Ventricular Regional Wall Motion Abnormalities Research Articles

Donor heart dysfunction and graft survival in liver and kidney transplants-A register-based study from Sweden.

Stress cardiomyopathy in donors can potentially affect graft function and longevity. This study aims to investigate the association between echocardiographic left ventricular ejection fraction (LVEF)<50%, and/or the presence of left ventricular regional wall motion abnormalities (RWMA) in organ donors, and short- and long-term liver and kidney graft survival. Our secondary aim was to link graft survival with donor and recipient characteristics. All donors considered for liver and kidney donation with echocardiographic records at Sahlgrenska University Hospital between 2006 and 2016 were matched with their recipients through the Scandiatransplant register. The studied outcomes were graft survival, re-transplantation, and recipient death. Kaplan-Meier curves were used to plot time to event. Multivariate Cox-regression was used to test independence. There were 370 liver donors and 312 kidney donors (matched with 458 recipients) with echocardiographic records at Sahlgrenska University Hospital between June 2006 and November 2016. Of patients with LV dysfunction by echocardiography, there were 102 liver- and 72 kidney donors. Univariate survival analyses showed no statistical difference in the short- and long-term graft survival from donors with LV dysfunction compared to donors without. Donor age>65 years, recipient re-transplantation and recipient liver tumor were predictors of worse outcome in liver transplants (p<.05). Donor age>65, donor hypertension, recipient re-transplantation, and a recipient diagnosis of diabetes or nephritis/glomerulonephritis had a negative association with graft survival in kidney transplants (p<.05). We found no significant association between donor LV dysfunction and short- and long-term graft survival in liver and kidney transplants, suggesting that livers and kidneys from such donors can be safely transplanted.

Imaging Features of Arrhythmogenic Cardiomyopathies.

Arrhythmogenic cardiomyopathy (ACM) is a genetic disease characterized by replacement of ventricular myocardium with fibrofatty tissue, predisposing the patient to ventricular arrhythmias and/or sudden cardiac death. Most cases of ACM are associated with pathogenic variants in genes that encode desmosomal proteins, an important cell-to-cell adhesion complex present in both the heart and skin tissue. Although ACM was first described as a disease predominantly of the right ventricle, it is now acknowledged that it can also primarily involve the left ventricle or both ventricles. The original right-dominant phenotype is traditionally diagnosed using the 2010 task force criteria, a multifactorial algorithm divided into major and minor criteria consisting of structural criteria based on two-dimensional echocardiographic, cardiac MRI, or right ventricular angiographic findings; tissue characterization based on endomyocardial biopsy results; repolarization and depolarization abnormalities based on electrocardiographic findings; arrhythmic features; and family history. Shortfalls in the task force criteria due to the modern understanding of the disease have led to development of the Padua criteria, which include updated criteria for diagnosis of the right-dominant phenotype and new criteria for diagnosis of the left-predominant and biventricular phenotypes. In addition to incorporating cardiac MRI findings of ventricular dilatation, systolic dysfunction, and regional wall motion abnormalities, the new Padua criteria emphasize late gadolinium enhancement at cardiac MRI as a key feature in diagnosis and imaging-based tissue characterization. Conditions to consider in the differential diagnosis of the right-dominant phenotype include various other causes of right ventricular dilatation such as left-to-right shunts and variants of normal right ventricular anatomy that can be misinterpreted as abnormalities. The left-dominant phenotype can mimic myocarditis at imaging and clinical examination. Additional considerations for the differential diagnosis of ACM, particularly for the left-dominant phenotype, include sarcoidosis and dilated cardiomyopathy. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Takotsubo syndrome: unravelling the enigma of the broken heart syndrome?-a narrative review.

Takotsubo syndrome (TTS) is a condition characterized by transient ventricular regional wall motion abnormalities, without causative coronary artery disease, typically triggered by emotional or physical stress. TTS is more common in post-menopausal women, closely resembling acute coronary syndrome (ACS) in its clinical presentation, with multiple proposed underlying pathophysiological mechanisms and no evidence-based treatments. This review aims to provide a comprehensive summary of the latest research, encompassing the pathophysiology, diagnostic findings, prognosis, and treatment options for TTS patients. Relevant literature from 1990 to June 2023 on TTS epidemiology, physiopathology, diagnosis, clinical manifestations, treatment, and prognosis was retrieved through PubMed research. Only English publications were included. TTS is an increasingly recognized cardiovascular disorder, a significant release of catecholamines is thought to be a key contributing element, yet its exact mechanism remains unclear. Notably, TTS poses significant short and long-term risks akin to ACS. Initial treatment should focus on ruling out ACS and providing standard care for subsequent left ventricular dysfunction and complications. Research hints at a potential role for Angiotensin-converting enzyme inhibitors and Angiotensin II receptor blockers in improving long-term prognosis in TTS patients. Significant knowledge gaps still exist in our understanding of the pathophysiology, treatment options, and areas for improvement in diagnosing and prognosticating this intriguing condition. Further research is therefore needed.

The Immunology of Takotsubo Syndrome.

Takotsubo syndrome (TTS) is a disorder characterized by transient cardiac dysfunction with ventricular regional wall motion abnormalities, primarily thought to be caused by the effects of a sudden catecholamine surge on the heart. Although the majority of patients exhibit prompt recovery of their cardiac dysfunction, TTS remains associated with increased mortality rates acutely and at long-term, and there is currently no cure for TTS. Inflammation has been shown to play a key role in determining outcomes in TTS patients, as well as in the early pathogenesis of the disorder. There are also cases of TTS patients that have been successfully treated with anti-inflammatory therapies, supporting the importance of the inflammatory response in TTS. In this article, we provide a comprehensive review of the available clinical and pre-clinical literature on the immune response in TTS, in an effort to not only better understand the pathophysiology of TTS but also to generate insights on the treatment of patients with this disorder.

#5621 BENEFICIAL EFFECTS OF CHRONIC INTRADIALYTIC EXERCISE TRAINING ON HEMODIALYSIS-INDUCED-MYOCARDIAL STUNNING

Abstract Background and Aims Hemodialysis (HD) induces left ventricular (LV) segmental regional wall motion abnormalities (RWMAs) due to hypoperfusion, leading to acute LV transient dysfunction, well known as myocardial stunning. Repeated episodes of HD-related myocardial stunning contribute directly to the development of heart failure and increased mortality in patients receiving HD (Burton et al., 2009). Exercise training exert pleiotropic favorable effects on the cardiovascular system. No study has however investigated its impact on the kinetics of regional myocardial function during HD. This study aims to evaluate the effect of intradialytic exercise (IDE) on RWMAs compared with standard care. Method This was a prospective, open-label, two-center trial (clinicaltrials.gov NCT04697459) with two parallel groups: 31 patients (ENT) undergoing a 4-month IDE program (30min of cycling + 30min of resistance training starting 30 min after HD onset) and 21 patients continuing usual care (CTRL). Untrained adults, aged 20-79 years, undertaking maintenance HD for &amp;gt;3 months were eligible to participate. Exclusion criteria were poor echogenicity, contraindication to exercise, orthopedic complications, severe heart (ischemic, valvular, ...), vascular or respiratory diseases, ejection fraction &amp;lt;45% and body mass index &amp;gt;35. Longitudinal strain (LS) using speckle-tracking echocardiography were measured during a standard HD session, just before HD onset (HDT0) and at peak stress of HD (30 min before HD-ending, HDPeak). The same procedure was used before and after 4-months of IDE or usual care. LS from a 18 LV segment model were used to assess the presence of HD-induced RWMAs, defined as a ≥20% reduction in LS at peak stress compared to baseline. A generalized linear mixed model (Poisson model) was used to analyze the effect of IDE on RWMAs. Results After 4 months of IDE, we observed a significant reduction of RWMAs at HDPeak (mean before: 6.03±3.19 vs after: 4.55±2.26; point estimate: -1.48, 95% confident interval CI: -0.39/-2.57, p = 0.03), whereas its occurrence remained unchanged in CTRL (mean before: 6.14±3.51 vs after: 6.09±3.16; point estimate: -0.05; 95% CI: 1.45/-1.54, p = 0.96). There was also evidence that IDE program significantly attenuated the decline of global LS observed during HD (before: 2.11±2.39% vs after: 1.10±1.95%; point estimate: -1.01%; 95% CI: -1.86/-0.13, p = 0.02) compared to the similar impairment in CTRL (before: 1.60±2.30% vs after: 1.79±2.08%; point estimate: +0.18%; 95% CI: +1.20/-0.85 p = 0.72). Conclusion There is clear evidence that chronic IDE is cardioprotective. Identifying the underlying mechanisms responsible for exercise-induced cardioprotection was beyond the scope of our study, but we can reasonably assume that structural and/or functional changes in the coronary arteries, especially in microcirculatory territories (i.e. increased collateral circulation due to angiogenesis/arteriogenesis, improved endothelial function, reduced blood viscosity) and/or intrinsic changes in the cardiac myocyte (reduced fibrosis, enhanced calcium handling/sensitivity, altered mitochondrial turnover and phenotype), related among others to reduced oxidative stress and/or inflammation, might play a role (Powers et al 2014). Whether our results translate to longer-term reduction in clinical outcomes and cardiovascular mortality in end-stage renal disease patients require further studies.

Stress Cardiomyopathy and Spontaneous Coronary Artery Dissection: Linked or Overlooked?

This case series aimed to explore the association between spontaneous coronary artery dissection (SCAD) and stress cardiomyopathy (SCM), which are conditions that share similar features and can present as acute coronary syndrome. Both can be precipitated by emotional and/or physical stressors. Diagnosis is with coronary angiogram for SCAD, and echocardiogram for SCM. It is less common for people to have features of both. The overlap syndrome becomes evident if the territory of the involved coronary artery is incongruent with the left ventricular (LV) regional wall motion abnormality (RWMA). This single-centre case series identified cases with possible overlap of stress cardiomyopathy and SCAD. Patients were searched for individually, using an electronic health database (Health Connect South) through discharge summaries over a 2-year period. Cases with a likely diagnosis of both stress cardiomyopathy and SCAD were identified. The echocardiographic abnormalities included LV apical hypo/akinesis in all cases. In most cases, SCAD was confined to the mid and/or distal left anterior descending (LAD) artery. Two cases involved SCAD in multiple coronary arteries. This case series was able to clearly see the coexistence of an overlap syndrome in some cases. However, the association between the two conditions is under-recognised. It is proposed that an invasive coronary angiogram or computerised tomography coronary angiogram be actively reviewed to diagnose SCAD in patients with SCM, and early and repeat imaging in patients with SCAD is essential to identify SCM.

Association between echocardiographic features and inflammatory biomarkers with clinical outcomes in COVID-19 patients in Saudi Arabia.

Respiratory infections are one of the most common comorbidities identified in hospitalized patients. The coronavirus disease 2019 (COVID-19) pandemic greatly impacted healthcare systems, including acute cardiac services. This study aimed to describe the echocardiographic findings of patients with COVID-19 infections and their correlations with inflammatory biomarkers, disease severity, and clinical outcomes. This observational study was conducted between June 2021 and July 2022. The analysis included all patients diagnosed with COVID-19 who had transthoracic echocardiographic (TTE) scans within 72 h of admission. The enrolled patients had a mean age of 55.6 ± 14.7 years, and 66.1% were male. Of the 490 enrolled patients, 203 (41.4%) were admitted to the intensive care unit (ICU). Pre-ICU TTE findings showed significantly higher incidence right ventricular dysfunction (28 [13.8%] vs. 23 [8.0%]; P = 0.04) and left ventricular (LV) regional wall motion abnormalities (55 [27.1%] vs. 29 [10.1%]; p < 0.001) in ICU patients compared to non-ICU patients. In-hospital mortality was 11 (2.2%), all deaths of ICU patients. The most sensitive predictors of ICU admission (p < 0.05): cardiac troponin I level (area under the curve [AUC] = 0.733), followed by hs-CRP (AUC = 0.620), creatine kinase-MB (AUC = 0.617), D-dimer (AUC = 0.599), and lactate dehydrogenase (AUC = 0.567). Binary logistic regression showed that reduced LV ejection fraction (LVEF), elevated pulmonary artery systolic pressure, and dilated right ventricle were echocardiographic predictors of poor outcomes (p < 0.05). Echocardiography is a valuable tool in assessing admitted patients with COVID-19. Lower LVEF, pulmonary hypertension, higher D-dimer, C-reactive protein, and B-type natriuretic peptide levels were predictors of poor outcomes.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is associated with cardiac injury and stroke severity in patients after acute ischemic stroke

Abstract Background Patients after acute stroke frequently show signs of myocardial injury. The pathophysiology and impact on patient's outcome are not fully understood. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is cytokine known to be associated with cardiovascular events. Purpose We aimed to assess TRAIL level dynamic changes in patients after acute ischemic stroke and its relations to cardiac injury, stroke severity and impact on short-term outcome. Methods Between August 2020 and August 2021, 104 consecutive patients after acute ischemic stroke (AIS) were enrolled in our study. Blood samples were obtained from patients at the time of admission, 24- and 48-hours later to determine levels of Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and high-sensitive Troponin I (hs-cTnI). Twelve lead ECG at admission, 24-, 48-hours later and at the release of the patients were obtained. Patients underwent echocardiographic examination within first 5 days of hospitalization, if eligible. National Institutes of Health Stroke Scale (NIHSS) at admission and modified Rankin Scale (mRS) at 90 days following the patient's discharge from the hospital were performed. Chi-square, Fishers exact test and regression analysis were performed to detect differences between variables using SPSS statistics. Results were considered statistically significant at a significance level of p&amp;lt;0.05. Results We found significant negative association between TRAIL and NT-proBNP at admission (p=0.039), after 24 (p=0.043) and 48 hours (p=0.023) of hospitalization. There was significant negative association between TRAIL and hs-cTnI at admission (p=0.04). Moreover, we found significant negative association between TRAIL and stroke severity evaluated by NIHSS at admission (p=0.044) and negative association with severe disability or death evaluated by mRS at 90 days both after 24 (p=0.0022) and 48 hours (p=0.044) of hospitalization. In ECG analysis, lower TRAIL levels were associated with the occurrence of premature ventricular extrasystoles (p=0.043), and there was a near statistically significant association with prolonged QTc interval (p=0.07). Two patients presented with new left ventricular regional wall motion abnormality. Conclusions Lower TRAIL levels are associated with laboratory markers of cardiac injury, stroke severity and unfavorable functional outcome in patients after acute ischemic stroke. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Charles University Research Program Cooperatio – Cardiovascular sciences

Preoperative Transthoracic Echocardiography Predicts Cardiac Complications in Elderly Patients with Coronary Artery Disease Undergoing Noncardiac Surgery.

PurposeGuidelines have not recommended routine transthoracic echocardiography (TTE) for elderly patients prior to noncardiac surgery. We aimed to evaluate the significance of preoperative TTE to predict perioperative cardiac complications (PCCs) for elderly patients with coronary artery disease (CAD) undergoing noncardiac surgery.Patients and methodsWe retrospectively reviewed 2204 patients over 65 years of age with CAD who underwent TTE before intermediate- or high-risk noncardiac surgery in a teaching hospital in China between September 2013 and August 2019. The revised cardiac risk index (RCRI) was assessed. PCCs comprised acute coronary syndrome, heart failure, new-onset severe arrhythmia, nonfatal cardiac arrest, and cardiac death. Logistic regression was used to build the prediction model for PCCs. Discrimination was evaluated using receiver operating characteristic curves, and a nomogram of the predictive model was constructed.ResultsPCCs occurred in 189 (8.6%) patients. Multivariable analysis showed that eight clinical risk factors (age, history of myocardial infarction, insulin therapy for diabetes, New York Heart Association classification, preoperative serum creatinine, preoperative electrocardiogram ST-T abnormality and pathological Q wave, and American Society of Anesthesiologists classification) and five TTE parameters (left atrial anteroposterior dimension, left ventricular ejection fraction, left ventricular diastolic dysfunction, pulmonary hypertension, and regional ventricular wall motion abnormality) were associated with PCCs. The receiver operating characteristic curve for the clinical plus TTE model provided better discrimination for PCCs compared with the RCRI model (area under the curve: 0.731 vs 0.564; P < 0.001) and the clinical model (area under the curve: 0.731 vs 0.697, P = 0.001), respectively. The clinical plus TTE model was presented as a prognostic nomogram.ConclusionPreoperative TTE may help predict PCCs in elderly patients with CAD undergoing noncardiac surgery, and the prognostic nomogram from this study appeared to be useful for the assessment of perioperative cardiac risk.

Assessment of the relationship between regional wall motion abnormality score revealed by parametric imaging and the extent of LGE with CMR

The aim of this study was to assess the relationship between left ventricular (LV) regional myocardial wall motion abnormality (WMA), revealed by visual interpretation of cardiac magnetic resonance (CMR) cine images together with the computed wall motion parametric image, and the transmural scar extent, as assessed by Late gadolinium Enhancement (LGE), in 40 patients. Each cine CMR short-axis loop was processed to compute a parametric image where each pixel represents the amplitude of the Hilbert transform of videointensity over time. Two expert radiologists blindly interpreted the cine CMR images in combination with the corresponding parametric image to assign a WMA score for each of the 16 myocardial sectors in which the LV myocardium was subdivided. Such score was compared per sector to the level of transmural scar extent obtained by LGE images.A total of 592 myocardial segments were analyzed. A significant decrease in regional wall motion was observed in sectors with LGE transmural hyperenhancement > 75% of tissue, as well as a correlation between parametric image amplitude and peak radial and circumferential strain, computed by feature tracking. The results showed a reduction in prediction error Lambda of WMA from LGE of 65%, and of LGE from WMA of 63%. In particular, the estimated probability of correct prediction of WMA from LGE was 76%, while that of LGE from WMA was 75%.The interpretation of myocardial viability by LGE images combined with the WMA information, derived from cine CMR and parametric images, could improve the clinical decision making process.

A prospective observational study of electrocardiographic and echocardiographic changes in traumatic brain injury – effect of surgical decompression

Background Traumatic brain injury (TBI) causes significant changes in myocardial function, which is represented by ECG and echocardiographic changes. We intended to study the effect of surgical decompression on these changes. Materials and methods We recruited adult TBI patients undergoing surgery within 48 h of injury. Preoperatively, the patient’s demographic and clinical details were recorded. ECG and TTE were performed before surgery and 24 h later (first postoperative day [POD1]). ECG was analyzed for heart rate, PR, QRS, and QTc intervals, morphologic end-repolarization abnormalities (MERA), and ST-segment and T wave changes. TTE data included left ventricular ejection fraction (LVEF) and regional wall motion abnormalities (RWMA). Glasgow coma scale (GCS) at discharge was recorded. ECG and TTE changes before and after surgery were compared, and its association with discharge GCS was analyzed. Preoperative predictors of LV dysfunction were analyzed. Results Of the 110 patients recruited, common ECG changes were prolonged QTc interval (42%) and MERA (47%). TTE showed poor LVEF (<50%) in 10% and RWMA in 10.8% of patients. Following surgery, both ECG and TTE changes improved. Preoperative LVEF <50% and/or RWMA were associated with a lower GCS score at discharge. Preoperative poor GCS motor score and prolonged QTc interval were independent predictors of LV dysfunction. Conclusions Poor LV function was associated with poor admission GCS and prolonged QTc interval. Patients with reduced LV function had lower GCS at discharge.

A STUDY OF CARDIAC MANIFESTATIONS IN PATIENTS WITH HIV/AIDS

Introduction:HIV/AIDS pandemic is evolving as a major public concern. Cardiovascular diseases are common in HIV-positive patients. Many patients without any symptoms or signs were found to have a cardiovascular disease on autopsy.It is expected that the risk of cardiovascular disease willrise in the following years due to the cardiovascular risk profile andincreased life expectancy of infected patients. Therefore,diagnosis andtherapy of HIV-associated cardiovascular diseases should be part of the evaluation and management of the HIV-positive patient. Objectives: To find out the frequency of cardiac manifestations on clinical examination, electrocardiography, chest X-ray, and echocardiographic examination. To assess the association of Cardiac abnormality with CD4 Count in patients with HIV/AIDS. Toevaluate the association between cardiac abnormalities with types and duration of antiretroviral therapy regimen (ART). Method:A total of 100 consecutive patients visiting ART OPD and admitted to our institute were examined for signs and symptoms of cardiovascular disease. All patients were evaluated with electrocardiography, chest X-ray, and 2 D echocardiography. CD4 count was measured for all patients using flowcytometry using a BD FACS Count system. Results:Out of 100 patients, 53% were male and 47% were female. Patients were divided into subgroups with CD4 count &lt;200, 200-349, 350-499, and ≥500. The mean CD4 count was 403.62 ± 284.98. Prevalence of the cardiovascular abnormality on ECG, chest X-ray, and echocardiography were 74%, 10%, and 51% respectively. The left ventricular systolic dysfunction was the most common finding in our study with fractional shortening ≤25% in 34% of patients and LVEF &lt;50% in 27% of patients followed by left ventricular diastolic function (26%), dilated cardiomyopathy (6%), pulmonary hypertension (4%), and regional wall motion abnormality (2%).Reduced LV ejection fraction (&lt;50%) and left ventricular diastolic dysfunction were statistically significant in patients with CD4 count less than 200/mm3. Conclusion: In present study electrocardiographic, chest X-ray and echocardiographic abnormalities were present in 74%, 10% and 51% patients respectively. Cardiac abnormalities such as QTc prolongation, LBBB, reduced left ventricular ejection fraction, and left ventricular diastolic dysfunction were more significantly higher in patients with CD4 count less than 200/mm3. We could not find any statistically significant difference in cardiac abnormalities in patients on different ART regimens. Further studies are required with a higher sample size.

Catecholamine-Induced Secondary Takotsubo Syndrome in Children With Severe Enterovirus 71 Infection and Acute Heart Failure: A 20-year Experience of a Single Institute.

Background: Acute heart failure (AHF) is the major cause of death in children with severe enterovirus 71 (EV71) infection. This study aimed to report our clinical experience with EV71-related AHF, as well as to discuss its pathogenesis and relationship to Takotsubo syndrome (TTS).Methods: A total 27 children with EV71-related AHF between 1998 and 2018 were studied. The TTS diagnosis was based on the International Takotsubo Diagnostic Criteria.Results: Acute heart failure-related early death occurred in 10 (37%) of the patients. Sinus tachycardia, systemic hypertension, and pulmonary edema in 100, 85, and 81% of the patients, respectively, preceded AHF. Cardiac biomarkers were significantly increased in most patients. The main echocardiographic findings included transient and reversible left ventricular (LV) regional wall motion abnormality (RWMA) with apical ballooning. High concentrations of catecholamines either preceded or coexisted with AHF. Myocardial pathology revealed no evidence of myocarditis, which was consistent with catecholamine-induced cardiotoxic damage. Patients with EV71-related AHF who had received close monitoring of their cardiac function, along with early intervention involving extracorporeal life support (ECLS), had a higher survival rate (82 vs. 30%, p = 0.013) and better neurological outcomes (59 vs. 0%, p = 0.003).Conclusion: EV 71-related AHF was preceded by brain stem encephalitis-related hypercatecholaminemia, which resulted in a high mortality rate. Careful monitoring is merited so that any life-threatening cardiogenic shock may be appropriately treated. In view of the similarities in their clinical manifestations, natural course direction, pathological findings, and possible mechanisms, TTS and EV71-related AHF may represent the same syndrome. Therefore, we suggest that EV71-related AHF could constitute a direct causal link to catecholamine-induced secondary TTS.

A Novel Diagnostic Score Integrating Atrial Dimensions to Differentiate between the Athlete’s Heart and Arrhythmogenic Right Ventricular Cardiomyopathy

Objective: The 2010 Task Force Criteria (TFC) have not been tested to differentiate ARVC from the athlete’s heart. Moreover, some criteria are not available (myocardial biopsy, genetic testing, morphology of ventricular tachycardia) or subject to interobserver variability (right ventricular regional wall motion abnormalities) in clinical practice. We hypothesized that atrial dimensions are useful and robust to differentiate between both entities and proposed a new diagnostic score based upon readily available parameters including echocardiographic atrial dimensions. Methods: In this observational study, 21 patients with definite ARVC were matched for age, gender and body mass index to 42 athletes. Based on ROC analysis, the following parameters were included in the score: indexed right/left atrial volumes ratio (RAVI/LAVI ratio), NT-proBNP, RVOT measurements (PLAX and PSAX BSA-corrected), tricuspid annular motion (TAM), precordial TWI and depolarization abnormalities according to TFC. Results: ARVC patients had a higher RAVI/LAVI ratio (1.76 ± 1.5 vs. 0.87 ± 0.2, p < 0.001), lower right ventricular function (fac: 29 ± 10.1 vs. 42.2 ± 5%, p < 0.001; TAM: 19.8 ± 5.4 vs. 23.8 ± 3.8 mm, p = 0.001) and higher serum NT-proBNP levels (345 ± 612 vs. 48 ± 57 ng/L, p < 0.001). Our score showed a good performance, which is comparable to the 2010 TFC using those parameters, which are available in routine clinical practice (AUC93%, p < 0.001 (95%CI 0.874–0.995) vs. AUC97%, p < 0.001 (95%CI 0.93–1.00). A score of 6/12 points yielded a specificity of 91% and an improved sensitivity of 67% for ARVC diagnosis as compared to a sensitivity of 41% for the abovementioned readily available 2010 TFC. Conclusions: ARVC patients present with significantly larger RA compared to athletes, resulting in a greater RAVI/LAVI ratio. Our novel diagnostic score includes readily available clinical parameters and has a high diagnostic accuracy to differentiate between ARVC and the athlete’s heart.

Acute Myocardial Injury in a Patient with Attention Deficit Hyperactivity Disorder and History of Substance Abuse: A Multimodality Imaging Point of View

Both cannabis and amphetamine are the most commonly used illegal substances worldwide and are associated with a number of adverse cardiovascular effects including transient coronary vasospasm. Here, we present the case of a 39-year-old male admitted to our institution with a 6-h history of severe chest pain and ST-segment elevation on the ECG. Coronary angiography on admission showed normal coronary arteries. The patient had a 14-year history of substance abuse, primarily amphetamine and cannabis, and was prescribed lisdexamfetamin (Aduvanz®) for attention deficit hyperactivity disorder (ADHD) for the past 2 years. A cardiac magnetic resonance (CMR) the following day showed widely distributed focal lesions of late gadolinium enhancement in mid- and sub-epicardial myocardium in the anterior, lateral and inferior walls, suggestive of chronic fibrotic lesions. There was no sign of acute myocardial edema. No viral cause was identified during a thorough investigation, including negative SARS-COV-2 and endomyocardial biopsy. Substance-abuse-induced coronary vasospasm leading to ST-segment elevation, myocardial damage with a rise and fall of cardiac TnT, as well as a slightly reduced left ventricular ejection fraction (48%) and regional wall motion abnormalities on echocardiography, was the most likely diagnosis.

Acute Heart Failure Post Liver Transplantation: A Systematic Literature Review

Purpose Acute severe heart failure (HF) developing shortly, within hours or days, after orthotopic liver transplantation (OLT) is a known but poorly understood phenomenon. The pattern of echocardiographic changes with profound drop in left ventricular ejection fraction (LVEF) and regional wall motion abnormalities typically matches Takotsubo cardiomyopathy. Our purpose is to conduct a literature review and analysis of all the published cases that had acute severe HF after OLT. Methods We found 20 published peer reviewed case studies that described cases of HF after OLT with individual patient data available. We excluded cases of patients that had any transplant other than liver. We compiled and analyzed all the available data from each of these cases using an Excel spreadsheet. Results Our final sample had 63 patients, 56% of which were males, who developed acute HF post OLT with a mean age of 55±10, median of 57, and ranging 26-73.The average Model for End-Stage Liver Disease score was 26 ±8. In 31 patients, ischemic evaluations were performed with either a nuclear stress, dobutamine stress, or angiography and almost all (97%) of them had no evidence of ischemia. Of the 49 patients with Biomarker data, 45 (92%) had a rise in cardiac markers (troponin or CKMB). Of the 17 patients with ECG data, 10 (59%) had abnormalities at the time of HF and 8 out of 9 (89%) had a prolonged QTc. On average, acute HF developed in 1.9 ± 2.7 days after OLT (median 1 day). The mean Left Ventricular Ejection Fraction (LVEF) prior to surgery was 62.2% ±7.3 and dropping to a mean of 23.2% ± 8.2 after surgery. Of the 39 cases with known outcomes, 9 (23%) had died and five of them for cardiac reasons. 28 (72%) had full EF recovery, 5 (13%) had incomplete EF recovery, and 6 (15%) had no EF recovery. The average Recovered LVEF was 51.4% ± 13.1. Of 54 patients with reported echocardiographic findings, 52 (96%) had findings that were consistent with Takotsubo Cardiomyopathy. Conclusion Acute HF post liver transplant is diagnosed within hours to days after OLT and results in high mortality (23%). A rapid drop in LVEF with frequent recovery (85%), elevated cardiac enzymes, negative ischemic evaluation, and ECG changes suggest Takotsubo-like syndrome. The timing of changes suggests that most cases of takotsubo post liver transplant get triggered intraoperatively. Patients should be aggressively supported as they have a good potential for recovery.

Abstract 15808: Relationship Between Myocardial Injury, Wall Motion Abnormalities and Mortality in Patients With Covid-19: The Circ-19 Registry

Introduction: Myocardial injury is commonly observed in patients (pts) with Coronarvirus disease 2019 (Covid-19) but its anatomical correlate has not been elucidated. We evaluated the association between presence of transthoracic echocardiographic (TTE) left ventricular (LV) regional wall motion abnormalities (RWMA), myocardial injury and outcomes in Covid-19 pts. Methods: We conducted a cohort study including 7 hospitals in New York City (US) and Milan (Italy) of hospitalized pts with confirmed Covid-19 who had a TTE during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin (cTn) during the hospitalization. Using multivariable logistic regression, we analyzed the association between RWMA, myocardial injury and in-hospital death. Results: Among 305 total pts included in the study, 49 (16%) had RWMA and 44 (14%) had global LV systolic dysfunction. Among those with RWMA, 31/49 (63%) had LV ejection fraction &lt;50%. Compared to pts without RWMA, pts with RWMA more commonly had chest pain at time of presentation (36% vs. 14%; p=0.001), ST segment changes on ECG (33% vs. 6%; p&lt;0.0001) and myocardial injury (90% vs. 57%; p&lt;0.001). After multivariable analysis, RWMA remained associated with myocardial injury (adjOR: 5.92; 95% CI: 2.17-16.17), but not death. Left heart catheterization (LHC) was performed in 9 of the 49 (18%) pts with RWMA, 8 of which had confirmed ACS and 7 underwent PCI. Myocardial injury was associated with higher risk of death regardless of the presence or absence of RWMA ( Figure 1 ). Conclusion: In Covid-19 pts, RWMA are associated with typical ACS presentation: chest pain, ST changes and cTn elevations. Accordingly, a large proportion of pts with RWMA who underwent LHC had confirmed ACS warranting PCI. Though myocardial injury was associated with increased risk of in-hospital death regardless of the presence of RWMA, LHC should be considered for pts with RWMA and myocardial injury to rule-out obstructive disease.

Familial Hypercholesterolaemia With Premature Coronary Artery Disease: A Case Report

A young, 18-year-old lady presented with history of chest pain on exertion typical of angina. General examination revealed multiple tendon xanthomas. Systemic examination was unremarkable. Electrocardiogram showed segment (ST) depression in inferior and lateral leads. Echocardiogram revealed normal left ventricular systolic function and no left ventricular regional wall motion abnormalities. Diastolic flow turbulence was noted in the left main coronary artery and proximal left anterior descending artery on color Doppler interrogation across the coronary arteries. Lipid profile showed unusually high total cholesterol and low-density lipoprotein cholesterol. Subsequent evaluation with coronary angiogram revealed triple vessel coronary artery disease. The patient underwent coronary artery bypass surgery and is on antiplatelet and lipid-lowering drug therapy.

Automated Recognition of Regional Wall Motion Abnormalities Through Deep Neural Network Interpretation of Transthoracic Echocardiography.

Automated interpretation of echocardiography by deep neural networks could support clinical reporting and improve efficiency. Whereas previous studies have evaluated spatial relationships using still frame images, we aimed to train and test a deep neural network for video analysis by combining spatial and temporal information, to automate the recognition of left ventricular regional wall motion abnormalities. We collected a series of transthoracic echocardiography examinations performed between July 2017 and April 2018 in 2 tertiary care hospitals. Regional wall abnormalities were defined by experienced physiologists and confirmed by trained cardiologists. First, we developed a 3-dimensional convolutional neural network model for view selection ensuring stringent image quality control. Second, a U-net model segmented images to annotate the location of each left ventricular wall. Third, a final 3-dimensional convolutional neural network model evaluated echocardiographic videos from 4 standard views, before and after segmentation, and calculated a wall motion abnormality confidence level (0-1) for each segment. To evaluate model stability, we performed 5-fold cross-validation and external validation. In a series of 10 638 echocardiograms, our view selection model identified 6454 (61%) examinations with sufficient image quality in all standard views. In this training set, 2740 frames were annotated to develop the segmentation model, which achieved a Dice similarity coefficient of 0.756. External validation was performed in 1756 examinations from an independent hospital. A regional wall motion abnormality was observed in 8.9% and 4.9% in the training and external validation datasets, respectively. The final model recognized regional wall motion abnormalities in the cross-validation and external validation datasets with an area under the receiver operating characteristic curve of 0.912 (95% CI, 0.896-0.928) and 0.891 (95% CI, 0.834-0.948), respectively. In the external validation dataset, the sensitivity was 81.8% (95% CI, 73.8%-88.2%), and specificity was 81.6% (95% CI, 80.4%-82.8%). In echocardiographic examinations of sufficient image quality, it is feasible for deep neural networks to automate the recognition of regional wall motion abnormalities using temporal and spatial information from moving images. Further investigation is required to optimize model performance and evaluate clinical applications.

High magnesium dialysate does not improve intradialytic hemodynamics or abrogate myocardial stunning.

Hemodialysis (HD) induces myocardial stunning and is associated with adverse cardiovascular outcomes. Intradialytic hypotension is a modifiable determinant of myocardial stunning. Magnesium (Mg) is reported to be valuable in maintaining intradialytic blood pressure, which potentially would protect against demand myocardial ischemia. This study aimed to compare high vs. low dialysate Mg effects on intradialytic hemodynamics and HD-induced myocardial stunning. Twenty stable prevalent HD patients entered a randomized cross-over trial of low (0.5 mmol/L) vs. high (1.0 mmol/L) dialysate Mg. Patients were studied after 2 weeks of standard HD with each Mg concentration. Serial echocardiography assessed myocardial stunning, measured by left ventricular regional wall motion abnormalities (RWMAs). Continuous intradialytic hemodynamics were measured noninvasively using thoracic bioimpedance. Median predialysis serum Mg was higher with high dialysate Mg (1.45[1.29-1.55] vs. 1.03[0.98-1.1] mmol/L, P < 0.0001). There was no significant difference in maximum intradialytic reduction in systolic BP. There was no significant difference in stroke volume, total peripheral resistance, and cardiac output. Overall ventricular global longitudinal strain (GLS) (as a sensitive marker of contractile function) was higher before dialysis in high Mg group, but there was no difference in GLS at peak stress. However, we showed a significant correlation between Mg changes and GLS changes, r = -0.47, P = 0.02. There was no difference in mean number of peak stress RWMAs per patient (4.0 ± 2.2 vs. 4.3 ± 2.9, P = 0.5). Ultrafiltration volume, a critical determinant of stunning, was not different between high and low dialysate Mg studies (1.35[0-3.3] vs. 1.5[0-2.8], P = 0.49). Manipulation of magnesium by altering dialysate magnesium concentration does not influence intradialytic hemodynamic response or HD-induced myocardial stunning in the short term. However, decreasing Mg changes appears to decrease GLS changes.