Ventricular Free Wall Research Articles

Alternative Method of Surgical Treatment of Post-Infarction Left Ventricular Free Wall Rupture. Case Report

Acute myocardial infarction (AMI) is one of the causes of death in developed countries, despite the latest medical technologies. AMI is usually accompanied by numerous fatal complications. One of these complications is left ventricular free wall rupture (LVFWR). Myocardial rupture after AMI can occur from 1 day to 3 weeks after the infarction. Most ruptures occur 3-5 days after a heart attack. Left ventricular free wall rupture requires only emergency surgical intervention, which in most cases consists in applying U-shaped sutures or wrapping sutures using Teflon patch.
 The aim. To demonstrate an example of alternative surgical tactics and intraoperative management of a patient with myocardial infarction complicated by rupture of the free wall of the heart with the transition to cardiogenic shock.
 Case report. We presented the clinical case of patient V., 72 years old, who was delivered by ambulance on January 10, 2023 to the intensive care department of the National Amosov Institute of Cardiovascular Surgery (Kyiv, Ukraine). Main diagnosis: ischemic heart disease, acute coronary syndrome with ST-elevation myocardial infarction, cardiogenic shock.
 Conclusion. The only effective method of treatment of rupture of the free wall of the heart is surgical intervention. Using a sandwich patch with resection of necrotic areas of the myocardium and U-shaped sutures with Teflon patch passed from the side of the left ventricular cavity through the myocardium in the peri-infarct zone and through a patch from a vascular prosthesis allows hermetically sew up the LVFWR.

Disruption of Z-Disc Function Promotes Mechanical Dysfunction in Human Myocardium: Evidence for a Dual Myofilament Modulatory Role by Alpha-Actinin 2.

The ACTN2 gene encodes α-actinin 2, located in the Z-disc of the sarcomeres in striated muscle. In this study, we sought to investigate the effects of an ACTN2 missense variant of unknown significance (p.A868T) on cardiac muscle structure and function. Left ventricular free wall samples were obtained at the time of cardiac transplantation from a heart failure patient with the ACTN2 A868T heterozygous variant. This variant is in the EF 3-4 domain known to interact with titin and α-actinin. At the ultrastructural level, ACTN2 A868T cardiac samples presented small structural changes in cardiomyocytes when compared to healthy donor samples. However, contractile mechanics of permeabilized ACTN2 A868T variant cardiac tissue displayed higher myofilament Ca2+ sensitivity of isometric force, reduced sinusoidal stiffness, and faster rates of tension redevelopment at all Ca2+ levels. Small-angle X-ray diffraction indicated increased separation between thick and thin filaments, possibly contributing to changes in muscle kinetics. Molecular dynamics simulations indicated that while the mutation does not significantly impact the structure of α-actinin on its own, it likely alters the conformation associated with titin binding. Our results can be explained by two Z-disc mediated communication pathways: one pathway that involves α-actinin's interaction with actin, affecting thin filament regulation, and the other pathway that involves α-actinin's interaction with titin, affecting thick filament activation. This work establishes the role of α-actinin 2 in modulating cross-bridge kinetics and force development in the human myocardium as well as how it can be involved in the development of cardiac disease.

Hybrid Closure of Postinfarction Apical Ventricular Septal Defect Using Septal Occluder Device and Right Ventricular Free Wall: The Apical BASSINET Concept.

Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD. Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure. All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1-2.6] hybrid repair versus 2.0:1 [IQR, 2.0-2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46-71] versus 49 [IQR, 43-54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m2) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10-50) versus 24 (IQR, 10-134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days). Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.

Role of radionuclide assessment of global and regional mechanical dyssynchrony of the heart in prognosis of cardiac resynchronization therapy in patients with heart failure

Aim. To determine the prognostic significance of cardiac regional mechanical dyssynchrony (MD), assessed by radionuclide equilibrium ventriculography (REVG) in candidates for cardiac resynchronization therapy (CRT).Material and methods. The study included 65 patients with indications for CRT according to current guidelines. Prior to CRT, all patients underwent REVG to assess cardiac contractile function and MD. According to the phase analysis, indicators of global and regional cardiac MD were evaluated: phase standard deviation (PSD), histogram band width (HBW), entropy, and interventricular dyssynchrony. The regional assessment included an evaluation of phase histograms obtained from the analysis of the contraction of certain walls: left ventricular (LV) anterior, lateral, posterior wall, right ventricular (RV) free wall, and the interventricular septum. To evaluate the effectiveness of treatment 6 months after CRT, all patients underwent echocardiography, on the basis of which patients were divided into groups of responders and non-responders.Results. REVG revealed significant differences in the initial regional MD values between the groups of responders and non-responders: in responders, MD values of RV free wall (PSD: 39 (28-67) vs 28 (20-50), p=0,03) and LV anterior wall (PSD: 28,5 (16-40) vs 14 (11-24), p=0,0005) were higher, and the LV lateral wall was lower (PSD: 10 (7-14) vs 15 (9-26), p=0,007) than in non-responders. Multivariate logistic regression found following independent predictors of a positive response to CRT: heart failure of ischemic origin, LV HBW, RV free wall PSD, anterior wall PSD, LV lateral wall HBW (p<0,001). The sensitivity and specificity of the model was 93% and 91%, respectively.Conclusion. Regional MD scintigraphy parameters increase the predictive value of REVG in CRT candidates. The most informative in this regard are the PSD of RV free wall and LV anterior wall, as well as the HBW of LV lateral wall.

Effect of right ventricular free wall longitudinal strain on all-cause death in patients with isolated severe tricuspid regurgitation and atrial fibrillation.

With the aging population and advanced catheter-based therapy, isolated tricuspid regurgitation (TR) with atrial fibrillation (AF) has gained increased attention; however, data on the prognostic effect of isolated TR with AF are limited because of the small number of patients among those with severe TR. Recently, right ventricular (RV) longitudinal strain by two-dimensional speckle-tracking echocardiography has been reported as an excellent indicator of RV dysfunction in severe TR. However, the prognostic implications of RV longitudinal strain in isolated severe TR associated with AF remain unclear. Therefore, this study aimed to reveal the prognostic value of this index in this population. We retrospectively studied patients with severe isolated TR associated with AF in the absence of other etiologies in the Cedars-Sinai Medical Center between April 2015 and March 2018. Baseline clinical and echocardiographic data were studied including RV systolic function evaluated by RV free wall longitudinal strain (FWLS) and conventional parameters. All-cause death was defined as the primary endpoint. In total, 53 patients (median age, 85 years; female, 60%) with a median follow-up of 433 (60-1567) days were included. Fourteen patients (26%) died, and 66% had right heart failure (RHF) symptoms. By multivariable analysis, reduced RVFWLS was independently associated with all-cause death. Patients with RVFWLS of ≤18% had higher risk of all-cause death adjusted for age (log-rank P = 0.030, adjusted hazard ratio 4.00, 95% confidence interval, 1.11-14.4; P = 0.034). When patients were stratified into four groups by RHF symptoms and RVFWLS, the group with symptomatic and reduced RVFWLS had the worst outcome. Reduced RVFWLS was independently associated with all-cause death in patients with isolated severe TR and AF. Our subset classification showed the worst outcome from the combination of RHF symptoms and reduced RVFWLS.

Risk of cardiac rupture among elderly patients with diabetes presenting with first acute myocardial infarction.

We aimed to analyze the risk of cardiac rupture (CR) in aged diabetic patients with acute ST-segment elevated myocardial infarction (STEMI) who were followed up for one month, and analyze its independent risk factors. A total of 3063 aged patients with first onset STEMI admitted to Beijing Anzhen Hospital from January 2001 to December 2020 were retrospectively included. There were 2020 patients without diabetes mellitus (DM) and 1043 patients with DM. We used propensity scores matching (PSM) method to balance baseline exposure factors between patients with or without DM, and all were divided the DM group (1043 cases) and the non-DM group (1043 cases) after the PSM. The primary outcome was CR (the composite rate of papillary muscle rupture, ventricular septum perforation, free wall rupture), which was diagnosed based on clinical manifestations and/or echocardiographic findings. Kaplan-meier survival analyses and log-rank test was used to evaluate the risk of CR between the two groups, and Cox regression analysis was used to evaluate the independent risk factors for CR. After PSM, the baseline clinical data were similar between the DM and non-DM group (all P>0.05). However, level of glycated hemoglobin was significantly higher in the DM group (P<0.05). During 1 month of follow-up, there were 55 (2.64%) cases of CR, most occurred within 48h after admission (40 cases). Among the 55 cases, 11(0.53%) had papillary muscle rupture, 18(0.86%) had ventricular septum perforation, and 26(1.25%) had free wall rupture. Kaplan-meier survival analyses detected that the DM group was associated with significantly increased risk of CR (3.36% vs. 1.92%, HR=1.532, 95% CI: 1.054-2.346, P=0.030), ventricular septum perforation (1.05% vs. 0.67%, HR=1.464, 95% CI: 1.021-2.099, P=0.038) and free wall rupture (1.63% vs. 0.86%, HR=1.861, 95% CI: 1.074-3.225, P=0.027) than those in the non-DM group. Among the 2031 aged STEMI patients without CR, 144 cases (6.90%, 144/2086) died; and among the 55 patients with CR, 37 cases (1.77%, 37/2086) died due to CR. Therefore, twenty percent (20.44%, 37/181) of death was due to CR. Multivariate Cox regression analysis indicated that DM (HR=1.532, 95%CI: 1.054-2.346), age (HR=1.390, 95%CI: 1.079-1.791), female (HR=1.183, 95%CI: 1.049-1.334), troponin I (HR=1.364, 95%CI: 1.108-1.679), brain natriuretic peptide (HR=1.512, 95%CI: 1.069-2.139), revascularization (HR=0.827, 95%CI: 0.731-0.936) and β-receptor blocker (HR=0.849, 95%CI: 0.760-0.948) were independent risk factors of CR (all P<0.05). DM as well as a few other factors, are independent determinants of CR. CR is not a rare event among the aged STEMI patients and twenty percent of deaths are due to CR. However, large sample-sized studies are warranted to confirm these findings.

Changes of biventricular contractile function depending on the types of left ventricular involvement in patients 1 year after COVID-19 pneumonia

Aim. To study the changes of biventricular contractile function depending on the types of left ventricular involvement according to the speckle tracking echocardiography (STE).Material and methods. Of the 380 patients from the Prospective Registry of People Survived COVID-19 Pneumonia, the study included 85 patients, which can be followed-up — 3 months (visit 1) and 12 months (visit 2) after COVID-19 pneumonia (men — 68,2%; mean age — 50,6±10,9 years).At visit 2, patients with diffuse left ventricle (LV) involvement according to STE (visual involvement of ≥4 segments of the same LV level) comprised group I (n=27), patients with regional LV involvement (≥3 segments corresponding to anterior, circumflex or right coronary arteries) — group II (n=39), patients without visual LV involvement — group III (n=19).Results. The groups were comparable in main clinical, functional and echocardiographic (conventional) parameters 3 and 12 months after COVID-19 pneumonia, with the exception of sex and body mass index. STE in group I showed a significant decrease in global longitudinal strain (GLS) (-18,0±2,0% at visit 1 and -16,9±1,4% at visit 2, p=0,025) and LS of all LV levels; in group II — an increase in right ventricular free wall strain (RV FWS) (-22,8±3,2% and -24,0±2,6%, respectively, p=0,006); in group III — an increase in GLS (-19,3±2,3% and -21,2±1,9%, p=0,005), LS of basal and medium LV levels, RV FWS (-23,3±2,9% and -25,0±3,0%, p=0,033). In group I, a significant increase in affected LV segments was revealed (7,0 [5,0;9,0] and 9,0 [7,0;10,0], p=0,010), while in group III there was a decrease in their number (5,0 [3,0;6,0] and 10,0 [1,0;2,0], p&lt;0,001). According to logistic regression, LV basal LS at visit 1 (odds ratio 0,420; 95% confidence interval 0,273-0,644; p&lt;0,001) had an independent association with diffuse LV involvement at visit 2. When it decreases, &lt;15,8% sensitivity and the specificity of this model in predicting diffuse LV involvement was 74,1% and 74,1%, respectively (AUC=0,807; p&lt;0,001).Conclusion. Patients with diffuse LV involvement according to STE are characterized by suppression of global biventricular contractile function during 1-year follow-up.

Evaluation of right ventricular longitudinal strain in pediatric patients with pulmonary hypertension by two-dimensional speckle-tracking echocardiography.

We aimed to investigate the association between right ventricular longitudinal strain measured by two-dimensional speckle-tracking echocardiography (2D-STE) and right heart catheterization data in pediatric patients with pulmonary hypertension (PH). Two groups were evaluated, each consisting of 58 patients. Group 1, patients with PH; Group 2, normal matched controls. Data were collected from 58 patients with PH who underwent invasive hemodynamic evaluation. Standard transthoracic echocardiographic assessment was performed in all patients under the same circumstances. All patients underwent 2D-STE, and off-line analysis generated right ventricle longitudinal strain (RVLS) and right ventricular free wall strain (RVFW) and collected echocardiographic conventional parameters of right ventricular function, including the control group. The relationship between invasive characteristics and right ventricular function parameters was analyzed. In all, 58 PH patients were included in our study. The mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) were strongly correlated with right ventricular free wall strain (RVFW) and right ventricular longitudinal strain (RVLS), moderately correlated with the right ventricle myocardial performance index (Tei index), weakly correlated with the transverse diameter of the right ventricle (RV) and the transverse diameter of the right atrium (RA), and moderately negatively correlated with right ventricular fractional area change (RVFAC). In terms of segments of the right ventricular free wall, the basal segment had the highest correlation coefficient with mPAP and PVR (r = 0.413, 0.523, 0.578, r = 0.421, 0.533, 0.575, p < 0.05, respectively). Tricuspid annular plane systolic excursion (TAPSE), main pulmonary artery diameter (MPA), peak systolic velocity of the right ventricle (RV-S'), and RA area parameters were not associated with mPAP and PVR (p > 0.05). Right ventricular longitudinal strain is a reliable indicator to evaluate right ventricular function in pediatric patients with PH. It can provide valuable reference information for the clinical judgment of the status and severity of the disease in children.

Libman–Sacks Vegetation, Infective Vegetation, and Pulmonic Valve Abscess in a Systemic Lupus Erythematosus Patient on Immunosuppressive Therapy

Abstract A 14-year-old girl, who is a known case of systemic lupus erythematosus and lupus nephritis, was admitted with complaints of fever for 10 days. Clinical examination did not show any focus of infection. Blood culture and sensitivity showed Staphylococcus aureus septicemia. She was started on antibiotics and subjected to routine transthoracic echocardiography. Transthoracic echocardiography showed Libman–Sacks vegetations (also known as nonbacterial thrombotic endocarditis) on all the cusps of both mitral and tricuspid valves, along with sessile freely mobile infective vegetation attached to the right ventricular free wall, and pulmonic valve abscess moving to and fro about the pulmonic annulus. Surgery was deferred due to poor general condition, and the patient was continued on parenteral therapy. The girl succumbed to her illness on the 6th day of her illness.

The impact of body mass index on cardiac structure and function in a cohort of obese patients without traditional cardiovascular risk factors

BackgroundObesity has been linked with alterations in hemodynamic, autonomic, and hormonal pathways in the body, leading to a spectrum of cardiovascular changes. We sought to evaluate the effects of obesity on structural and functional changes of the heart in the absence of cardiac disease and associated risk factors. MethodsWe identified healthy outpatients without any cardiovascular disease or risk factors from our institution's echocardiography database (2017–2020). Patients were stratified by body mass index (BMI; normal: 18.5–25 kg/m2; overweight: 25–30 kg/m2; class 1 obesity: 30–35 kg/m2; class 2 obesity: 35–40 kg/m2; class 3 obesity: >40 kg/m2). Traditional and advanced echocardiographic parameters of cardiac chamber size and function including left ventricular global longitudinal strain (LV-GLS), left atrial reservoir strain (LASr), and right ventricular free wall strain (RV-FWS) were examined. The optimal cut-off BMI for discriminating LV-GLS (>-17.5%), LASr (<23%), and RV-FWS (>-23%) impairment was calculated using ROC curves. Results307 patients were assessed (41.5 ± 13.3yrs; 36.5%male; LVEF 61.3 ± 4.8%). No significant differences in indexed chamber volumes or LVEF were appreciated across BMI groups (p > 0.05 for all). LV-GLS, LASr, and RV-FWS were all significant on one-way ANOVA for differences from the group mean (all p < 0.01). Jonckheere-Terpstra test confirmed a significant trend of lower absolute LV-GLS, LASr and RV-FWS values across the rising BMI groups. On ROC curve analysis, a BMI value of 29.9 kg/m2, 35.1 kg/m2, and 37.3 kg/m2 were associated with LASr (AUC: 0.75), RV-FWS (AUC: 0.72), and LV-GLS (AUC: 0.75) impairment respectively. ConclusionObesity is linked with subclinical reduction of cardiac function in otherwise healthy subjects without cardiovascular risk factors, with reduction of left atrial function occurring at lower BMI, followed by the right and left ventricular function.

Right heart echocardiography findings in hypoxic pneumonia patients during the COVID-19 pandemic in a South African population.

The right ventricle is affected by Coronavirus disease 19 (COVID-19) via multiple mechanisms, which can result in right ventricular dysfunction (RVD). This study aimed to provide an assessment of right heart function using conventional echocardiography and advanced strain imaging, in patients with hypoxic pneumonia during the COVID-19 pandemic. This study was an observational, prospective, single-centre study, including adults with hypoxic pneumonia, in two groups: COVID-19 pneumonia; and non-COVID-19 pneumonia. Bedside echocardiography was performed according to a pre-specified protocol and all right heart measurements were done as per standard guidelines. Right ventricular free wall strain (RVFWS) was measured using Philips® QLAB 11.0 speckle tracking software. Descriptive and comparative statistics were used to analyse data. Spearman Rank Order Correlations were used to determine the correlation between right ventricular (RV) parameters and clinical parameters. Univariate and multivariate logistic regression analyses were performed to characterize the predictors of in-hospital mortality. We enrolled 48 patients with COVID-19 pneumonia and 24 with non-COVID-19 pneumonia. COVID-19 patients were significantly older with a higher frequency of hypertension and diabetes and a trend towards a lower severity of illness score. Mean RVFWS yielded the highest estimates for the prevalence of RVD (81%), with no difference between the two pneumonia groups. Median Tricuspid Annular Plane Systolic Excursion (TAPSE) and right ventricular systolic excursion velocity (RVS') were not significantly different between COVID-19 (TAPSE 17.2 and RVS' 12), and non-COVID-19 pneumonia (TAPSE 17.8 and RVS' 12.1) with P values of 0.29 and 0.86, respectively. Non-COVID-19 pneumonia patients with moderate to severe hypoxaemia (PF < 150) were at greater risk of an elevated RV Systolic Pressure >30 mmHg respiratory rate = 3.25 (CI 1.35-7.82) on admission. Troponin levels discriminated between COVID-19 survivors (6 ng/L) and non-survivors (13 ng/L), P = 0.04. The mortality rate for COVID-19 was high (27%) compared to non-COVID-19 pneumonia (12%). Patients with COVID-19 pneumonia had a similar admission prevalence of RVD when compared to patients with non-COVID-19 pneumonia. Despite preserved traditional parameters of RV systolic function, RVFWS was diminished in both groups, and we propose that RVFWS serves as an important marker of the subclinical disease of RV.

Long-Term Effects of Pulmonary Endarterectomy on Right Ventricular Stiffness and Fibrosis in Chronic Thromboembolic Pulmonary Hypertension.

Surgical removal of thromboembolic material by pulmonary endarterectomy (PEA) leads within months to the improvement of right ventricular (RV) function in the majority of patients with chronic thromboembolic pulmonary hypertension. However, RV mass does not always normalize. It is unknown whether incomplete reversal of RV remodeling results from extracellular matrix expansion (diffuse interstitial fibrosis) or cellular hypertrophy, and whether residual RV remodeling relates to altered diastolic function. We prospectively included 25 patients with chronic thromboembolic pulmonary hypertension treated with PEA. Structured follow-up measurements were performed before, and 6 and 18 months after PEA. With single beat pressure-volume loop analyses, we determined RV end-systolic elastance (Ees), arterial elastance (Ea), RV-arterial coupling (Ees/Ea), and RV end-diastolic elastance (stiffness, Eed). The extracellular volume fraction of the RV free wall was measured by cardiac magnetic resonance imaging and used to separate the myocardium into cellular and matrix volume. Circulating collagen biomarkers were analyzed to determine the contribution of collagen metabolism. RV mass significantly decreased from 43±15 to 27±11g/m2 (-15.9 g/m2 [95% CI, -21.4 to -10.5]; P<0.0001) 6 months after PEA but did not normalize (28±9 versus 22±6 g/m2 in healthy controls [95% CI, 2.1 to 9.8]; P<0.01). On the contrary, Eed normalized after PEA. Extracellular volume fraction in the right ventricular free wall increased after PEA from 31.0±3.8 to 33.6±3.5% (3.6% [95% CI, 1.2-6.1]; P=0.013) as a result of a larger reduction in cellular volume than in matrix volume (Pinteraction=0.0013). Levels of MMP-1 (matrix metalloproteinase-1), TIMP-1 (tissue inhibitor of metalloproteinase-1), and TGF-β (transforming growth factor-β) were elevated at baseline and remained elevated post-PEA. Although cellular hypertrophy regresses and diastolic stiffness normalizes after PEA, a relative increase in extracellular volume remains. Incomplete regression of diffuse RV interstitial fibrosis after PEA is accompanied by elevated levels of circulating collagen biomarkers, suggestive of active collagen turnover.

Survivors of Pediatric Hematopoietic Stem Cell Transplantation Exhibit Progressive Diastolic Dysfunction Over Years of Follow-Up

Patients who have undergone hematopoietic stem cell transplantation (HSCT) in childhood have a higher risk of diastolic heart failure (HF). The rate of progression of diastolic dysfunction in aging pediatric patients is unknown and is more difficult to assess in young patients secondary to changes in diastolic indices as they grow. HSCT recipients at our center were previously found to have decline in diastolic function indices at 1 year after HSCT. This study provides follow-up of this cohort, using age-normalized z-scores to assess whether the decline in diastolic function noted at 1-year post-HSCT persists, worsens, or improves over time. Patients age <21 years who underwent HSCT at Boston Children's Hospital/Dana-Farber Cancer Center between 2005 and 2008 with ≥3 surveillance echocardiograms, including 1 performed pre-HSCT, were included. Diastolic measures included mitral inflow (E/A ratio) and Doppler tissue imaging of left ventricular lateral wall (LV lateral e'), LV septal wall (septal e') and right ventricular free wall (RV e'). Systolic function was measured by LV ejection fraction (LVEF). Normalization by age was done using z-scores, and >±2 SD was defined as abnormal in linear modeling of diastolic dysfunction and systolic dysfunction over time. In a subset of patients with adequate post-HSCT images of the entire left atrium (LA), LA volume and LA strain analyses also were performed. The study cohort comprised 61 patients (41% female; median age at HSCT, 10.7 years; median follow-up, 7.4 years). Diastolic index z-scores declined by -.045/year for LV lateral e', -.06/year for LV septal e', and -.14/year for RV e' (P < .01). The E/A ratio z-score increased by .034/year (P=.028). Linear modeling demonstrated that LV lateral e' and LV septal e' would become abnormal at 25 and 20 years post-HSCT, respectively, whereas RV e' would become abnormal sooner, at 12.6 years. LVEF z-score declined by -.04/year (P < .01) and was estimated to become abnormal at 40 years post-HSCT. Exposure to total body irradiation (TBI) was associated with worsening diastolic indices, lower LVEF (P ≤ .002), and decreased LA reservoir strain (42.0% versus 45.0%; P=.016) and conduit strain (-31.5% versus -35.1%; P=.029), although there was significant overlap between TBI and anthracycline exposure. Treatment with anthracyclines even at low doses (median, 150 mg/m2) was associated with declining LVEF but not with changes in diastolic indices. Long-term survivors of childhood HSCT exhibit declines in both LV and RV diastolic function indices. These results inform the rate of progression of LV and RV diastolic dysfunction indices over time in long-term survivors of pediatric HSCT. A significant association was observed between TBI and diastolic dysfunction and a decline in LVEF. Treatment with anthracyclines even at low doses was associated with a mild decline in LVEF. Our results can inform a lifespan perspective on disease management in this population, encourage clinicians and patients to be vigilant in following guideline-directed surveillance echocardiography, and inform anticipatory responses by clinicians as patients transition from pediatric care to adult care.

Abstract P129: Cardiovascular Safety Of Severe And Sustained Hypoxia Exposure In Physically Fit Patients Following Myocardial Infarction

In mice, hypoxia exposure corresponding to 8000 m altitude over several weeks induced myocardial proliferation and improved left ventricular ejection fraction following myocardial infarction. To enable translation of these findings from mice to patients with myocardial infarction, we determined whether exposure to severe sustained hypoxia is limited by right ventricular failure secondary to hypoxia-induced pulmonary hypertension. We enrolled three men who suffered myocardial infarctions 49-126 months prior to the study (left ventricular ejection fraction 47±7 %) but were otherwise healthy and one male, healthy control person. We induced hypoxia by adding nitrogen to ambient air until alveolar oxygen partial pressure decreased to 35 mmHg. Normobaric hypoxia was then maintained for 14 consecutive days (FiO2=0.095) corresponding to 6062- 6224 m altitude. We added 1% oxygen over night to ameliorate sleep and prevent acute mountain sickness. We conducted echocardiography at baseline, during hypoxia in hypoxic conditions and 3 days after reconditioning. Measurements included right ventricular to atrial pressure gradient as surrogate for pulmonary artery systolic pressure (PAPsys), tricuspid annulus systolic excursion (TAPSE) and right ventricular (RV) free wall strain. Hypoxia induced pulmonary hypertension, that rapidly abated in recovery (baseline: 35±3 mmHg, hypoxia: 47±9, recovery: 28±1, p=0.0292). TAPSE was not reduced by hypoxic exposure (baseline: 28±3 mmHg, hypoxia: 26±1 recovery: 29±2, p=0.0693) and right ventricular free wall strain was maintained (baseline: -22.4±3.9 mmHg, hypoxia: -24±5.4 recovery: -22.7±1.5, p=0.8493). The healthy control person showed similar responses. No signs or symptoms of right heart failure occurred throughout the study. In highly selected patients with myocardial infarction, substantial normobaric hypoxia induced pulmonary hypertension, however, right ventricular function was well preserved. These observations pave the way for translational studies on hypoxia-induced cardiovascular regeneration and may have implications for patients traveling to high altitude.

Diastolic myocardial mechanics and their relation to ventricular filling pressures and post-operative course in functionally single ventricles.

Diastolic dysfunction affects outcomes in patients with functionally single ventricles (FSV). To study the association of ventricular mechanics and interventricular dependence on diastolic parameters and early post-Fontan outcomes. Sixty-one FSV patients underwent echocardiography, cardiac catheterization and magnetic resonance imaging on the same day before or after the Fontan procedure. Echocardiographic diastolic parameters, ventricular mass and incoordinate wall motion, defined by the number of dyskinetic segments or by the lateral wall delay, were determined and studied for relationships with invasively measured hemodynamics and early post-operative Fontan course. In subjects with a sizable secondary ventricle, incoordinate motion was additionally analyzed at the left and right sided ventricular free-walls. Resting ventricular end diastolic pressure (VEDP) was ≤10 mmHg in most subjects. Echocardiographic parameters of diastolic flow and tissue velocities did not correlate with VEDP or post-Fontan clinical course. Incoordinate wall motion in the dominant and sizeable secondary ventricle, defined by the lateral wall delay or by the number of dyskinetic segments, was the only echo parameter correlating, albeit weakly, with VEDP (r=0.247, p=0.040), oxygen saturation (r=-0.417, p=0.001), pulmonary vascular resistance and flow (Qp) (r=-0.303, P=0.011) and duration of endotracheal intubation (r =0.292, p=0.022). When incoordinate wall motion was analyzed in the secondary ventricle these associations strengthened. The degree of diastolic incoordinate ventricular wall motion was associated with VEDP and post-operative Fontan course. Analysis of incoordinate wall motion of the dominant and sizeable secondary ventricle should be included in the assessment of the FSV after Fontan .

Right ventricular and right atrial free wall deformation predicitive value in transformation of preclinical diastolic disfunction to heart failure with preserved ejection fraction.

Aim To study echocardiographic parameters of heart chamber strain in patients with left ventricular (LV) preclinical diastolic dysfunction (PDD) for determining predictors of the PDD transition to heart failure with preserved LV ejection fraction (HFpEF).Material and methods The study included 113 patients (including 69 women) with metabolic syndrome and LV PDD (mean age, 65±7 years). The control group consisted of 40 healthy individuals (mean age, 63.0±6.0 years, including 59% women). Metabolic syndrome was diagnosed in consistency with criteria of NCEP-ATP III 2001. PDD was diagnosed based on the absence of heart failure symptoms, normal level of brain natriuretic peptide, and the presence of at least three of the following echocardiographic criteria at rest or after diastolic stress-echocardiography (stress-echoCG): left atrial volume index (LAVI) &gt;34 ml / m2; the ratio of peak early transmitral filling velocity (E) to average lateral and medial mitral annular velocity (e'), Е / е' &gt;14, е' &lt;8.5, and peak tricuspid regurgitation velocity &gt;2.8 m /s. EchoCG that determined LV longitudinal strain (LS), right ventricular (RV) LS, right atrial (RA) LS, and left atrial (LA) LS was performed every year during the 3-year follow-up.Results During the follow-up period, 31 patients developed HFpEF. 19 of them reported symptoms while in the other 12 patients, HFpEF was detected by diastolic stress-echoCG. Patients with HFpEF had significantly lower absolute values of RV LS, LA LS, and RA LS (-27.8±2.9 in the PDD group vs. -23.8±3.2 in the HFpEF group; р&lt;0.03; 38.2±9.1 vs. 28.6±10.2; р&lt;0.03; and 46.2±10.4 vs. 31.6±8.3; р&lt;0.03, respectively). RV LS and RA LS were the strongest independent predictors for PDD transformation into HFpEF (odds ratio, OR, 2.7; 95 % confidence interval, CI, 1.48-2.91; р&lt;0.001 and OR 2.6; 95 % CI: 1.40-2.75; р&lt;0.001, respectively).Conclusion PDD is not a separate clinical nosology but rather an initial stage in the pathogenesis of HFpEF. Approximately ⅓ of PDD patients develop HFpEF. RV LS and RA LS are considered predictors of HFpEF. The duration of PDD is apparently an important factor that provides the development of HFpEF.

Peripheral VA-ECMO and pericardial drainage connected to the ECMO circuit for cardiac tamponade from blowout rupture: a case report

BackgroundLeft ventricular free wall rupture, particularly the blowout type, is still one of the most lethal complications of myocardial infarction and can cause catastrophic cardiac tamponade. Extracorporeal membrane oxygenation (ECMO) is often used to treat haemodynamic instability due to cardiac tamponade. However, elevated pericardial pressure can cause collapse of the right atrium, resulting in inadequate ECMO inflow and preventing the stabilisation of the circulation. Further, it can interfere with the venous return from the superior vena cava (SVC), increasing the intracranial pressure and reducing cerebral perfusion levels.Case presentationA 65-year-old man was hospitalised for out-of-hospital cardiac arrest. We used ECMO for cardiopulmonary resuscitation. After the establishment of ECMO, transthoracic echocardiography and left ventriculography revealed massive pericardial effusion. The treatment was supplemented with pericardial drainage since ECMO flow was frequently hampered by suction events. However, the blowout rupture led to the requirement of constant drainage from the pericardial catheter. To tend to this leak, we connected the venous cannula of ECMO and the pericardial drainage catheter. The surgery was performed with stable circulation without suction failure of ECMO. During the course of the intensive care management, the neurological prognosis of the patient was revealed to be poor, and the patient was shifted to palliative care. Unfortunately, the patient died on day 10 of hospitalisation.ConclusionWe present a case wherein the combination of pericardial drainage and ECMO was used to maintain circulation in a patient with massive pericardial effusion due to cardiac rupture.

Understanding Cardiac Anatomy and Imaging to Improve Safety of Procedures: The Right Ventricle

Right ventricular perforation is a catastrophic complication of catheter-based intracardiac interventions. In this context, appreciation of 5 attachments of the right ventricle to the aortoventricular unit is essential to recognize extent of right ventricular free wall. We herein present progressive dissection and virtual and photographic endoscopic images of the hearts without distortion. Real dissection images show us how and where to avoid this complication by indicating the true muscular component of the ventricular septum. Both virtual and photographic endoscopic images, when combined with transillumination, beautifully shows the thin wall regions and trabeculations with unprecedented clarity. We believe recognition of these anatomical nuances can reduce the likelihood of right ventricular perforation.

423 Up Against the Wall - Emergency Double Myocardial Rupture Repair

Abstract Background Left ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together ("double myocardial rupture" (DMR)), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient. Case presentation Our 57-year-old male patient self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA). He was rapidly transferred to our regional cardiac surgical unit, arriving at the theatre in cardiogenic shock but conscious before arresting and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple ITU complications to be eventually transferred, neurologically intact, on postoperative day 66 to a peripheral unit to complete his rehabilitation. He has been discharged from the rehabilitation centre 88 days after the operation, and He is now able to ambulate with a walking frame. Conclusions Our patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. We hope patients with meagre probabilities, such as the patient seen in this case, are not given up on; hence, our final message from this report is to persevere and persist against all odds.

Epicardial fat in patients with metabolic syndrome: A systematic review and meta-analysis

PurposeAbnormally increased epicardial fat appears to be associated with an additional risk of major adverse cardiovascular events (MACEs) in the context of metabolic syndrome (MetS). However, evidence on the relationship between epicardial fat volumes (EFVs), epicardial fat thickness (EFT) and MetS remains inconsistent. MethodsSpecific searches of electronic databases from 1 January 2000 to 31 October 2022 were independently performed by two researchers. In this study, two quantification measures of epicardial fat were included: comparison of total computed tomography–based EFVs and EFT between two groups (individuals with and without MetS), estimating standardized mean difference (SMD) with corresponding 95 % confidence intervals (CIs) through a random-effects model analysis. The heterogeneity in the included studies was explored by meta-regression and subgroup analyses. ResultsThe EFVs were significantly increased in MetS subjects compared with non-MetS subjects (SMD: 1.07, 95 % CI: 0.69–1.45, p < 0.001), and the EFT was also significantly larger in MetS patients than in the Non-MetS (SMD: 1.12, 95 % CI: 0.84–1.41, p < 0.001). We compared the Caucasian and American subgroups with the Asian and African subgroups, and the EFT was greater in the former subgroups (SMD: 1.32, 95 % CI: 0.44–2.20, p < 0.001). When comparing the EFT among the age subgroups, there was a significant SMD between adolescents and adults or elderly individuals (SMD: 1.21, 95 % CI: 0.84–1.52, p < 0.001). ConclusionsMetS patients tend to present greater EFT near the right ventricular free wall and greater total EFVs. Increased epicardial fat, an imaging biomarker, independently affects the onset of MetS.