Systolic Displacement Research Articles

Prognostic significance of the echocardiographic estimate of pulmonary hypertension and of right ventricular dysfunction in acute decompensated heart failure. A pilot study in HFrEF patients

BackgroundMortality following an admission for acute decompensated heart failure (ADHF) is high and risk stratification in this context remains a challenge. The objective of the present study was to assess whether a simple echocardiographic assessment of pulmonary hypertension (PH) and/or of right ventricular (RV) dysfunction is associated with cardiovascular events in a 1-year follow-up after hospital discharge. Methods and resultsThe present prospective longitudinal study included 214 patients admitted to hospital with a cardiologist-adjudicated diagnosis of ADHF and a left ventricular ejection fraction (LVEF) at echocardiography < 40%. Echocardiography was performed at admission and at discharge and included pulmonary artery systolic pressure (PASP) and RV function as defined by the tricuspid annular plane systolic displacement (TAPSE). The primary end-point was the combination of all-cause mortality and re-hospitalization for worsening heart failure at 1 year after hospital discharge. During an average follow-up period of 230 ± 130 days, 40 patients died and 41 patients underwent re-hospitalization due to ADHF. At multivariate analysis the independent predictors were LVEF, PASP at discharge and creatinine plasma levels (all p < 0.001). At ROC analysis the best threshold of PASP to discriminate low-risk from high-risk patients was 40 mm Hg. ConclusionsIn ADHF patients with reduced LVEF, PH at discharge is a pivotal prognostic feature to predict morbidity/mortality within the first year after the acute episode.

Geometrical and functional cardiac changes after cardiac surgery: a phisiopatological explanation based on speckle tracking.

Cardiac surgery induces geometrical and functional changes, which are not clearly explained. Objective: to investigate the physiopathology of the heart after cardiac surgery using advanced techniques of echocardiography. Thirty patients undergoing cardiac surgery had echocardiographic study prior and after surgery. Left and right ventricular (RV) longitudinal displacement and strain were studied with speckle-tracking. Using longitudinal displacement, we defined a static longitudinal reference-point (sLRP) to which the other segments moved during systole. Transversal displacement and global function were determined by conventional-echo. Left and RV segments showed systolic longitudinal displacement towards the apex, which was the sLRP before surgery; and towards the medium segment of lateral RV-wall one week after surgery. The displacement of basal RV segment towards this sLRP was smaller, causing decreased TAPSE. Apical segments showed an inverse displacement towards the new sLRP, and septum displacement was decreased or inverted towards the lateral RV-wall, causing paradoxus septal motion. RV-wall longitudinal strain was reduced (- 23.1 ± 8.6 vs. - 14.6 ± 5.3;p < 0.001), RV transversal fractional shortening was increased (36.5 ± 10.5 vs. 41.7 ± 13; p = 0.011), and the RV fractional area change was unchanged (46.7 ± 9.5 vs. 47.8 ± 11.7; p = 0.625). The medium segment of RV lateral wall, in contact with sternotomy, remains static after surgery and acts as a new sLRP towards which the rest of segments move, explaining the reduction of TAPSE and paradoxus septal motion. The longitudinal strain of the lateral RV-wall gets impaired, but an increase of transversal motion maintains global RV function.

Carotid artery longitudinal wall motion: regulatory factors and implications for arterial health.

The carotid artery wall moves longitudinally along the length of the vessel, although little is known about what causes this motion, or what health information it represents. The overarching purpose of this dissertation was to investigate the regulation of carotid artery longitudinal wall motion (CALM) in humans, as well as how CALM can be used to infer information about arterial health. Through observational and experimental designs, we tested evidence for a structural ventricular-vascular coupling effect, which postulates that systolic anterograde CALM is influenced by the forward blood shear rate while systolic retrograde CALM is influenced by left ventricular rotation, although the data suggest a moderate influence of left ventricular rotation, and minimal influence of shear rate. In cross-sectional analyses, we demonstrated that diastolic CALM variables are better related to age and health status compared with systolic CALM displacement and that this relationship was independent of traditional measures of arterial stiffness. These experimental and observational results directed the use of diastolic CALM as a potential indicator of arterial health in subsequent studies, owing to the relative independence from systolic events. While there was no effect of 12 weeks of exercise training in healthy men on diastolic CALM variables, we observed increased systolic retrograde CALM and diastolic CALM acceleration in men with a history of resistance exercise training compared with sedentary men, suggesting an effect of habitual exercise training. Our novel findings suggest that CALM is regulated by a complex system, in part related to both arterial wall structure and ventricular-vascular coupling, and may have clinical value in complimenting measures of traditional arterial stiffness in humans. Future studies should examine whether local changes to arterial wall structure or indirect changes in regulatory control dictate differences in CALM with aging and with chronic exercise training, before integrating CALM into routine measurement of arterial health.

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

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

Longitudinal rotation: a new way to detect the cardiotoxicity of anthracycline-based chemotherapy in breast cancer patients

Background and aimsThe study was to compare cardiac parameters before and after anthracycline-based chemotherapy and identify a parameter for detecting cardiotoxicity in breast cancer patients.MethodsCardiac function in 43 female breast cancer patients was evaluated at three time points: baseline, 1-3 days before the initiation of anthracycline-based chemotherapy; 3 weeks and 6 months after the final cycle of chemotherapy. At each visit, the peak longitudinal velocity; strain rate; peak systolic strain; peak systolic longitudinal displacement, and segmental and global longitudinal rotation degrees of the left ventricular were measured.ResultsThe peak early-diastole left ventricular wall velocity at baseline was significantly higher than the values at 3 weeks and 6 months after the final cycle of chemotherapy. The absolute value of the lateral wall peak systolic longitudinal rotation degrees was significantly higher at baseline than at 3 weeks and 6 months after the final cycle of chemotherapy, whereas the absolute value of the global peak systolic longitudinal rotation degrees at baseline was significantly lower than the values at 3 weeks and 6 months after the final cycle of chemotherapy. None of the measured parameters differed significantly between the 3 weeks and 6 months after the final cycle of chemotherapy.ConclusionsCardiac diastolic and systolic dysfunction was found after anthracycline-based chemotherapy in this study, and the peak systolic longitudinal rotation degrees can be used to detect dysfunction after chemotherapy. The cardiotoxicity of epirubicin-based chemotherapy is stronger than that of therarubicin-based chemotherapy.

Abstract 87: Alterations to Cardiac Mechanics Do Not Preserve Normal Cardiac Function in a Novel Ossabaw Swine Model of Heart Failure with Preserved Ejection Fraction

Introduction: Heart failure with preserved ejection fraction (HFpEF) is clinically characterized by an increased incidence in females and many comorbidities including type 2 diabetes (T2D) and obesity. Animal models accurately representing clinical HFpEF are lacking; thus, the purpose of this study was to examine left ventricular (LV) mechanics in a novel Ossabaw swine model of chronic pressure-overload (aortic-banding; AB) and T2D (Western diet; WD) using two dimensional speckle tracking echocardiography (2D-STE). We hypothesized that global LV strain would be decreased primarily in the longitudinal direction in WD-AB animals. Methods: Female Ossabaws were randomly divided into 2 groups: CON (n=5) and WD-AB (n=5). LV function and strain were measured at 1 year of age after 6 mo. of AB and 9 mo. of WD via pressure-volume relations and 2D-STE. Significance was set at P &lt; 0.05 using t-test vs. CON. Results: In the WD-AB group, ejection fraction (EF%) and end diastolic volume were normal (&gt;50%), and observed in parallel with increased LV weight, lung weight, and LV diastolic wall thickness (i.e. concentric hypertrophy). WD-AB group had increased HOMA-IR and body surface area, two common features in T2D. In WD-AB animals, although global longitudinal systolic strain rate and end systolic displacement were increased, stroke volume index was decreased. Early diastolic rotation rate was decreased, while global longitudinal late diastolic strain rate was increased in the WD-AB group. These changes, considered in parallel with an increased end diastolic pressure-volume relationship in WD-AB animals, are consistent with diastolic dysfunction. In contrast, longitudinal, radial, and circumferential early diastolic strain rates increased in the WD-AB group. Conclusion: Contrary to our hypothesis, LV longitudinal strain was increased during both systole and diastole, and observed in parallel with decreased early diastolic untwisting in WD-AB animals. Our results suggest alterations to LV mechanics do not preserve normal systolic and diastolic cardiac function, despite normal resting EF%, in this novel translational model of pressure-overload HF with potential relevance to human HFpEF including associated clinical comorbidities (sex, obesity, and T2D).

Complement factor 5 blockade reduces porcine myocardial infarction size and improves immediate cardiac function

Inhibition of complement factor 5 (C5) reduced myocardial infarction in animal studies, while no benefit was found in clinical studies. Due to lack of cross-reactivity of clinically used C5 antibodies, different inhibitors were used in animal and clinical studies. Coversin (Ornithodoros moubata complement inhibitor, OmCI) blocks C5 cleavage and binds leukotriene B4 in humans and pigs. We hypothesized that inhibition of C5 before reperfusion will decrease infarct size and improve ventricular function in a porcine model of myocardial infarction. In pigs (Sus scrofa), the left anterior descending coronary artery was occluded (40 min) and reperfused (240 min). Coversin or placebo was infused 20 min after occlusion and throughout reperfusion in 16 blindly randomized pigs. Coversin significantly reduced myocardial infarction in the area at risk by 39% (p = 0.03, triphenyl tetrazolium chloride staining) and by 19% (p = 0.02) using magnetic resonance imaging. The methods correlated significantly (R = 0.92, p < 0.01). Tissue Doppler echocardiography showed increased systolic displacement (31%, p < 0.01) and increased systolic velocity (29%, p = 0.01) in coversin treated pigs. Interleukin-1β in myocardial microdialysis fluid was significantly reduced (31%, p < 0.05) and tissue E-selectin expression was significantly reduced (p = 0.01) in the non-infarcted area at risk by coversin treatment. Coversin ablated plasma C5 activation throughout the reperfusion period and decreased myocardial C5b-9 deposition, while neither plasma nor myocardial LTB4 were significantly reduced. Coversin substantially reduced the size of infarction, improved ventricular function, and attenuated interleukin-1β and E-selectin in this porcine model by inhibiting C5. We conclude that inhibition of C5 in myocardial infarction should be reconsidered.

Gravity Compensation Method for Combined Accelerometer and Gyro Sensors Used in Cardiac Motion Measurements.

A miniaturized accelerometer fixed to the heart can be used for monitoring of cardiac function. However, an accelerometer cannot differentiate between acceleration caused by motion and acceleration due to gravity. The accuracy of motion measurements is therefore dependent on how well the gravity component can be estimated and filtered from the measured signal. In this study we propose a new method for estimating the gravity, based on strapdown inertial navigation, using a combined accelerometer and gyro. The gyro was used to estimate the orientation of the gravity field and thereby remove it. We compared this method with two previously proposed gravity filtering methods in three experimental models using: (1) in silico computer simulated heart motion; (2) robot mimicked heart motion; and (3) in vivo measured motion on the heart in an animal model. The new method correlated excellently with the reference (r 2>0.93) and had a deviation from reference peak systolic displacement (6.3±3.9mm) below 0.2±0.5mm for the robot experiment model. The new method performed significantly better than the two previously proposed methods (p<0.001). The results show that the proposed method using gyro can measure cardiac motion with high accuracy and performs better than existing methods for filtering the gravity component from the accelerometer signal.

Mitral Annular Dynamics and Left Ventricular Diastole.

BackgroundThough diastolic interrogation of the mitral annulus (MA) using tissue Doppler imaging (TDI) has been quite useful in assessing left ventricular (LV) diastolic function, the relative contribution of the previous cycle MA systolic displacement or velocity components to subsequent LV diastole has not been previously investigated. We therefore sought to determine the association between MA systolic dynamics and LV diastolic function parameters.MethodsFor this retrospective study, only complete echocardiograms having good endocardial border resolution of both left atrial (LA) and LV chambers with M-mode (MAPSE) and tissue Doppler of the lateral MA (MA TDI S’) as well as complete Doppler data to perform assessment of LV diastole were included in our analysis.ResultsData from 100 patients (mean age 54 ± 14) showed that both MA systolic displacement and velocity correlate with LV ejection fraction (P < 0.05). Only MA displacement was associated with age and LV mass. Most importantly no correlation was found between MAPSE and LV diastole. However, in sharp contrast MA TDI S’ correlated with MA relaxation velocities during both early and late LV diastole.ConclusionEven though MAPSE and MA TDI S’ are surrogate measures of LV ejection fraction, only MA TDI S’ correlates with diastolic MA velocities as no correlation was identified between MAPSE and measures of LV diastole. Additional studies are now warranted to explore whether a reduced MA TDI S’ may affect the symptomatic profile or the overall prognosis of patients with LV diastolic dysfunction.

Coexistence of abnormal systolic motion of mitral valve in a consecutive group of 324 adult Tetralogy of Fallot patients assessed with echocardiography

BackgroundThe presence of mitral valve prolapse (MVP) in congenital heart disease (CHD) patients is not well described. Tetralogy of Fallot (TOF) is the most common cyanotic CHD associated with overall...

Simulations of morphotype-dependent hemodynamics in non-dilated bicuspid aortic valve aortas

Bicuspid aortic valves (BAVs) generate flow abnormalities that may promote aortopathy. While positive helix fraction (PHF) index, flow angle (θ), flow displacement (d) and wall shear stress (WSS) exhibit abnormalities in dilated BAV aortas, it is unclear whether those anomalies stem from the abnormal valve anatomy or the dilated aorta. Therefore, the objective of this study was to quantify the early impact of different BAV morphotypes on aorta hemodynamics prior to dilation. Fluid-structure interaction models were designed to quantify standard peak-systolic flow metrics and temporal WSS characteristics in a realistic non-dilated aorta connected to functional tricuspid aortic valve (TAV) and type-I BAVs. While BAVs generated increased helicity (PHF>0.68) in the middle ascending aorta (AA), larger systolic flow skewness (θ>11.2°) and displacement (d>6.8mm) relative to the TAV (PHF=0.51; θ<5.5°; d<3.3mm), no distinct pattern was observed between morphotypes. In contrast, WSS magnitude and directionality abnormalities were BAV morphotype- and site-dependent. Type-I BAVs subjected the AA convexity to peak-systolic WSS overloads (up to 1014% difference vs. TAV). While all BAVs increased WSS unidirectionality on the proximal AA relative to the TAV, the most significant abnormality was achieved by the BAV with left-right-coronary cusp fusion on the wall convexity (up to 0.26 decrease in oscillatory shear index vs. TAV). The results indicate the existence of strong hemodynamic abnormalities in non-dilated type-I BAV AAs, their colocalization with sites vulnerable to dilation and the superior specificity of WSS metrics over global hemodynamic metrics to the valve anatomy.

New Automatic Tools to Identify Responders to Cardiac Resynchronization Therapy

New echocardiographic parameters (apical rocking [AR], septal flash [SF]) are intended to detect patternsspecific to responders to cardiac resynchronization therapy (CRT). The patterns are visually recognized and qualitatively described, requiring experience and training. Speckle-tracking echocardiography can reflect SF and AR by using newly developed, dedicated parameters, such as start systolic index (SSI) and peak longitudinal displacement (PLD). The aim of this study was to investigate whether SSI and PLDcan identifypotential CRT responders. In 125 patients, echocardiograms from before and 9±3months after CRT were retrospectively analyzed with dedicated EchoPAC prerelease software. From speckle-tracking baseline images, color-coded bull's-eye displays of SSI and PLD were generated. Cutoff values for both parameters were derived from 25 randomly selected patients and applied to the remaining 100 patients to identify CRTresponse, defined as a decrease in end-systolic volume of ≥15% during follow-up. The performance of SSI and PLD was compared with the visual assessment of AR and SF by expert and novice readers. Expert readers detected 77 patients with AR, identifying CRT responders with sensitivity and specificity of 85±2% and 82±2%, respectively. Novice readers reached 74±7% sensitivity and 55±11% specificity,while the sensitivity and specificity of the quantitative analysis were 72±3% and 84±4% for SSI and 80±1% and 75±2% for PLD, respectively. New speckle-tracking-based quantitative assessment of mechanical dyssynchrony by SSI and PLD performs comparably in identifying CRT responders as visual analysis by expert readers and performs significantly better than novice readers.

A clinical study on tricuspid annular displacement predicting the right ventricular function of pulmonary hypertension measured by two-dimensional speckle tracking echocardiography

Objective To measure tricuspid annular displacement by two-dimensional speckle tracking echocardiography in pulmonary hypertension (PH) patients, and compare with the right ventricular function parameters, finally discuss the clinical application value of this technology in evaluating the right ventricular function in PH. Methods A total of 58 patients diagnosed or suspected diagnosed as PH were divided into PH group and control group according to pulmonary arterial systolic pressure measured by echocardiography. The right ventricular function parameters included: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (FAC), tissue Doppler-derived tricuspid lateral annular systolic velocity (s') and right ventricular index of myocardial performance (RIMP). The parameters of tricuspid annular displacement included: the peak systolic tricuspid annular displacement at right ventricular free wall (TMAD1), the peak systolic tricuspid annular displacement at interventricular septum (TMAD2), the peak systolic tricuspid annular displacement at midpoint of tricuspid annulus (TMADm) and the right ventricular longitudinal shortening (TMADm%). Results ① There were significant statistical differences between two groups in TAPSE, RIMP, FAC and s' (P 0.54 and s'<9.5 cm/s, their sensitivities were 81.8%, 84.4%, 85.7% and 72.3% respectively, and their specificities were 72.0%, 73.1%, 70.3% and 100% respectively. Conclusions The tricuspid annular tissue displacement parameters can predict the decrease of right ventricular function in patients with PH, and provide a new diagnostic index for clinical treatment and prognosis. Key words: Echocardiography; Pulmonary hypertension; Tissue motion annular displacement; Ventricular function, right; Speckle tracking imaging

Systolic flow displacement using 3D magnetic resonance imaging in an experimental model of ascending aorta aneurysm: impact of rheological factors.

The impact of systolic flow displacement on the development and progression of ascending aorta dilatation in aortic valve disease is a matter of controversy. Our objective was to study the association between rheological stimuli and development of aortic dilatation in a large animal model of supravalvular aortic stenosis and eccentric flow. Twenty-four pigs weighing 10-14 kg were randomly allocated (ratio 2:1) to either restrictive ascending aortic banding or sham operation. Aortic diameter and systolic flow displacement were assessed by three-dimensional phase-contrast magnetic resonance imaging at 6 and 18 weeks after surgery. Twenty pigs (n = 14, banded vs n = 6, sham) completed full imaging protocol and were included in the analysis. After the last follow-up, a subset of 14 animals was sacrificed for histological analysis. All banded animals developed significant progressive aortic dilatation both at 6 and 18 weeks, compared with sham-operated pigs: 34.3 ± 4.8 vs 21.4 ± 2.7 mm at 6 weeks (P < 0.001); and 50.0 ± 8.4 vs 38.0 ± 8.3 mm at 18 weeks (P = 0.002). The peak gradient at 6 weeks showed a trend to positively correlate with aortic diameter at 18 weeks (R = 0.50, P = 0.06), whereas the systolic flow displacement at 6 weeks correlated better with aortic diameter at 18 weeks (R = 0.59, P = 0.02). The aortic wall thickness was significantly decreased in the anterior aortic section in banded, compared with sham-operated, pigs (1.5 ± 0.4 vs 2.0 ± 0.1 mm, respectively; P = 0.03). In addition, banded pigs showed a higher degree of cystic medial necrosis and elastin fibre fragmentation, compared with sham-operated animals. In this preclinical model of supravalvular aortic stenosis and eccentric flow, we found that systolic flow displacement at earlier stages is positively correlated with the degree of aortic dilatation during follow-up as assessed by three-dimensional phase-contrast magnetic resonance imaging. If our findings are confirmed in further studies, this imaging parameter might be useful to identify those subjects with aortic valve disease who are at risk of developing aortic dilatation at a later stage.

Evolution of Mitral Valve Prolapse: Insights From the Framingham Heart Study.

Longitudinal studies of mitral valve prolapse (MVP) progression among unselected individuals in the community, including those with nondiagnostic MVP morphologies (NDMs), are lacking. We measured longitudinal changes in annular diameter, leaflet displacement, thickness, anterior/posterior leaflet projections onto the annulus, coaptation height, and mitral regurgitation jet height in 261 Framingham Offspring participants at examination 5 who had available follow-up imaging 3 to 16 years later. Study participants included MVP (n=63); NDMs, minimal systolic displacement (n=50) and the abnormal anterior coaptation phenotype (n=10, with coaptation height >40% of the annulus similar to posterior MVP); plus 138 healthy referents without MVP or NDMs. At follow-up, individuals with MVP (52% women, 57±11 years) had greater increases of leaflet displacement, thickness, and jet height than referents (all P<0.05). Eleven participants with MVP (17%) had moderate or more severe mitral regurgitation (jet height ≥5 mm) and 5 others (8%) underwent mitral valve repair. Of the individuals with NDM, 8 (80%) participants with abnormal anterior coaptation progressed to posterior MVP; 17 (34%) subjects with minimal systolic displacement were reclassified as either posterior MVP (12) or abnormal anterior coaptation (5). In comparison with the 33 participants with minimal systolic displacement who did not progress, the 17 who progressed had greater leaflet displacement, thickness, coaptation height, and mitral regurgitation jet height (all P<0.05). NDM may evolve into MVP, highlighting the clinical significance of mild MVP expression. MVP progresses to significant mitral regurgitation over a period of 3 to 16 years in one-fourth of individuals in the community. Changes in mitral leaflet morphology are associated with both NDM and MVP progression.

0131: A phenotypic study of ARHGAP24 mitral valve prolapse suggests a genetic origin for fibro elastic deficiency

Mitral valve prolapse (MVP) by Barlow disease is recognized a genetic disease. Fibro-elastic deficiency (FED)-MVP is considered a pure degenerative condition. FLNA, the first gene involved in MVP, encodes for Filamin-A, a cytoskeleton associated protein. It interacts with a protein named Filgap, encoded by ARHGAP24 (Chr. 4), in the mechanical transduction. We hypothesized that ARHGAP24 mutations could elicit MVP with same pathway. Four probands with ARHGAP24 mutations were identified among 96 MVP. By a familial echocardiographic screening we enrolled 19 adults of whom 13 had an ARHGAP24 mutation. The mutated group was matched with a control group of 39 healthy adults. Anterior (AML) and posterior (PML) mitral leaflets length and thickness were measured. The coaptation point position was the ratio of coaptation height on the systolic annulus diameter. MVP (displacement >2mm above the annulus line), minimal systolic displacement (MSD, displacement <2mm) and abnormal antero-posterior coaptation position (AAC, ratio <60%) were assessed. The conjunction of MSD and AAC defines a MVP prodromal form (MVP-prod). There was no difference between the two groups on baseline characteristics. Leaflets were thin in the mutated group (PML: 2.7±1 vs 2.2±0.5mm in control, P=0.21, AML: 2.5±0.9 vs 2.1±0.4mm, P=0.25), as reported in FEDMVP. Only the PML was elongated (8.2±1.6 vs 6.0±1.2mm/m 2 , P=0.0003) in the mutated group, leading to an anterior displacement of the coaptation point (51±11 vs 66±7%, P=0.0003). Abnormal mitral phenotype (70% of MVP, 23% of MVP prod) and mitral regurgitation (93 vs 38%, P=0.0007) were frequent in the mutated group. Two probands were operated for severe MR related to chordal rupture; histological examination confirmed the leaflets thinness. ARHGAP24 is the first gene for autosomal dominant inherited MVP. Our limited series of patients exhibit typical features of FED-MVP. Our results could change the paradigm of a pure degenerative disease for FED-MVP.

Young Investigator Award session – Clinical Science442Left bundle branch block and coronary artery disease in coronary ct angiography443Focal myocardial fibrosis and abnormal left ventricular strain in patients with sarcoidosis without clinical evidence of cardiac disease444Arhgap24, a first gene for fibro elastic deficiency mitral valve prolapse? A phenotypic study445Advantage of using ASE/EACVI criteria for detection of subclinical cardiotoxicity in breast cancer

Young Investigator Award session – Clinical Science442Left bundle branch block and coronary artery disease in coronary ct angiography443Focal myocardial fibrosis and abnormal left ventricular strain in patients with sarcoidosis without clinical evidence of cardiac disease444Arhgap24, a first gene for fibro elastic deficiency mitral valve prolapse? A phenotypic study445Advantage of using ASE/EACVI criteria for detection of subclinical cardiotoxicity in breast cancer

Transaortic Chordal Cutting: Mitral Valve Repair for Obstructive Hypertrophic Cardiomyopathy With Mild Septal Hypertrophy

BackgroundIn severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM) and mild septal hypertrophy, mitral valve (MV) abnormalities may play an important role in MV displacement into the left ventricular (LV) outflow tract. Therefore, isolated myectomy may not relieve outflow obstruction and symptoms, and MV replacement is often the surgical alternative. ObjectivesThis study sought to assess the clinical and hemodynamic results of cutting thickened secondary MV chordae combined with a shallow septal muscular resection in severely symptomatic patients with obstructive HCM and mild septal hypertrophy. MethodsClinical features were compared before surgery and at most recent clinical evaluation in 39 consecutive patients with obstructive HCM. ResultsOver a 23 ± 2 months follow-up, New York Heart Association functional class decreased from 2.9 ± 0.5 pre-operatively to 1.1 ± 1.1 post-operatively (p < 0.001), with no patient in class III at most recent evaluation. The resting outflow gradient decreased from 82 ± 43 mm Hg to 9 ± 5 mm Hg (p < 0.001) and septal thickness decreased from 17 ± 1 mm to 14 ± 2 mm (p < 0.001). No patient had MV prolapse or flail and 1 had residual moderate-to-severe MV regurgitation at most recent evaluation. MV geometry before and after surgery was compared with that of 25 consecutive patients with similar clinical profile and septal thickness that underwent isolated myectomy. After adjustment for differences in pre-operative values between the groups, the post-operative anterior MV leaflet-annulus ratio was 17% greater and tenting area 24% smaller in patients with chordal cutting, indicating that MV apparatus had moved to a more normal posterior position within the LV cavity, preventing MV systolic displacement into the outflow tract and outflow obstruction. ConclusionsThis procedure relieves heart failure symptoms, abolishes LV outflow gradient, and avoids MV replacement in patients with obstructive HCM and mild septal thickness.

Left Ventricular Longitudinal Systolic Function, Afterload and Contractility in Severe Aortic Stenosis

Background: In patients with severe aortic stenosis (AS), left ventricular systolic longitudinal function (SLF) is impaired despitenormal ejection fraction (EF). However, similarly to other shortening indexes, SLF depends on afterload and its relationshipwith contractility has not been thoroughly studied.Objective: The aim of this study was to evaluate SLF alterations and their relationship with afterload and myocardial contractilityin patients with severe AS.Methods: One hundred and one patients with severe AS (AVA <1 cm2) and 63 normal control subjects were studied withDoppler echocardiography. Left ventricular systolic longitudinal function was evaluated by lateral mitral annulus systolicdisplacement (MASD) and peak S wave velocity (tissue Doppler imaging). Contractility was assessed by the midwall fractionalshortening (mFS)–end-systolic stress (ESS) relationship in control subjects. Contractility level (CL) was defined as measuredmFS minus predicted mFS for a defined ESS value.Results: Lateral mitral annulus systolic displacement and S wave correlated directly with shortening indexes as EF and mFSand inversely with afterload indexes as ESS. There was no correlation between SLF and CL. In the multivariate analysisESS and EF were predictors of SLF.Conclusions: In patients with severe AS, SLF correlated inversely with afterload. The presence of decreased MASD or S wavewas not associated with abnormal left ventricular contractility.

Dilated Cardiomyopathy: Normalized Multiparametric Myocardial Strain Predicts Contractile Recovery

Left ventricular contractile injury in dilated cardiomyopathy (DCM) may occur in a consistently heterogeneous distribution, suggesting that early-injury sentinel regions may have prognostic significance. Heightened surveillance of these regions with high-resolution contractile metrics may predict recovery in DCM. Multiple three-dimensional strain parameters were calculated at each of 15,300 left ventricular grid points from systolic displacement data obtained from cardiac magnetic resonance imaging in 124 test subjects. In 24 DCM patients, Z-scores for two strain parameters at each grid point were calculated by comparison of patient-specific strain values to respective point-specific mean and standard deviation values from a normal human strain database (n= 100). Multiparametric strain Z-scores were averaged over six left ventricular regions at basilar, mid, and apical levels (18 subregions). Patients with DCM were stratified into three groups on the basis of a blinded review of clinical contractile recovery (complete, n= 7; incomplete, n= 7; none, n= 10). Basilar-septal subregions were consistently heavily injured. Basilar-septal Z-scores were significantly larger (worse) than those for the rest of the left ventricle (2.73 ± 1.27 versus 2.22 ± 0.83; p= 0.011) and lateral wall (2.73 ± 1.27 versus 1.44 ± 0.72; p < 0.001). All patients with sentinel region average multiparametric strain Z-scores less than two standard deviations (n= 6) experienced complete recovery, whereas 17 of 18 DCM patients with Z-scores greater than two standard deviations experienced incomplete or no contractile recovery. Contractile injury in DCM is heterogeneous, with basilar-septal regions injured more than lateral regions. The targeting of early-injury sentinel regions for heightened surveillance with high-resolution metrics of microregional contractile function may accurately predict recovery on medical therapy. A two standard deviation Z-score threshold may predict contractile recovery.