Transthoracic Echocardiography Imaging Research Articles

Comprehensive assessment of unexplained sudden cardiac death and idiopathic ventricular fibrillation during the index hospitalization: A systematic thorough investigation to unmask specific etiology

The previous studies have shown that a systematic assessment, during the initial hospitalization after sudden cardiac death (SCD), provides the capacity to unmask specific etiology. The diagnosis of idiopathic ventricular fibrillation (IVF) is probably overestimated because of an unsystematic workup. We aimed to assess the profitability of comprehensive medical investigation strategy after SCD in a single university center. Based on an implantable cardiac defibrillator data-base interrogation, the patients who survived from ventricular fibrillation without reversible cause were identified between 2012 and 2019. The etiological examinations performed during the initial hospitalization or planned after discharge were collected. In a cohort of 66 patients, retrospectively included, a minimal assessment including twelve-lead ECG, trans-thoracic echocardiography and coronary imaging allowed to unmask etiology for 40 (61%) patients. Ventricular fibrillation remained idiopathic for 16(24%) patients by adding magnetic resonance imaging, and for 12(18%) patients by performing provocative and genetic tests. Among the 54 patients for whom the diagnosis was confirmed, we reported 12(22%) electrical cardiac disorders, 11(20%) ischemic cardiopathy, 9(17%) dilated cardiomyopathy, 9(17%) valvular disease, 8(15%) hypertrophic cardiomyopathy, 4(7%) myocarditis and 1(2%) tako-tsubo syndrome. The number of examinations carried out in the IVF cohort did not differ from the others (6 vs. 5, P = 0.06). In the IVF group, SCD event occurred more frequently at rest (8/12 vs. 14/54, P = 0.02) and the patients were preferably women (9/12 vs. 13/54, P = 0.02). Systematic etiologic investigations, carried out during initial assessment after SCD, allowed to unmask etiology for a large number of patients. Further studies are needed to standardize the workup to implement in all tertiary centers.

P350 Right atrial remodelling in atrial fibrillation using three dimensional transthoracic echocardiography and strain imaging

Abstract Background Evaluation of right atrial cavities and right atrial (RA) remodelling in atrial fibrillation (AF) has been poorly studied. Purpose The aim of this study was to evaluate in AF, the role of three-dimensional (3D) transthoracic echocardiography (TTE) and strain to refine the evaluation of the RA according to evolution of cardiac rhythm ad mid-term follow-up. Methods A complete 2D and 3D TTE was performed in patient hospitalized for AF. In addition to the usual parameters, RA parameters were specifically assessed: 3D RA end-systolic (ES) and end-diastolic (ED) volume, RA ejection fraction (EF) and the global longitudinal strain (GLS) of the RA. A complete clinical evaluation and electrocardiogram were performed at admission (M0) and 6 months after inclusion (M6) to determine the cardiac rhythm at follow-up. Results 34 consecutive patients hospitalized for AF were analysed. At M0, there was no significant difference between 2D RA ES volume and the 3D RA ES volume. Three groups of patients were individualized according to cardiac rhythm at M0 and M6: AF at M0 and AF at M6 (AF-AF), AF at M0 and sinus rhythm (SR) at M6 (AF-SR), SR at M0 (spontaneous reduction before the admission ECG) and SR at M6 (SR-SR). At M0 echocardiography, in the AF-AF group and AF-SR in comparison with SR-SR group were as follow: the 3D RA ED volume was significantly higher (respectively 21.6 (18.2-26.6) and 26.9 (19.4-36.8) versus 11.3 (6.9-16.6) mL/m2 ; p = 0.0025), the 3D RAEF was significantly lower (42.2 (35.1-44.7) and 34.5 (24.1-38.6) versus 57.6 (53.4-62.2)%; p = 0.0105) and the RA GLS was also significantly lower (7.6 (6.5-10.5) and 9.1 (5.8-11.2) versus 26.6 (22.0-35.0)%; p = 0.0001) (Figure 1). Conclusion 3D ultrasound and strain could be useful tools for evaluating the anatomical and functional RA remodelling in AF, to be further validated in a larger ongoing study. Abstract P350 Figure 1

Study on Image Acquisition of Transthoracic Echocardiography in Mechanically Ventilated ICU Patients

Objective This study aimed to determine which parameters in transthoracic echocardiography (TTE) are more likely to be affected when applied in a critical care setting with mechanical ventilation.Methods Ninety mechanically ventilated ICU patients were enrolled into the study group. The control group consisted of 90 patients who underwent interventional therapy. All patients had bedside TTE for parametric measurements including the right ventricular size, septal kinetics and left ventricular ejection fraction (LVEF) by eyeballing (visual assessment), the tricuspid annular plane systolic excursion (TAPSE), mitral annular plane systolic excursion (MAPSE) by M-mode sonography, the right ventricular outflow tract velocity-time integral (RVOT VTI) and left ventricular outflow tract velocity-time integral (LVOT VTI) by pulse-Doppler, the right ventricular fraction of area change (FAC) and left ventricular ejection fraction (LVEF Simpson) by endocardium tracing. We compared the differences in the frequency of optimal image acquisition in assessments of these parameters between the two groups, as well as the differences in acquisition rates of parameter measurements in ventilated ICU patients.Results There were significantly fewer patients in the study group than in the control group who had optimal images acquisitions for parameter assessments with M-mode method, pulse Doppler method and endocardium-tracing method (P<0.05); no significant difference was obsered in the number of patients with optimal images for RV eyeballing and LVEF eyeballing between the two groups. In the study group, significantly fewer optimal images were acquired for FAC than for TAPSE (22.2% vs. 72.2%, χ2=45.139, P<0.001) and RVOT VTI (22.2% vs. 71.1%, χ2=43.214, P<0.001); there were also fewer optimal images acquired for LVEF Simpson than for MAPSE (37.8% vs. 84.4%, χ2=41.236, P<0.001) and LVOT VTI (37.8% vs. 85.6%, χ2=43.455, P<0.001).Conclusions Images acquisition of optimal TTE images tend to be difficult in mechanically ventilated ICU patients, but eyeballing method for functional evaluation could be an alternative method. For quantitative parameters measurements, M-mode based longitudinal function evaluation and pulse Doppler-based VTI were superior to the endocardium-tracing based parameter assessments.

P1322 Role of echocardiography in the assessment of mechanical complications of acute myocardial infarction: case report series

Abstract INTRODUCTION The incidence of the mechanical complications of acute myocardial infarction (AMI) has noticeably decreased throughout the world after the era of primary percutaneous coronary intervention (PCI); nonetheless, when they present, the mortality rate continues being high, requiring for their diagnosis an adequate clinical suspicion, followed by intensive care therapy and in most cases, surgical treatment. In the current report we present 4 cases of mechanical complications using transthoracic echocardiography (TTE) as diagnostic tool: a ventricular septal defect, a papillary muscle rupture, a left ventricular (LV) free wall rupture and a ventricular aneurysm. PATIENT 1: A 71-year-old male who presented with inferior AMI and no reperfusion therapy, complicated with transitory AV block, ventricular fibrillation and severe mitral regurgitation secondary to posteromedial papillary muscle rupture (Panel A). He followed surgery with biological mitral valve replacement and PCI of the right coronary artery (RCA). PATIENT 2: A 71-year-old male who presented with anterior AMI and no reperfusion therapy, suddenly showed signs of cardiogenic shock. The TTE demonstrated pericardial effusion associated with an image of thrombus fixed to the antero-apical wall of the LV of 21 mm in dimension, apical segments akinesia and left ventricular ejection fraction (LVEF) of 40% (Panel B). These findings concluded LV free wall rupture, that required urgent surgical repair of the apical region with sphacelated myocardium. PATIENT 3: A68-year-old male, with history of hospitalization 2 months prior for an event of acute coronary syndrome. Admitted again for chest pain, with a TTE that demonstrated a ventricular septal defect associated with intramyocardial dissection, apical thrombus of 17x11 mm in dimension, apical dyskinesis and LVEF of 30% (Panel C). Coronary angiography documented critical obstruction of proximal left anterior descending coronary artery (LAD) and chronic total occlusion of the RCA. He was taken to surgical repair of the defect and coronary artery bypass (CABG). PATIENT 4: A 77-year-old male, with a history of PCI in 2009 (unknown coronary vessel), presented with inferior AMI and no reperfusion therapy. TTE demonstrated an aneurysm in the basal inferior segment of 55x44 mm in dimension, partially thrombosed, with a neck of 23 mm, severe mitral regurgitation and LVEF of 45% (Panel D). Coronary angiography documented multivessel disease with unsuitable coronary anatomy for CABG. CONCLUSIONS The incidence of AMI mechanical complications has decreased noticeably to less than 1% in the era of primary PCI. These include free wall rupture (0.17%), papillary muscle rupture (0.26%) and LV free wall rupture (0.17%). Immediate echocardiographic assessment is needed when clinical findings suggest such complications; urgent treatment is fundamental to improve short term prognosis. Abstract P1322 Figure. Bidimensional TTE images.

P274 Continous echocardiographic monitoring in intensive cardiac care unit with external probe stabilizer - preliminary experience

Abstract Background The role of transthoracic echocardiography (TTE) in the intensive cardiac care unit is crucial. Imaging is currently performed at the bedside for diagnosis but TTE has also potential to noninvasively provide critical views to assist in patient monitoring. Continuous monitoring would be especially helpful when the patient is unstable; however, continuous availability of skilled sonographers to obtain appropriate views represents a limiting factor. Purpose Recently, an innovative external fixation device allowing prolonged stabilization of transthoracic ultrasound transducer was introduced. The ring-shaped device fitted for TTE probes is attached to the patient by elastic straps to hold the probe in contact with the skin at a fixed but adjustable angle. We developed a research project to assess for the first time the feasibility of continuous TTE imaging with external probe fixation in the intensive cardiac care unit. Methods 12 patients (10 men, mean age 66,5 ± 15 years) hospitalized in intensive cardiac care unit due to cardiac arrest, myocardial infarction, pulmonary embolism, end-stage heart failure or respiratory failure were included in the study. The echocardiographic probe be was fixed in the apical window providing a four-chamber view to monitor left ventricular function. We assessed the patient’s tolerance and comfort as well as the quality of images acquired at baseline and at the end of monitoring. Results Fixation of the probe was successful in all patients (figure 1). The mean time of fixation was 10 ± 1 minute, with a clear learning curve. The quality of obtained images was sufficient for evaluation and was maintained throughout the entire period of monitoring in all patients. Monitoring was stopped at patients’ request when discomfort caused by the compression of the skin by the probe and the fixation device became significant (figure 2). The mean duration of monitoring was 85 + 64 minutes (range 15 to 240 minutes). Conclusions In this preliminary series we have demonstrated for the first time the feasibility of echocardiographic continuous monitoring of patients in the intensive cardiac care unit using TTE probe with the external fixation device. The design of the fixation device opens the evident field for optimization to extend monitoring duration at acceptable levels of discomfort in conscious intensive care patients. We hope the improved version of the fixator will decrease the pressure on the body. Abstract P274 Figure. Fixation of the device

Comparison of transthoracic echocardiography with computed tomography in evaluation of pulmonary veins

BackgroundTransesophageal echocardiography may be used to assess pulmonary veins for atrial fibrillation ablation. No study focused on the role of transthoracic echocardiography (TTE) in evaluating the diameter and anatomy of pulmonary veins.MethodsAmong 142 atrial fibrillation patients (57.7% men; mean age, 60.5) hospitalised for catheter ablation, we assessed pulmonary veins and compared the measurements by TTE with cardiac computed tomography (CT) before ablation. Among 17 patients who had follow-up examinations, the second measurements were also studied.ResultsTTE identified and determined the diameters of 140 (98.6%) right and 140 (98.6%) left superior PVs, and 136 (95.7%) right and 135 (95.1%) left inferior PVs. A separate middle PV ostia was identified in 14 out of the 22 patients (63.6%) for the right side and in 2 out of 4 (50.0%) for the left side. The PV diameters before ablation assessed by CT vs. TTE were 17.96 vs. 18.07 mm for right superior, 15.92 vs. 15.51 mm for right inferior, 18.54 vs. 18.42 mm for left superior, and 15.56 vs. 15.45 mm for left inferior vein. The paired differences between the assessments of CT and TTE were not significant (P ≥ 0.31) except for the right inferior vein with a CT-minus-TTE difference of 0.41 mm (P = 0.018). The follow-up PV diameters by both CT (P ≥ 0.069) and TTE (P ≥ 0.093) were not different from baseline measurements in the 17 patients who had follow-up measurements.ConclusionsWith a better understanding of PV anatomy in TTE imaging, assessing PV diameters by non-invasive TTE is feasible. However, the clear identification of anatomic variation might still be challenging.

Predictors for In-hospital Mortality in Pediatric Patients with Acute Myocarditis – a Retrospective Study

Abstract Background: Acute myocarditis, a primary inflammatory cardiac disease commonly caused by viral infection, is an important cause of morbidity and mortality in children. Data obtained from forensic studies found an incidence of 15–33% for acute myocarditis in sudden deaths in the pediatric age group. Currently, there is a lack of data regarding the incidence and factors associated with short-term outcomes in pediatric patients admitted for acute myocarditis. The aim of the study was to identify predictors for in-hospital mortality in a pediatric population admitted with acute myocarditis. Material and methods: We conducted a retrospective observational cohort study that included 21 patients admitted for acute myocarditis. Clinical, laboratory, ECG, and imaging data acquired via 2D transthoracic echocardiography and cardiac magnetic resonance imaging were collected from the medical charts of each included patient. The primary end-point of the study was all-cause mortality occurring during hospitalization (period ranging from 10 to 14 days). The study population was divided into 2 groups according to the occurrence of the primary end-point. Results: The mean age of the study population was 99.62 ± 77.25 months, and 61.90% (n = 13) of the patients were males. The in-hospital mortality rate was 23.9% (n = 5). Patients in the deceased group were significantly younger than the survivors (55.60 ± 56.18 months vs. 113.4 ± 78.50 months, p = 0.039). Patients that had deceased presented a significantly higher level of LDH (365 ± 21.38 U/L vs. 234.4 ± 63.30 U/L, p = 0.0002) and a significantly higher rate of ventricular extrasystolic dysrhythmias (60% vs. 6.25%, p = 0.02, OR: 22.5, 95% CI: 1.5–335) compared to survivors. The 2D echocardiography showed that patients that had deceased presented more frequently an impaired left ventricular ejection fraction (&lt;30%) (p = 0.001) and a significantly higher rate of severe mitral regurgitation (p = 0.001) compared to survivors. Conclusions: The most powerful predictors for in-hospital mortality in pediatric patients admitted for acute myocarditis were the presence of ventricular extrasystolic dysrhythmias on the 24h Holter ECG monitoring, impaired left ventricular systolic function (LVEF &lt;30%), the presence of severe mitral regurgitation, and confirmed infection with Mycoplasma pneumoniae.

New horizon of fusion imaging using echocardiography: its progress in the diagnosis and treatment of cardiovascular disease.

Cardiac imaging modalities are essential for the management of cardiac diseases. Multimodality imaging, such as echocardiography, cardiac computed tomography (CT), cardiac magnetic resonance imaging, and fluoroscopy, is required for assessing cardiac condition. In recent years, fusion imaging, which integrates different imaging modalities on the same screen, has been developed. Because the fusion imaging is able to merge the advantages of each modality, it has the potential to be valuable for accurate diagnosis as well as the planning of therapeutic strategies. In the clinical setting, the fusion imaging of real-time transthoracic echocardiography with cardiac CT displayed side by side has reportedly been effective for the diagnosis and the assessment of disease severity in patients with adult congenital heart disease. The overlay of real-time three-dimensional transesophageal echocardiography onto fluoroscopy, which is dynamic fusion imaging, has been used for structural heart disease interventions. The fusion imaging has become increasingly important in the field of cardiac diseases. This review discusses the benefits of echocardiographic fusion imaging.

Evaluation of left ventricular systolic function by Myocardial Deformation Imaging in asymptomatic HIV patients

Background and Aims: Despite improvements in clinical care, evidence from both industrialized and developing countries indicates that the prevalence of subclinical cardiac dysfunction in individuals with well-controlled HIV infection may approach 50% and represent a newly recognized comorbid condition. The aim of our study was to reveal abnormalities in cardiac function using conventional transthoracic echocardiography and left ventricular strain imaging in HIV infected patients without cardiovascular disease.&#x0D; Methods: This was a hospital based, single center descriptive cross-sectional comparative study conducted in National Academy of Medical Sciences (NAMS), Bir Hospital which included HIV patients with baseline examination including a patient medical history, clinical examination, baseline CD4 count, viral load and a standardized transthoracic echocardiography and strain imaging examination and the findings were compared among age and sex frequency matched healthy adult population.&#x0D; Results: Our study enrolled 142 patients out of which 95 HIV positive patients (mean age 36.7±9.2 years with 58% female) and 47 healthy control (mean age 33.7±8 years with 57.4% female). The median duration of HIV diagnosis was 7 years (IQR 2, 10) and median CD4 count was 464 cells/mm3 (IQR 259,750). There was no significant difference in conventional echocardiographic parameters between two groups except for transmitral E velocity that was lower in HIV group (P value of 0.001). The HIV population has lower mean global longitudinal strain (GLS) value of -19.92% ± 2.54 SD compared to the healthy control population with mean of -21.39% ± 1.54 SD(P value of 0.001) and patients with CD4 count less than 300 cell/mm3 had GLS value significantly lower than -18% (P value of 0.05).&#x0D; Conclusion: HIV infected population without established cardiovascular disease have subclinical left ventricular dysfunction revealed by GLS imaging technique.

Neoaortic Regurgitation in Patients with Transposition Long Term After an Arterial Switch Operation and Its Relation to the Root Diameters and Surgical Technique Used

Neoaortic regurgitation and root dilatation are common findings in patients with transposition after an arterial switch operation. The aim of this study was to describe the relation between neoaortic regurgitation long term after an arterial switch procedure, aortic root diameters, and surgical technique used. We also assessed the agreement of the neoaortic regurgitation grade and root diameters in different imaging modalities. For this retrospective study, we qualified 56 consecutive patients who, according to our institutional protocol, had a routine postoperative evaluation of more than 16 years with multimodality imaging studies. Neoaortic regurgitation was assessed by both transthoracic echocardiography and magnetic resonance imaging, and the root diameters obtained by echocardiography and tomography were compared to the reference values and associated with the presence of neoaortic insufficiency. Neoaortic insufficiency was present in 75% of examined patients; the vast majority of them had trace or mild regurgitation, and its qualitative evaluation was significantly different between echocardiography and magnetic resonance imaging. In our study group, the neoaortic valve and aortic sinus were larger in relation to the normal values, and they were significantly correlated with the presence of neoaortic insufficiency, but not with the surgical technique used. Values obtained by echocardiography and tomography correlated well but were significantly different. Transthoracic echocardiography has a tendency to overestimate the severity of regurgitation compared to magnetic resonance imaging. Neoaortic valve and sinus dilatation are significantly correlated with valve insufficiency, but in most cases of root dilatation, the valve remains competent.

Echocardiographic evaluation of the effects of sacubitril-valsartan on vascular properties in heart failure patients.

Increased vascular stiffness is known to be an independent predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). The effects of sacubitril-valsartan on vascular structure and function have not been systematically studied in this patient population. We hypothesized that aortic distensibility (AD) and fractional area change (AFAC), as assessed by 2D transthoracic echocardiography (TTE), would improve over time in HFrEF patients on sacubitril-valsartan therapy, due to the vasodilatory properties of the medication. We prospectively studied 30 patients with HFrEF (25 < EF < 40%) on optimal guideline-directed medical therapy who were subsequently started on sacubitril-valsartan. Patients underwent serial 2D TTE imaging at baseline, 3 and 6months following therapy initiation. Ascending aortic diameters were measured 3cm above the aortic valve in the parasternal long-axis view and used to calculate AD and AFAC, two markers of vascular compliance. For reference, we also measured AD and AFAC in 30 healthy, age and gender-matched controls at a single time point. Normal controls had significantly higher values of AD and AFAC than HFrEF patients at baseline (AD: 4.0 ± 1.1 vs. 2.2 ± 0.9 cm2dyne-110-3, p < 0.0001 and AFAC: 18.8 ± 3.7% vs. 10.3 ± 4.3%, p < 0.0001). In HFrEF patients on sacubitril-valsartan, both indices of aortic compliance progressively improved towards normal from baseline to 6months: AD from 2.2 ± 0.9 to 3.6 ± 1.5 cm2dyne-110-3 (p < 0.0001) and AFAC from 10.3 ± 4.3 to 13.7 ± 4.1% (p < 0.0001). In conclusion,AD and AFAC are decreased in patients with HFrEF and gradually improve with sacubitril-valsartan treatment. The echocardiographic markers used in this study may become a useful tool to assess the effectiveness of sacubitril-valsartan therapy in HFrEF patients.

P4645Prevalence of interatrial communications in 7,000 newborns from a large, prospective population study

Abstract Introduction The prevalence of any interatrial communication (IAC) (patent foramen ovale (PFO) or atrial septal defect (ASD)) in newborns has previously been reported to be between 24% and 92%. However, previous studies were relatively small, and no universal classification of IACs exists. We proposed a new echocardiographic diagnostic algorithm developed in collaboration with a group of international experts to classify IACs based on echocardiographic findings on subxiphoid transthoracic echocardiographic (TTE) images of the atrial septum in unselected newborns. Purpose To determine the prevalence of IACs (PFO and ASD) in newborns based on the new diagnostic algorithm. Method Echocardiograms of newborns (age 0–30 days) consecutively included in a large, prospective population study (n=25,000) were analyzed using the new algorithm. The algorithm classifies IACs into PFO and ASD based on transthoracic echocardiographic (TTE) findings including size and number of the communication(s) as well as the morphology and structure of the atrial septum, taking the normal fetal development into consideration. An IAC was classified as a PFO when either there was only one communication located in the upper 2/3 of the atrial septum with a visible communication having a diameter of ≤3.4 mm or a channel-like structure; or there was no visible communication on 2D but acceleration of colour Doppler flow crossing the septum was documented. An IAC was classified as an ASD if the diameter of a visible communication was &gt;3.4 mm, or the communication was located in the lower 1/3 part of the atrial septum, or more than one communication was present. No visible communication on 2D and no flow acceleration despite possible colour Doppler flow crossing the atrial septum was classified as an absence of IAC. Preliminary results As of 3 February 2019, 9,028 echocardiograms have been analyzed. A total of 2,026 (22.4%) were excluded due to poor image quality of the atrial septum. Of the 7,002 included echocardiograms, an IAC was detected on the TTE images in 85.9% of the newborns (median age 12 days [IQR 8; 15], 47.9% females). According to the algorithm 78.7% of the newborns were classified as having a PFO (see Table 1) whereas 7.2% were classified as having an ASD. Table 1. Prevalence of interatrial communications in newborns aged 0–30 days Type of interatrial communication: Prevalence (n=7,002): Patent foramen ovale 78.7% Atrial septal defect 7.2% No interatrial communication 14.1% Conclusion An IAC was present in the vast majority of newborns aged 0–30 days. PFOs were 11 times more frequent than ASDs. Acknowledgement/Funding Danish Heart Association, Danish Children's Heart Foundation, Candy's Found., Toyota Found., Herlev-Gentofte Hospital Research Found., Gangsted Found.

P4644Distribution of newly defined subtypes of interatrial communications in 7,000 newborns from a general population study

Abstract Introduction The prevalence of interatrial communications (IACs) (patent foramen ovale (PFO) or atrial septal defect (ASD)) in newborns has previously been reported to be between 24% and 92%. However, previous studies were generally small, and no universal classification of IACs exists. We proposed a new echocardiographic diagnostic algorithm developed in collaboration with a group of international experts to classify IACs into subtypes based on echocardiographic findings on transthoracic echocardiographic (TTE) images of the atrial septum in unselected newborns. Purpose To describe the distribution of the six newly defined subtypes of IACs in newborns based on the new diagnostic algorithm. Method Echocardiograms of newborns (age 0–30 days) consecutively included in a large, prospective population study (n=25,000) were analyzed using the new algorithm. The algorithm classifies IACs into three subtypes of PFO and three subtypes of ASD based on subxiphoid TTE findings considering the normal fetal development. The images were examined for colour Doppler signal possibly crossing the atrial septum, with or without acceleration, and with or without a visible communication on 2D. Furthermore, the size and morphology (channel-like structure or open hole) of a possible IAC as well as the number of communications were evaluated in determining the subtype of IAC according to the algorithm. The three subtypes of PFO were determined as follows: PFO1 were only detectable using colour Doppler; PFO2 had a channel-like structure visible on 2D; and PFO3 had a diameter of ≤3.4 mm and no channel-like structure. The three subtypes of ASD were determined as follows: ASD1 had a diameter of &gt;3.4 mm; ASD2 was located in the inferior 1/3 part of the septum; and ASD3 had more than one IAC. Preliminary results As of 3 February 2019, 9,028 echocardiograms have been analyzed. A total of 2,026 (22.4%) were excluded due to poor image quality of the atrial septum. Of the 7,002 included echocardiograms, an IAC was detected on the TTE images in 85.9% of the newborns (median age 12 days [IQR 8; 15], 47.9% females). According to the algorithm, 78.7% of the newborns were classified as having a PFO (35.0% had a PFO1; 21.8% had a PFO2; and 21.9% had a PFO3) whereas 7.2% were classified as having an ASD (3.5% had an ASD1; 0.2% has an ASD2; and 3.5% had an ASD3) (see Figure 1). Figure 1. Distribution of subtypes Conclusion An IAC was present in the vast majority of newborns aged 0–30 days. The most frequent PFO subtype was PFO1, which was only detectable by colour Doppler and was 1.6 times more frequent than the two other PFO subtypes, which had equal frequencies. The most uncommon ASD subtype was ASD2 which was located in the lower 1/3 part of the atrial septum and was 17.5 times less frequent than the ASD1 and ASD3 subtypes, which had equal frequencies. (Figure 1: PFO: Patent foramen ovale, ASD: Atrial septal defect, IAC: Interatrial communication) Acknowledgement/Funding Danish Heart Association, Danish Children's Heart Foundation, Candy's Found., Toyota Found., Herlev-Gentofte Hospital Research Found., Gangsted Found.

P2462Left atrial appendage wall velocity evaluated by transthoracic echocardiography is a feasible parameter for predicting cardiac prognosis in patients with heart failure

Abstract Background It was reported that left atrial (LA) remodeling is occurred in patients with heart failure (HF), and increased LA volume index (LAVI) is a feasible predictor for poor prognosis of HF. It was reported that LA remodeling is associated with LA appendage (LAA) dysfunction. We previously reported that LAA wall motion velocity (LAWV) obtained by transthoracic echocardiography (TTE) can noninvasively evaluate LAA dysfunction. However, it remains to be determined whether LAWV is useful for predicting poor prognosis in patients with HF. Purpose We investigated whether LAA dysfunction assessed by LAWV is associated with poor prognosis in patients with HF. Methods We performed TTE at discharge in 217 consecutive patients who hospitalized for HF (126 males, 71±13 years) and prospectively followed them up. LAWV was measured using Doppler tissue imaging at the LAA tip from the parasternal short-axis view on TTE imaging. Results There were 86 patients with cardiac events including 14 cardiac deaths and 72 rehospitalizations for HF during a median follow-up period of 404 days (interquartile range 168–748 days). LAWV was significantly lower in patients with cardiac events than in those without. LAWV was significantly decreased with advancing left ventricular diastolic dysfunction grade. Kaplan-Meier analysis demonstrated that significantly higher cardiac event rate was observed in patients with low LAWV (log-rank test, P=0.004). Cox multivariate hazard analysis revealed that LAWV was an independent predictor for cardiac events after adjusting for confounding factors (hazard ratio 0.57, 95% confidence interval 0.40–0.82, P&lt;0.05). Further, we categorized the patients into 3 groups based on the median of LAWV and left atrial volume index (LAVI), and Kaplan-Meier analysis showed that patients with both low LAWV and high LAVI had the highest rate of cardiac events among 3 groups (log-rank test, P&lt;0.001; Figure). Figure 1 Conclusion LAWV may be a feasible parameter for predicting cardiac prognosis in patients with HF.

P3381Quantification of hypo-attenuated leaflet thickening after transcatheter aortic valve implantation - clinical relevance of HALT volume

Abstract Background Hypo-attenuated leaflet thickening (HALT) is a recently recognized phenomenon following transcatheter aortic valve implantation (TAVI) and there is no consensus over the standardized assessment of HALT and its clinical relevance is poorly understood. We sought to determine the predictors and clinical significance of HALT volume. Methods Patients, who previously underwent TAVI between 2011 and 2016 were prospectively enrolled in the RETORIC (Rule out Transcatheter Aortic Valve Thrombosis with Post Implantation Computed Tomography) study, a single-center observational study. At inclusion cardiac computed tomography angiography (CTA), transthoracic echocardiography (TTE) and brain magnetic resonance imaging (MRI) was performed. HALT was volumetrically quantified on cardiac CTA images by segmenting the inner volume of the TAVI frame at the level of the leaflets and applying a threshold of −200 to 200 Hounsfield units. We evaluated the clinical predictors of HALT volume, and its association with ischemic brain MRI lesions (recent and chronic large vessel ischemic focuses, microbleed/microembolization, white matter or small vessel disease) and all-cause mortality. Results In total, we analyzed 111 patients with CoreValve bioprosthesis (56.7% female, mean age 80.3±7.4 years). A median of 19 [IQR: 11–29] months passed between TAVI procedure and enrollment. The mean HALT volume was 111.0±163.4 mm3. Current malignant disease, prosthesis implantation depth measured on CTA images acquired at inclusion, and aortic mean gradient and aortic valve area evaluated on TTE images at inclusion predicted HALT volume by univariate analysis (all p&lt;0.05). After multivariate adjustment, aortic mean gradient remained a significant predictor of HALT volume (beta-coefficient: 11.5, 95% CI: 5.0–18.0; p&lt;0.001). HALT volume was not associated with ischemic brain MRI lesions (all p&gt;0.05) and did not predict all-cause mortality (median follow-up: 20 months [IQR: 18–23]; HR: 1.0; 95% CI: 1.0–1.0; p=0.15). Volumetric quantification of HALT. Conclusion Aortic mean gradient was the only predictor independently associated with HALT volume. Our results suggest that TAVI valve function is negatively affected by HALT volume, however, we found no association of HALT volume with cerebrovascular ischemic lesions or increased risk for all-cause mortality.

P2454Left atrial strain and recurrence of atrial fibrillation after thoracoscopic atrial fibrillation surgery

Abstract Background Left atrial (LA) strain has a prognostic value for atrial fibrillation (AF) recurrence after AF ablation. The value of LA strain as a predictor of AF recurrence after thoracoscopic AF surgery in patients in sinus rhythm (SR) or AF during echocardiography is unknown. Purpose To assess the association between LA strain and AF recurrence after thoracoscopic surgery for AF in both patients in SR and AF during baseline echocardiography. Methods Patients participating in the AFACT trial (n=240) with baseline transthoracic echocardiography (TTE) suitable for LA strain analysis were included in this subanalyses. All patients underwent thoracoscopic pulmonary vein isolation (PVI) with left atrial appendage (LAA) exclusion, and were randomized to ganglion plexus (GP) or no GP ablation. LA strain and mechanical dispersion (MD) of the LA reservoir, conduit and contraction phase were determined retrospectively from TTE images of both patients in AF and SR before thoracoscopic AF surgery. AF recurrence was defined as any recorded atrial tachyarrhythmia lasting &gt;30 sec during a one year FU period. Results A total of 204 patients (58.6±7.8 years, 73% male, 57% persistent AF) were included. Of the 204 patients 121 (59%) were in SR and 83 (41%) were in AF during baseline TTE. Patients in SR during TTE had higher LA strain values and lower MD compared to patients in AF. Of all patients, those with AF recurrence had lower LA strain of the reservoir phase (13.0% vs. 16.6%; p=0.003) and contraction phase (7.4% vs. 11.5%; p=0.012). MD of the contraction phase was increased in patients with AF recurrence (65.1msec vs. 19.2 msec; p=0.003). Multivariable cox regression analysis showed an association between LA strain, MD and AF recurrence (figure). Conclusions Left atrial strain and mechanical dispersion prior to thoracoscopic AF surgery are associated with recurrence of AF. LA strain showed to be a valuable tool to add in the decision making for thoracoscopic AF surgery regardless rhythm during baseline echocardiography.

P2730Pericardial and pleural effusion in patients with cardiac amyloidosis

Abstract Background Pericardial and pleural effusion are common findings in patients with cardiac amyloidosis (CA). While this might be suggestive of a sign of right heart failure, it is not known, whether effusions correlate with right ventricular (RV) function in patients with CA. Furthermore, data on the prognostic significance of pleural and pericardial effusion in CA is scarce. Methods Patients with cardiac transthyretin (ATTR) and light chain (AL) amyloidosis were included in a clinical registry at our dedicated CA outpatient clinic. CA was diagnosed according to current guidelines. All patients underwent a comprehensive transthoracic echocardiography (TTE) exam at the time of study inclusion. The TTE protocol included standard and advanced parameters describing left ventricular and RV function, including speckle-tracking imaging to assess global longitudinal left ventricular and RV free wall (RV-FW) strain. The presence of pericardial and pleural effusion was determined in every patient and was verified by cardiac magnetic resonance imaging when present. The size of pericardial effusion was measured at the point of its maximum extension. The clinical endpoint was defined as all-cause death. Results Between March 2012 and February 2019, 177 patients were included in our CA registry, however, TTE image quality was only sufficient for analysis in 143 patients. Of these, 83 patients (59.4%) were diagnosed with ATTR and 60 patients (42.0%) with AL. In total, 23 patients (16.1%) presented with isolated pericardial effusion and 36 (25.2%) with isolated pleural effusion. In 17 patients (11.9%) both pericardial and pleural effusion were found and in 66 patients (46.2%) no effusion was present at baseline. Overall, there was no significant difference in the type of effusion between patients with AL and ATTR. In general, pericardial effusions were small (median diameter 7.1 mm (IQR 5.2–9.7) and none were hemodynamically compromising. Interestingly, the presence of pleural effusion correlated well with poor RV function, measured by RV-FW strain (p=0.034). However, no such correlation could be found for pericardial effusion and RV-FW strain (p=0.319). Kaplan Meier analysis showed that patients presenting with pleural effusion had a worse prognosis compared to patients with pericardial effusion alone or no effusion at baseline (p=0.001, Figure 1). Figure 1 Conclusion More than 50% of patients with CA presented with pleural and/or pericardial effusions. While pleural effusion was clearly associated with poor RV function, we were not able to detect this association with pericardial effusion. In addition, patients with pleural effusions had an exceptionally poor prognosis compared to patients with pericardial effusions or no effusion at baseline.

Association Between Serum Leptin Level and Calcific Aortic Valve Disease.

BackgroundThe pathophysiological process of calcific aortic valve disease (CAVD) is similar to that of atherosclerosis. Leptin accelerates the process of atherosclerosis. We sought to examine the relationship between leptin and CAVD.Methods and ResultsSerum leptin was measured in 397 consecutive patients undergoing standard transthoracic echocardiography and Doppler flow imaging. Multiple logistic regression analyses were used to assess the association between leptin and CAVD. Western blotting was performed to detect the expression of phosphorylated and total extracellular signal‐regulated kinase. Serum leptin (median) was higher in 200 patients with CAVD than that in 197 non‐CAVD controls (20.07 versus 9.03 ng/mL; P<0.01). Leptin correlated positively with age (r=0.37, P<0.01) and negatively with estimated glomerular filtration rate (r=−0.37, P<0.01). Multivariate analysis indicated that elevated leptin was an independent determinant for the presence of CAVD (P<0.01). Receiver‐operating characteristic curve analysis of leptin to detect the presence of CAVD showed that the area under the curve was 0.74 (95% CI, 0.69–0.79; P<0.01). The diagnostic value of leptin for the detection of CAVD was higher among younger patients (aged ≤65 years) or those with at least mildly reduced renal function (estimated glomerular filtration rate ≤82.06 mL/min per 1.73 m2). The activation of extracellular signal‐regulated kinase 1/2 was stronger in calcific aortic valves than in normal aortic valves.ConclusionsElevated leptin is associated with the presence of CAVD, especially among younger patients or those with renal dysfunction.

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO): echocardiography performance protocol

Background The incidence of ischemic stroke in young patients is increasing and associated with unfavorable prognosis due to high risk of recurrent cardiovascular events. In many young patients the cause of stroke remains unknown, referred to as cryptogenic stroke. Neuroimaging frequently suggests a proximal source of embolism in these strokes. We developed a comprehensive step-by-step echocardiography protocol for a prospective study with centralized reading to characterize preclinical cardiac changes associated with cryptogenic stroke.Methods and study designSECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome; NCT01934725) is an ongoing multicenter case–control study enrolling patients (target n = 600) aged 18–49 years hospitalized due to first-ever ischemic stroke of undetermined etiology and age- and sex-matched controls (target n = 600). A comprehensive assessment of cardiovascular risk factors and extensive cardiac imaging with transthoracic and transesophageal echocardiography, electrocardiography and neurovascular imaging is performed. Transthoracic and transesophageal echocardiograms will be centrally read, following an extensive protocol particularly emphasizing the characteristics of left atrium, left atrial appendage and interatrial septum.Conclusions A detailed assessment of both conventional and unconventional vascular risk factors and cardiac imaging with transthoracic and transesophageal echocardiography are implemented in SECRETO, aiming to establish indirect and direct risk factors and causes for cryptogenic stroke and novel pathophysiological brain–heart pathways. This may ultimately enable more personalized therapeutic options for these patients.

Comparison of intranasal midazolam, intranasal ketamine, and oral chloral hydrate for conscious sedation during paediatric echocardiography: results of a prospective randomised study.

There are several agents used for conscious sedation by various routes in children. The aim of this prospective randomised study is to compare the effectiveness of three commonly used sedatives: intranasal ketamine, intranasal midazolam, and oral chloral hydrate for children undergoing transthoracic echocardiography. Children who were referred to paediatric cardiology due to a heart murmur for transthoracic echocardiography were prospectively randomised into three groups. Seventy-three children received intranasal midazolam (0.2 mg/kg), 72 children received intranasal ketamine (4 mg/kg), and 72 children received oral chloral hydrate (50 mg/kg) for conscious sedation. The effects of three agents were evaluated in terms of intensity, onset, and duration of sedation. Obtaining high-quality transthoracic echocardiography images (i.e. absence of artefacts) were regarded as successful sedation. Side effects due to medications were also noted. There was no statistical difference in terms of sedation success rates between three groups (95.9, 95.9, and 94.5%, respectively). The median onset of sedation in the midazolam, ketamine, and chloral hydrate was 14 minutes (range 7-65), 34 minutes (range 12-56), and 40 minutes (range 25-57), respectively (p < 0.001 for all). However, the median duration of sedation in study groups was 68 minutes (range 20-75), 55 minutes (range 25-75), and 61 minutes (range 34-78), respectively (p = 0.023, 0.712, and 0.045). Gastrointestinal side effects such as nausea and vomiting were significantly higher in the chloral hydrate group (11.7 versus 0% for midazolam and 2.8% for ketamine, respectively, p = 0.002). Results of our prospectively randomised study indicate that all three agents provide adequate sedation for successful transthoracic echocardiography. When compared the three sedatives, intranasal midazolam has a more rapid onset of sedation while intranasal ketamine has a shorter duration of sedation. Intranasal ketamine can be used safely with fewer side effects in children undergoing transthoracic echocardiography.