the current effective management of acute myocardial infarction, post-infarction heart failure (post-MI HF) continues to be a significant medical problem, with high morbidity and mortality. The robust risk score based on readily available clinical and echocardiographic data might help to recognize patients at risk and initiate early preventive/treatment strategies for post-MI HF. The aim of the work: identify clinical and echocardiographic independent predictors of MACE (post-MI HF hospitalization or cardiovascular death) and develop a simplified risk score to predict MACE. Material and methods the retrospective study, 330 post-MI patients were initially included. Clinical (age, diabetes mellitus-DM, atrial fibrillation-Afib, chronic kidney diseases-CKD, cerebrovascular insult-CVI and gastro-bleeding) and standard echocardiographic parameters were analyzed. Results 104 patients have complete data set for analysis and represent final cohort. During the follow-up period (median: 57 months), 24% of them experienced MACE. Significant clinical MACE predictors were: chronic kidney diseases (CKD: HR 1.95, 95% CI 1.124-3.394, p = 0.017) and atrial fibrillation (Afib: HR 2.66, 95% CI 1.522-4.647, p = 0.001). Significant echocardiographic MACE predictors were: left ventricular ejection fraction (EF&amp;lt;40%: HR 2.40, p = 001), right ventricular systolic pressure (RVSP≥33mmHg: HR 4.043, 95% CI 2.104-7.767, p&amp;lt;0.001), left atrial volume (LAVi≥46ml/m2: HR 4.377, 95%CI 1.852-10.348, p = 0.001), deceleration time of transmitral E wave (Dct≤188 ms: HR 4.00, 95%CI 1.739-9.201, p = 0.001), right ventricular diameter (RVd≥26mm: HR 2.056, 95%CI 1.221-3.462, p = 0.007), the systolic velocity of tricuspid annuli (Sm&amp;lt;9.3 cm/sec: 2.068, 95%CI 0.954-4.485, p = 0.006), mitral regurgitation (MR≥2+: HR 3.657, 95% CI 2.079-6.433, p&amp;lt;0.001) and tricuspid regurgitation (TR≥2+: HR 2.824, 95%CI 1.669-4.778, p&amp;lt;0.001). A risk score for post-MI HF or CV mortality (UCCS-HF score) of 10 variables was defined with good discrimination (c-statistic 0.85) (Picture 1). Conclusion nearly 1/4 of post-MI patients experienced HF hospitalization or CV death within 5 years after MI. A simplified risk score (UCCS-HF score) merging clinical risk factors (CKD and Afib), and echo variables (parameters of LV systolic function, LV diastolic properties, and RV systolic pressure and function) is a potentially easy, helpful, and robust tool to predict post-MI HF hospitalization and CV death. External validation and on larger patient population is needed.

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

Abstract Background The early AF treatment by radio-frequency catheter ablation (CA) 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 CA 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 CA. Methods We prospectively enrolled 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 &amp;lt; 0.001) and LASct (10.9% vs. 13.2%, p &amp;lt; 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 &amp;lt; 0.001) and the strongest independent predictive value (LASr &amp;gt; 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 CA, LASr is more accurate predictor of SR maintenance than other standard echocardiographic parameters in long-term follow-up.

Comprehensive echocardiographic evaluation in CTEPH: the impact of TAPSE/sPAP and RVOT acceleration time on the diagnostic performance of peak tricuspid regurgitation velocity

Abstract Introduction The hemodynamic definition of pulmonary hypertension (PH) has been updated, with lowering of the mean pulmonary arterial pressure (mPAP) threshold from 25 to 20 mmHg according to the new 2022 ESC/ERS Guidelines. Peak tricuspid regurgitation velocity (PTRV) remains the key variable for assigning the echocardiographic probability of PH, but a comprehensive echocardiographic evaluation also includes detecting additional signs suggestive of PH. Since the cut-off for PTRV remained the same (&amp;gt;2.8m/s), the potential impact of other echocardiographic variables in the diagnosis of PH according to the new criteria has not been extensively evaluated. Objectives To evaluate the screening power of the standard echocardiographic parameters to detect PH according to the new guidelines and to establish the sensitivity and specificity of adding tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure ratio (TAPSE/sPAP) and right ventricular outflow tract acceleration time (RVOT AT) to PTRV in the diagnosis of PH. Methods Prospective registry of consecutive intermediate-high- and high-risk PE pts submitted to CDT in a single tertiary center. 3 months after the procedure, patients were submitted to a right heart catheterization and echocardiogram to screen chronic thromboembolic pulmonary hypertension (CTEPH). According to new PH criteria, patients were divided in two groups, and echocardiographic parameters were analyzed. ROC curve was performed to evaluate the sensitivity and specificity of each variable. Results 17 pts (60% women, mean age 59 ± 16 years) were included. Among these, 7 pts (41,2%) were diagnosed with pre-capillary PH by RHC at 3 months of follow-up. Among echocardiographic parameters, PTRV (p 0.015), presence of tricuspid regurgitation (0.034) and TAPSE/sPAP (p 0.041) were significantly different between groups. Other parameters did not show significant differences (Fig 1). Regarding PTRV, the cut-off of 2.8 m/s achieved a low sensitivity of 28.6%, although 100% of specificity (AUC 0.643) for the diagnosis of PH. Adding TAPSE/sPAP &amp;lt; 0,55 mm/mmHg (recommended cut-off) to the screening, increased the sensitivity to 42,9% without losing specificity (AUC 0,714). When adding RVOT AT &amp;lt; 105 ms (recommended cut-off) to the analysis, meaning, using three echocardiographic variables combined, it achieved a sensitivity of 85,7%, although the specificity was lower – 80% (AUC 0,829) (Fig 2). Conclusion PTRV and TAPSE/sPAP ratio are the only conventional echocardiographic parameters to be significantly different when comparing patients with and without PH. However, with the recent update in PH criteria, the use of the PTRV recommended cut-off leads to a significant underdiagnosis in our population. Although PTRV did not seem to predict accurately the presence of PH when used alone, when combined with TAPSE/sPAP and RVOT AT, our data suggests a growth in the screening power, without a major loss in specificity.Figure 1Figure 2

Abstract 14093: Effects of Continuous Accelerated Pacing on Cardiac Structure and Function in Patients With Heart Failure With Preserved Ejection Fraction: Insights From the MyPACE Randomized Clinical Trial

Introduction: Heart failure with a preserved ejection fraction of 50% or higher (HFpEF) is prevalent and has few evidence-based therapies. In a trial of HFpEF patients with specialized pacemakers, treatment with an accelerated personalized pacing rate averaging 75 bpm (myPACE) markedly improved quality of life, NT-proBNP, physical activity, and atrial fibrillation burden compared with the standard lower rate setting of 60bpm (usual care). Methods: Provider-initiated echocardiographic studies obtained before and after the trial were assessed for changes in left ventricular (LV) structure and function amongst participants who continued their pacing assignment. The analytic approach aimed to detect differences in standard and advanced echocardiographic parameters within and between study arms. Results: Of the 100 trial participants, 16 patients in the myPACE arm and 20 in the usual care arm had a qualifying set of echocardiograms with a mean±SD time of 3.7±2.0 years apart. Heart rates were expectedly higher among myPACE patients after the trial (in bpm: myPACE 75±6 vs. usual care 65±7, p&lt;0.001). Sustained exposure to moderately accelerated pacing resulted in a reduced septal wall thickness (myPACE 1.07±0.05mm vs usual care 1.23±0.04, p=0.008) and a lower LV mass to systolic volume ratio (myPACE 1.52±0.09 vs. usual care 1.84±0.05, p=0.038) accompanied by a small reduction in LV ejection fraction (in %: myPACE 55±1 vs usual care 60±1, p=0.015). These changes were paralleled by marked improvements in heart failure-related quality of life (MLHFQ points: myPACE 17±21 vs usual care 28±22, p&lt;0.001). Markers of diastolic function and LV performance were not affected. Conclusions: Exposure to continuous accelerated pacing in HFpEF is associated with a reduced LV wall thickness and a lower mass to systolic volume ratio and ejection fraction that remained within normal limits.

Positive left atrial remodeling in patients with paroxysmal atrial fibrillation after a successful radiofrequency pulmonary vein isolation.

The potential relationship between the initial left atrial (LA) echocardiographic parameters and LA remodeling after pulmonary vein isolation with RF energy (PVI) with effectiveness of this treatment is discussed. To determine the influence of initial and after follow-up transthoracic echocardiography derived predictors of successful PVI in patients with paroxysmal atrial fibrillation (AF). 80 patients with paroxysmal AF (58 [interquartile range, IQR], 50-63] years, males: 58 [IQR, 50-63]), hospitalized for the first time PVI procedure were included. Before and after a minimum of 6 months of follow-up period a clinical and echocardiographic evaluation were performed. LA morphological parameters (diameter, volumes and other detailed LA parameters), as well as LA peak segmental and global longitudinal strains (PLS) and LA wall strain synchrony were assessed. In the whole group after a follow-up period, patients presented higher mean LA Volconduit. Patients with no AF recurrences had lower post-PVI LA volumes, higher LA ejection fraction and LA expansion index, when compared to the patients after ineffective PVI. Patients who maintained sinus rhythm after PVI procedure were characterized by a higher initial segmental strains: LA PLSbasal-inferior and PLSapical-septal, as well as higher LA wall strain dispersion in time. Some echocardiographic parameters related to LA morphology improve after successful PVI treatment. LA strains and wall strain dispersion in time are not related to LA remodeling after successful PVI procedure. However the baseline LA standard and novel echocardiographic parameters cannot be used as a remote evaluation of the effectiveness of the PVI procedure.

New 2022 ESC/ERS definition of pulmonary hypertension: can we rely on the same non-invasive echocardiographic parameters?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The hemodynamic definition of pulmonary hypertension (PH) has been updated, with lowering of the mean pulmonary arterial pressure (mPAP) threshold from 25 to 20 mmHg according to the new 2022 ESC/ERS Guidelines. Although there is no single echocardiographic parameter that reliably informs about PH status, some of the echocardiographic parameters cut-offs remained the same, including a peak tricuspid regurgitation velocity (PTRV) &amp;gt;2.8m/s. The potential underdiagnosis of PH has not been evaluated. Objectives To evaluate the screening power of the standard echocardiographic parameters to detect PH according to the new guidelines and to establish new predictors. Methods A prospective registry of consecutive intermediate-high- and high-risk PE pts submitted to CDT in a single tertiary center was used. 3 months after the procedure, the patients were submitted to a right heart catheterization and echocardiogram to screen chronic thromboembolic pulmonary hypertension (CTEPH). According to new PH criteria, patients were divided in two groups, and echocardiographic parameters were analyzed regarding their predictive power. A ROC curve analysis was performed to evaluate optimal cut-offs in predicting PH according the new guidelines. Results 17 pts (60% women, mean age 59 ± 16 years) were included. Among these, 7 pts (41,2%) were diagnosed with pre-capillary PH by RHC at 3 months of follow-up. Among echocardiographic parameters, PTRV (p 0.015), presence of tricuspid regurgitation (0.034) and right ventricle-pulmonary artery (RV-PA) coupling (p 0.041) were significantly different between groups (Fig 1 A). Other parameters, such as right ventricle dilation (p 0.849), TAPSE (p 0.100), annular tricuspid s’ velocity (p 0.646), right ventricle outflow tract acceleration time (p 0.229) and the presence of pericardial effusion (p 0.849) did not show significant differences. Regarding the PTRV, a ROC curve analysis revealed an PTRV optimal cut-off of 2.6 m/s (pressure gradient 27mmHg) in our population (AUC 0.911, p 0.030, Sn 71.4%, Sp 100%), compared to the conventional cut-off of 2.8 m/s (pressure gradient 31 mmHg) (p 0.470, Sn 28.6%, Sp 100%). The use of PTRV &amp;gt; 2.6 m/s allows to reduce false negatives without losing specificity (Fig 1 B, C and D). Conclusion With the recent update in PH criteria, the use of the conventional PTRV cut-off leads to a significant underdiagnosis in our population. Lowering the PTRV threshold seems to increase sensitivity, without losing specificity. Other standard echocardiographic parameters did not seem to predict accurately the presence of PH.